Preterm Labor/Birth: before 37 weeks Late Preterm: 34-37 weeks Very Preterm: less than 32 weeks

LBW: less than 2500 g Very LBW: less than 1500 g Extremely LBW: less than 1000 g

Low positive predictive value but a high negative

predictive value - BEST in predicting who will

NOT deliver preterm

IV Drip Insulin Protocol based in blood glucose q1-2 hours

blood glucose < 100, insulin drip 0.5U/hour in D5LR or
D5NS
blood glucose 100-140, insulin drip 1.0U/hour in NS
blood glucose 141-180, insulin drip 1.5U/hour in NS
blood glucose 181-220, insulin drip 2.0U/hour in NS
blood glucose>220, insulin drip 2.5U/hour in NS

Insulin Management in Labor Intrapartum Monitoring Postpartum Monitoring

preparation of the insulin drip finger stick blood glucose q1-2 hours discontinue insulin drip
dilute 25U Humulin Regular in 250 target blood glucose between 80-110 check finger stick blood glucose q2-4
mL NS mg/dL hours
coadminister maintenance fluids at check urine ketones with each void finger stick blood glucose before meals
125 mL/hour and at bedtime
decrease monitoring to a fasting
morning blood glucose


BP, HR, and breath sounds - crackles may indicate PE

Neurological: headache, visual changes (diplopia, blurred vision, floaters), LOC & affect

Check for epic Astrid pain and systemic edema, especially periorbital, facial, and epigastrum edema

DTRs: at be diminished because of magnesium sulfate administration

Monitor UO hourly either by Foley or urimeter

Monitor Medications

MgSO4 - check drug levels, BP, RR; fetal VS for FHR, variability, accelerations and decelerations

Pitocin

Check Labs: fibrin split products, preeclamptic lab panel, platelets

Study: Maternal and Umbilical Cord Plasma are in Activity in PIH

High [renin] and low [renin substrate] are present in the fetus early in the pregnancy. It is believed that the fetal RAAS system contributes to the pathogenesis of PIH. The
maternal RAAS system is suppressed in PIH as part of the defense mechanism of the body against elevated BP. Speculation in that preeclampsia is fetoplacental in origin and
maternal systems are involved in fighting HTN to correct the disturbances caused by the fetus. The maternal RAAS system is stimulated by normal pregnancy leading to a high
level of plasma renin activity, but this level is decreased when PIH develops related to decreased renin production by the kidney due to sodium and water retention as a negative
feed back mechanism. The key may lie in the increased sensitivity to angiotensin II in PIH than in normal pregnancy and not in the [angiotensin II], which is actually decreased
in PIH.

Study: Preeclampsia, a Disease of the Maternal Endothelium

Preeclampsia is a clinical syndrome of new onset of HTN and proteinuria during the 2nd half of pregnancy. It is the leading cause of maternal mortality and the only known
remedy is devliery of the placenta. Both HTN and proteinuria implicate the endothelium as the target of the disease. The HTN characterized by peripheral vasoconstriction and
decreased arterial compliance. The proteinuria is associated with glomerular endotheliosis, a pathognomonic renal lesion, in which the endothelial cells of the glomerulus swell
and endothelial fenestrations are lost. The GFR is decreased compared to normotensive pregnant women and in rare cases, ARF may develop. Preeclampsia is a systemic
vascular disorder that may also affect the maternal liver and brain. When the liver is involved, women may prevent with abdominal pain, nausea, vomiting, and elevated liver
enzymes. Pathological hepatic examination reveals periportal and sinusoidal fibrin deposition and in more extensive cases, hemorrhage and necrosis. The severe HELLP
syndrome (hemolysis, elevated liver enzymes, low platelets) occurs in 20% of women with severe preeclampsia. Approximately 20% of women with HELLP syndrome develop
DIC. Placental abruption, ascites, hepatic infarction, hepatic rupture, intra-abdominal bleeding, pulmonary edema and ARF are all severe clinical manifestations associated with
preeclampsia that can result in maternal death. Eclampsia, the presence of seizures, is a complication of preeclampsia and is treated with MgSO4. Smoking during pregnancy
protects against preeclampsia. The diagnosis of preeclampsia is clinical. Hyperuricemia, which is more likely to be present in women with preeclampsia has been used as a
diagnostic aid and to predict adverse outcomes in preeclampsia, but its predictive value is generally modest. An imbalance of proangiogenic and antiangiogenic proteins are key
factors in the pathogenesis of preeclampsia.

Induced: the medical or surgical termination of pregnancy before fetal viability

Elective: termination of pregnancy before fetal viability at the request of the mother but not for reasons of impaired maternal or fetal health
termination is done trans-cervically through dilation of the cervix, then evacuation of the uterus by mechanical curettage, scraping of uterine
contents or by vacuum suction
Therapeutic: termination of pregnancy for serious maternal medical indications or serious fetal anomalies
Spontaneous: abortion occurring without medical or mechanical means (miscarriage)
hemorrhage in the decidua basalis is usually followed by necrosis of tissue

Threatened: vaginal bleeding/spotting with mild abdominal cramps in the 1st half of pregnancy
the cervix is closed, uterus soft and non-tender & uterine enlargement is appropriate for gestational age
no effective therapy other than bed rest to diminish uterine irritability
Inevitable: termination of pregnancy is in progress - cervix is dilated with ROM and vagina bleeding with mild to moderately painful contractions
Incomplete: fragments of the products of conception expelled with parts remaining in the uterus
profuse bleeding occurs related to retained products of conception
Complete: products of conception are completely expelled from the uterus and there is minimal vaginal bleeding evident
Missed: embryo/fetus dies within 20 weeks gestation & is retained in the uterus for 4 weeks or more afterward
intermittent vaginal bleeding, spotting or brownish discharge
Septic: condition in which the products of conception become infected during the abortion process
foul smelling vaginal discharge
IV antibiotics are necessary
Recurrent Spontaneous: condition in which 3 or more successive pregnancies end in spontaneous abortion where gestation is less than 20 weeks
TOP: termination of pregnancy
VIP: voluntary interruption of pregnancy

Choriocarcinoma

Partial Molar Pregnancy

HIV/AIDS
The screening test for HIV is a blood test known as the enzyme immunoassay or ELISA. Testing requires a small sample of blood. Typically the test
requires 2 visits - one to receive protest counseling and have your blood drawn and the second to receive HIV testing results, post-test counseling and
medical referrals for HIV care if the results are positive. Rapid HIV testing is a type of HIV testing that makes it possible for patients to get pre-test and
post-test counseling, their test results, and any medical referrals they may need all in one visit and in a very short amount of time. It is state law that
mothers who don't know their HIV status are offered an ELISA HIV test in the MD office or hospital. Mothers with an unknown HIV status and who refuse
HIV testing during pregnancy are generally asked to sign a waiver indicating that they were offered a test, but refused testing.

Chlamydia: silent disease because women have no symptoms, but may present as burning on urination or abnormal vaginal discharge & can cause preterm birth & conjunctivitis
Neisseria Gonorrhea: most women have no symptoms but some have burning on urination, a purulent yellow-green vaginal discharge or bleeding between periods, or a rectal infection which can cause
itching, discharge & bleeding
maternal: PID
fetal: opthalmia neonatorum can cause sepsis/blindness so it is state law to protect NB eyes OU within 1 hour of delivery with erythromycin ophthalmic ointment
Group A Beta Streptococcus: women are generally a symptomatic carriers but s/s can include abnormal vaginal discharge, UTI, and chorioamnionitis
NB transmission is 1-2% but infection can result in invasive GBS causing permanent NB neurological impairment in the NB
Hepatitis B: 50% symptomatic but some may have low grade fever, anorexia, nausea and vomiting, fatigue and rashes; chronic infection can lead to maternal cirrhosis & hepatic cancer
HPV: majority of HPV infections are asymptomatic but can cause genital warts, which are flat, popular or pedunculated growths on the genital mucosa
cause respiratory papillomatosis in the NB
Syphillis: ulcer or chancre, then a maculopapular rash advancing to CNS and multi-organ damage/failure
involves fetal transplacental transmission- preterm birth, physical deformity, CNS/neurological damage, stillbirth, NB death
VDRL/RPR is used to diagnose - RPR is either reactive or nonreactive
Trichomonas Vaginalis: malodorous yellow-green vaginal discharge with vulvar irritation that can lead to PROM & preterm labor
NB may experience respiratory & genital infection
Candidiasis: directly related to a disturbance in the vaginal flora, which alters the pH & presents with pruritis, vaginal soreness, dyspareunia, abnormal vaginal discharge with a yeasty odor
Bacterial Vaginosis: 50% are asymptomatic but can present as a foul smelling fishy odor vaginal discharge which can lead to preterm labor, PROM, & chorioamnionitis


Toxoplasmosis: toxoplasma Gondi is a single felled protozoan parasite that is transmitted transplacentally
the infection can lead to spontaneous abortion, LBW, hepatosplenomegaly, icterus, chorioretinitis, chorioretinitis, and neurological disease
mother needs to avoid eating raw meats as well as avoidance of handling cat litter/feces
maternal treatment: sulfadiazine after the 1st trimester
Hepatitis B: 30-50% are asymptomatic
s/s: low grade fever, nausea, anorexia, jaundice, hepatomegaly, preterm L&D
NB has a 90% risk of being chronically infected & a 25% chance of developing liver disease
with maternal consent, NB receives HBIG & hepatitis vaccine
Rubella (German Measles): transmitted via nasopharyngeal secretions & via the placenta
maternal: erythematous maculopapular rash, lymphoma node enlargement, slight fever, headache, malaise
fetal/NB: deafness, eye defects, CNS anomalies, severe cardiac malformations
primary management is immunization - if the woman is pregnant and non-immune she should not receive the vaccine until the postpartum period; a
non-immune mother should not become pregnant until at least 3 months after delivery
CMV: virus of the herpes group that is transmitted by droplet contact & via the placenta
15% of adults infected may have mononucleosis like symptoms
fetal: maternal infection may result in LBW infant, IUGRA, hearing impairment, microcephalic & CNS abnormalities
HSV: chronic, life long virus transmitted to the fetus/NB through contact at delivery and ascending infection
maternal: painful genital lesions on the external/internal genitalia
NB: neurological complications
treatment: acyclovir is often given to the mother to suppress an outbreak of lesions; active maternal lesions require C/S

Standard Dilution for Labor Induction or Augmentation - 20U in 1000 mL of LR or D5 via IV pump in mU/minutes. The mother will have a primary line IV
ordered as oxytocin is NEVER used to induce or augment labor without a primary line just in case the effects of pitocin need to be reversed quickly, such
as in uterine hyperstimulstion & hypertonus.
Alternate Dilution for Labor Induction or Augmentation - 10U in 1000 mL of LR of D5 via IV pump in mU/minutes
Protocol - begin pitocin drip at 0.5 mU/min (1cm/hr) & increase by 1-2 mU/min q30-60 minutes until UC interval is q2-3 minutes with 45-60
seconds duration. Institutions have specific protocols for how high administration can go but most protocols reflect that RNs should not administer doses
higher than 20 mU/minute. MOST hospitals use the dilution of pitocin, 20 U in 1000 mL of IV fluid where 3 mL fluid = 1 mU/minute on the IV pump.

Prior to the AROM, position the mother for a SCE. Check the EFM for FHR pattern including rate, variability, accelerations & decelerations. Assist the
practitioner with the procedure. Post amniotomy, check the FHR pattern, variability, accelerations & decelerations. Reposition mom post procedure to a
comfortable position. Be sure to inspect the amniotic fluid for all of the following - color & amount. Amniotic fluid should be clear, colorless, and odorless.
Sometimes you will see mucous or strands of blood. The amount is estimated as small, moderate, or large. If the mom is at a minus station, be sure to
check the perineum for cord prolapse. After AROM, maternal temperature is checked q2 hours in most hospitals.

C/S Incisions

Ruptured Vasa Previa

Very Premature: <32 weeks Premature: 32-34 weeks Late Premature: 34-37 weeks Term: 37-40 weeks Post Term: after 41 weeks

 Feeding Facts - breast milk container more carbohydrates, less protein and more cholesterol than cow's milk while commercially prepared formulas use
vegetable oils which are void of cholesterol. A determined schedule for pumping will help keep milk flow steady. Magnesium and calcium prevents
undermineralization of bones and is higher in formula. Infant ready to feed when baby begins to stir, bobs head against mother's neck, makes hand to mouth
or hand to hand movements, exhibits sucking or licking, exhibits rooting, or increased activity with arms and legs flexed and hands in a fist. Normal to
breastfeed every 2 hours.
Spare Unnecessary Oxygen Consumption - a decrease in environmental temperature leads to a decrease in the neonate's body temperature which
leads to an increase in RR & HR. Cluster nursing care to decrease stress & don't prolong feeding session due to increases in energy consumption that
increase oxygen consumption.
Skin Considerations - decrease skin breakdown with the use of gelled mattresses, emollients and transparent dressings. Actively removing vernix can
irritate skin and powder is not recommended for use on babies. Female perineum is cleansed front to back and eyes cleaned for inner tougher canthus.
Water temperature should be 38 C.
Discharge Teaching - reassure parents that it is normal to feel overwhelmed, guilty and anxious. Cord should be allowed to fall off on its own and greenish
discharge could be a sign of infection; no need to cover the cord. Strings should be removed from bedding, sleepwear, and pacifiers to decrease the risk of
strangulation. Crib slates should be no wider than 2 3/8 inches.
Review with Parents - thermoregulation, signs of respiratory distress, CPR, proper feeding techniques & I&O, strategies to prevent infection

Influencing Factors - how the new parents were parented by their own caregivers, previous family life experiences, parent relationships & partner (length/
strength), desire to be a parent, age/maturity, education level, financial considerations & support systems

Becoming a Father
Some men reflect in how they were fathered & how they seem themselves fathering, but the reality of being a father may not be fully understood until the
baby is born. Cultural aspects may be a major factor in deterring the paternal role.
Influencing factors - emotional/developmental age, how he was fathered, cultural expectations, relationship with partner, personal understanding of fathering
roles, previous experience in a paternal role, level of education, job status, finances & support from family/friends/social networks

Bonding & Attachment

Bonding is defined as the emotional feelings that begin during pregnancy or shortly after birth between the parent and NB
Attachment is an emotional connection that forms between the NB & the parents. Attachment has a life long effect on an individual - the quality of
attachment influences the person's physical & emotional development & is the foundation for the formation of future relationships
pre-attachment stage: from birth - 3 months, infants do not show any particular attachment to a specific caregiver - infant's signals such as crying
and fussing attract the caregiver and the baby's positive responses encourage the caregiver to remain close
indiscriminate attachment: from around 6 weeks - 7 months, infants begin to show preferences for primary and secondary caregivers
discriminate attachment: 7-11 months, infants show a strong attachment and preference for 1 specific individual
multiple attachments: after 9 months, children begin to form strong emotional bonds with other caregivers beyond the primary attachment figure
Bonding & Attachment are affected by time, proximity of parent/NB, whether the pregnancy is planned/wanted & the ability of the parents to process
through the necessary developmental tasks of parenting
Research suggests that children who don't form secure bonds and attachments can have a negative impact on behavior- ODD, CD, PTSD. Children adopted
after 6 months have a higher risk of attachment problems. Children who have strong attachments tend to have good self esteem, strong romantic
relationships and the ability to self disclose to others.
Maternal & NB Bonding/Attachment - mother and NB are equally & mutually engaged in the interaction
Maternal Behaviors - close proximity, enhance position, vocalizes to the NB
initial stage: mother touches her NB tentatively, often with one fingertip & then with all other fingertips
second stage: mother uses her hand to stroke NBs head or body
final stage: mother cradles NB in her arms & draws NB closely to her body
NB Behaviors - eye to eye contact, mouth open as if cooing or vocalizing, crying, facial expressions, smelling, cuddling, arm/leg movements
entertainment: phenomenon on which the NBs move their arms/legs in rhythm to adult speech patterns
Paternal Behaviors - early physical contact with the NB allows the new father to become comfortable touching & holding the baby
engrossment: new fathers experience an intense preoccupation & interest in their NBs
couvade syndrome: fathers experience pregnancy like symptoms, such as N&V, weight gain, and abdominal pain


Let Down/Milk Ejection Reflex: results in milk being ejected into the lactifierous duct system under the influence of oxytocin, which is released in response
to the NB suckling and crying prior to a feeding
stimulated during orgasmic sexual response and decreased in response to maternal anxiety, stress, pain, and fatigue
occurs multiple times during a feeding

 Evaluating Effective Breastfeeding *to break a latch, place a clean finger in the corner of the NBs mouth to break the suction
The mother feels physically & emotionally comfortable pre/during/post feeding
The NB has an effective latch as indicated by no maternal nipple pain
The NB suckles & the mother can hear/see swallowing, indicating the transfer of milk from the breast to NB
The NB is drowsy - arms/legs are relaxed at the end of a feeding
The NB has at least 8 wet diapers & several stools/day once breast milk has come in & breastmilk is established
The NB recovers birth weight by 2 weeks of age
Breastfed NBs need to eat q1.5-3 hours as breastmilk is more easily digested

Reva Rubin: maternal role attachment and developmental tasks of pregnancy -

Seeking safe passage: mother focuses on her own safety for the 1st trimester. Mother is protective of the fetus during the 2nd trimester - seeks additional
knowledge regarding pregnancy, reads books/magazines, mother places information from primary OB in high regard, cradles her abdomen for protection.
During the 3rd trimester, focus is directed inward to self/baby - conjured up an identity for the child (name, physical attributes), wonders about the labor
process & may have increasing concerns/fears regarding the impending delivery.
Acceptance of the child by significant others takes place in the 1st trimester - reorganizes relationships with family & friends for acceptance of the
pregnancy. In the 2nd trimester, acceptance of the child into the family - mother has ideas of the child's place within the family. In the 3rd mother tries to
ascertain the level of family/friend's acceptance of her child.
1st trimester - mother accepts that reality of being pregnant.
2nd trimester- mother begins to enjoy the company of friends/relatives who are pregnant or have young children
3rd trimester- mother begins to worry about delivery & her own capacity to mother effectively