Maternity Ati Key Points
Maternity Ati Key Points
Maternity Ati Key Points
Chapter 1: Contraception
Chapter 2: Infertility
Female: >35 yrs, more than 1 yr w/o contra, >35 only 6 mos, endocrine dx,
tobacco, heroin, methadone,, dx: pelvic exam, hormone analysis, postcoital test,
transfer, donor oocyte, donor embryo, gestational carrier, surrogate mother, donor
sperm
test, positive: FHR, ultrasound, movement felt by provider; Serum tests: hCG (7-
8 days)
EDD: Naegle’s Rule: LMP minus 3 months plus one week plus one year, 18-32
number of pregnancies that fetus aged to 20 wks, GTPAL: G: grava, T: term birth
(38 wks) P: preterm (37 wk or less) Abortion (prior to 22 wk) L: living children
Physio Changes: repro: uterus grows, CV: CO inc 50%, BV inc, HR inc, resp:
lungs smaller, RR increase, MS: relaxin, GI: N/V/C, renal: frequency, endocrine:
Ax: BP: slight increase, pulse: slight increase, RR: slight increase, may hear S3,
Ax: hx, birth plan, medical hx, psych, care begins @ 12 wks, monthly appt from
Lab tests: blood type, Rh, irreg antibodies, Rh neg Coombs’ test @ 24/38 wks,
Rhogam after amnio… CBC, Hgb, Hct, Rubella, GBS (35-37 wks,) Hep B,
urinalysis, GTT (>140 requires follow up,) PPD, CXR, HIV, MSADP (down
syndrome, TORCH
provider, tobacco (low birth weight,) alcohol (birth defect,) exercise q30/day, no
o Second tri: benefits of BF, discomforts, sex, posture, clothing, seat belt,
Discomforts: N/V: crackers before rising, no spicy foods, avoid empty tummy,
breasts: tight, supportive bra, urinary freq: Kegel’s, UTI: cotton undies, water,
retaining urine is no good, heartburn: sit up after meals, small feels, not too full or
too hungry, leg cramps: extend the leg, keep knee straight, dorsiflexion of foot,
ab cramp, vaginal bleeding, gush of fluid from vagina, changes in fetal activity,
headaches, dysuria, blurred vision, edema of face and hands, epi pain, fruity
breath
Gain 25-30 lb during preg, 1-2 kg (2.2-4.4 lb) first tri, 0.4 kg (1 lb) per week after
Increase calories 340/day second tri, 462/day third tri, 450-500 for BF moms, 400
mcg folic acid non preg, 600 mcg/day preg woman, iron (vit C aides in
absorption,) calcium: 1,000 mg/day >19 yrs old, 1,300/day <19 yrs old, no more
Risk factors: pica: eating non nutritive foods, vegeterains need protein, calcium,
iron, zinc, B12; ED, do not take nausea meds (call provider,) ginger may help,
protein foods avoided, aspartame avoided, monitor carbs and limits sweets
Ultrasound: 20 min, full bladder for external, 2D, 3D, 4D (video,) why? Confirm
preg, gestational age, growth, site of placenta, confirm viability, rule out
hypoxia. Variables: FHR: reac: 2, NR: 0, RR: 1> 30 sec in 30 min: 2, ab/no: 0,
flexion: 2, low, lack of, or none: 0, amniotic fluid: 1 pocket >2cm in 2 places: 2,
absent, less than 2 cm: 0… score: 8-10: norm, 4-: abnormal, >4: suspect fetal
demise
NST: watch FHR for 30 min, reactive: baseline, mod variability, accelerates at
least 15/min for 15 sec, 2 or more times in 20 m, press button when fetus moves
CST: contractions, watch FHR, pattern of 3 contract in 10 mins that last 40-60
sec, nipple or oxytocin, watch for s/s labor (accidental) negative: no decels,
Amniocentesis: after 14 wks, empty bladder, high AFP presence: neural tube
mole, assess for leakage of fluid, bleeding, contractions, baby not moving
blood supply
Quad Marker Screening: hCG, AFP, estriol, Inhibin A: low AFP down syndrome,
high AFP: neural tube defects, high ACG, inhibin A: down syndrome, low estriol:
down syndrome
Maternal Serum AFP: high: neural tube defect, open abdominal defect, low: down
syndrome
Ectopic pregnancy: ovum implanted in fallopian tube, IUDs are RF, stabbing pain
in abdomen, tender lower quadrants, scant dark red or brown spotting, red
remove tube
fluid, no placenta to receive blood; partial mole: maternal and paternal, abnormal
embryonic parts, anomalies are present, excess vomiting, rapid uterine growth,
dark brown blood, or bright red blood, hCG levels are high, Rh women need
Rhogam post removal, contraception for follow up care, f/u d/t choriocarcinoma
there,) incomplete (partially there,) marginal (barely there,) painless bright red
bleeding during second or third tri, Kleihauer-Betke test: fetal blood in maternal
complete, after 20 weeks, sudden back pain with dark red bleeding, contractions,
Vasa previa: velamentous cord: cord vessels begin to branch at membranes then
course to placenta, succentriate cord: placenta has divided into two or more lobes,
Chapter 8: Infections
blood test or inject until first bath is done, confirmed by Western blot test or
TORCH: toxoplasmosis: raw meat, cat feces, rubella: children w/ rashes, mom is
pos during preg, cytomegalovirus: droplet, semen, vaginal, breast milk, urine,
feces, herpes: direct contact of active lesions, rubella: immunize post birth if neg
spotting, meds: erythromycin to all babies post birth (1hr post birth)
azithromycin PO
organs, penicillin G IM x1, abstain from sex until sores heal, test partners, safe
sex
Trichomoniasis: STI, penis to vagina, vagina to vagina, lead to PID, more likely
to deliver preterm or baby with LBW (5.5 lbs) penile itching, dysuria, frothy
Candidasis: fungal, thick creamy white cottage cheese like discharge, vulvar or
vaginal erythema, inflammation, white patches, gray patches on tongue and gums
closure of cervix) done at 12-14 wks, removed around 37, avoid intercourse,
tampons, douching
Hyperemesis gravidarum: excessive N/V, past 12 wks, 5% body wft loss, assess
for urinalysis of ketones, acetones, urine specific gravity, chemistry profile (met
acidosis due to starvation and met alkalosis d/t excess vom) throid test, CBC, IV
cereals, then soft diet, then normal, enteral nutrition may be indicated in serious
cases
Iron-deficiency anemia: inadequate iron stores, no dietary iron, pica, Hgb: <11,
Hct: <3, increase iron, prenatal vitamin has 30 mg typically, may need 60-120,
legumes, green leafy vegetables, meat, ferrous sulfate (take w/ vit. C [orange
juice])
Gestational Diabetes Mellitus: ideal BG: 70-110, 50% will develop Type II,
pain, flushed dry skin, fruity breath, GTT: 130-140 come back for 3 hr GTT
o Gestational: after 20th week, 140/90 or greater @ 2 diff times, 4 hrs apart,
irritable
o HELLP: h: hemolysis, EL: elevated liver enzymes, LP: low platelets (less
than 100,00)
Meds: methyldopa, nifedipine, hydralazine, labetalol, avoid ACE and ARBs, mag
sulfate: anticonvulsant, depresses CNS and lowers BP, flushed, hot, sedated,
monitor BP, HR, RR, DTR, LOC, urinary output, headache, epi pain, fluid
Preterm labor: uterine contractions, cervical changes 20-37 weeks, FFP in vaginal
secretions can be d/t inflamed placenta, restrict activity, ensure hydration, ID/treat
corioamnionitis, greater than 34 wks gestation, acute fetal distress, d/c for pulm
to be effective, fetal lung maturity and surfactant (24-34 wks) deep gluteal muscle
pprom: after 20 weeks, prior to 37 wks, r/f infx, monitor FHR immediately if
Edu: don’t put anything in your vagina, if you’re less than 3 cm you’re going
home, no sex, no tubs, wipe from front to back, call about a temp that is greateer
First stage: 12.5 hr, latent: 0-3 cm, active: 4-7 cm, transition: 8-10 cm
Physiological changes: backache: low, dull, weight loss, lightening (fetal head
drops,) bloody show, energy burst (nesting,) GI changes (N/V/I,) cervical ripening
(soft and open, effaced, dilated,) ROM (transition phase,) amniotic fluid (500-
5 P’s: passenger: presentation: part of fetus entering inlet first, lie: fetal to
spines, minus above, plus below, passageway: pelvis, cervix, vagina, and
dilation (opening of cervix and canal,) involuntary urge to push, position: gravity
can aide, psychological response: stress and pain can impair progress
Pre: Leopold’s Manuever: assess part, lie, attitude, descent, loc of heart tones,
Intra: VS, temp q1-2h post ROM, FHR, contractions (beginning of one to
end, intensity is the peak, mild, moderate, or strong, resting tone, vaginal exam:
Post: VS, fundus, lochia, perineum, output, bonding, VS q 15m/2hr, temp q4h/8h,
Leopold’s, empty bladder before, supine with pillow under head, knees slightly
dec during contraction, latent phase: q30-60m, active: 15-30m, second: 5-15m
absent, early decels: pres or absent, variable or late decels: absent, cat II: tachy,
brady, minimal variability, marked variability, cat III: variable/late decels, brady
Variable Cord
Early Head
Acceleration Okay!
First stage: regular contractions to full effacement and dilation of cervix, assess
for meconium post ROM (green,) amniotic fluid ferns, deep breaths, effleurage
Second stage: dilated cervix fully to birth, 1st-4th degree lacs, partner involvement,
Third stage: birth of fetus until placenta, fundus firm, swift gush of blood,
Fourth stage: placenta to first 2 hours, BP, HR q15m/2hr, temp q4h/8h then q8h,
encourage voiding
Cervical ripening: balloon, membrane stripping, misoprostol, void prior to, side
happen, r/f cord prolapse, infx, presenting part engaged prior to ROM, temp q2h
Forceps-assisted birth: spoon like blades assist in delivery head, monitor for
Episiotomy: median, out towards rectum, least painful, higher incidence of third
and fourth degree lac, mediolateral: towards left or right, blood loss is greater,
placenta previa, abruption placentae, high risk: HIV, hypertensive, DM, active
Vaginal birth after cesarean (VBAC:) attempting, only titled this when it happens,
trial of labor
Prolapsed umbilical cord: umbilical cord is displaced, call for assistance, use
sterile gloved hand, apply pressure to either side of cord to the fetal presenting
part to elevate it off the cord, saline soaked towel to exposed, knee chest,
hypoxia can stimulate vagal nerve, green fluid, NICU team on standby, APGAR
counter pressure, hypertonic: fluids, lateral position, rest, oxygen, do not give
oxytocin
Uterine rupture: ripping, tearing, sharp pain, ab pain, uterine tenderness, IVF, O2,
immediate C-section
circulatory collapse
Physical changes: oxytocin released from BF, helps uterus clamp down on open
vagina, dec progesterone results in inc muscle tone, non BF women: period in 4-6
weeks
(normal)
Fundus: every 24h descend 1 cm, 2 weeks uterus back in true pelvis, midline,
Lochia: rubra: red, 1-3 days, serosa: pink-brown, 4-10 days, alba: yellow, creamy,
11 days-4/8 wks; scant: less than 2.5, light: 2.5-10, mod: >10cm, heavy: one pad
saturated in 2 hr, excessive: one pad saturated in 15m, pooling of blood under
buttocks
muscle tone never restored, pelvic floor muscles overstretched, weak, bright red
Breasts: colostrum: 2-3 days, milk 3-5 days, assess for correct latch, early demand
CV: ABL: 500 mL vaginal, 1,000 C-section, diuresis and diaphoresis first 2-3
days d/t excess fluid, 500 mL of blood back into mom’s system after delivery of
placenta, hypercoaguability
VS: 24h PP temp (100.4) not abnormal, pulse inc, encourage early ambulation
GI: constipation not abnormal, hemorrhoids, inc apetite, soften stools (ambulate,
Urinary: loss of elasticity in bladder, void q2-3h, uterine atony: up and to the
MS: Joints return to pre-pregnant state, feet may stay large, disastis recti: broken
abdominal muscles, 6 wks will resolve, postpone abdominal muscles for 4 wks w/
C-section
Immure: rubella: neg titer, SQ inject, no pregnancy for 1 mo, hep B: vax and
Maternal identity around 4 mos post birth, dependent: taking in phase, 24-48h,
days, focus on baby care, need acceptance, learn and practice, independent:
Assess: infant as family member, face to face, eye contact, skin-to-skin, smiles at,
confronting reality: expectations might not be met, sad, jealous, creating role of
Sibling: bring a gift and give it “from” the infant, may experience regression in
one to see him, one parent to spend with infant, encourage family togetherness
Self care
o Breast: well fitting supportive bra, feed on demand, cool compresses for
nipples between fingers, allow nipples to air dry, if you choose not to
than the baby, do not cross legs, limit stair climbing, do not drive for the
first 2 weeks
vaginal discharge is white (alba,) 2-4 weeks, OTC lube needed 6 wks to 6
mos
well established
sad, intense mood swings, wgt loss, flat affect, rejection of infant, anxiety, within
Monitor client and infant, encourage bonding, reinforce that feeling down is
normal and self limiting, reinforce compliance with med regimen, ask about
APGAR 0 1 2
HR Absent <100 >100
RR Absent Weak Good cry
Tone Flaccid Some flexion Well flexed
Reflex None Grimace Cry
Color Blue Acrocyanosis Pink
Measurements: wgt: 2,500-4,000g, (5.5-8.8 lb,) length: 45-55cm (18-22 in,) head:
VS: RR: 30-60, brief 5 sec periods of apnea normal, grunting and nasal flaring
bad, HR: 110-160, full min, apical, BP: 6-80/40-50, normal temp: 36.5-37.5
(97.7-99.5,)
H to T
skin folds, lanugo: ears, forehead, shoulders, milia: small white spots on
arks that blanch on neck nose eyelids, fade by year 2, nevus flammeus:
o Head: 2-3 cm longer than chest, bulging fontanels: increased ICP, caput:
o Ears: draw imaginary line through eyes, cartilage firm, respond to voices
o Neck: short, thick, skin folds, no webbing, absence of head ctrl: down
syndrome (?)
hymenal tag, urine passed within 24h, uric acid crystals (rust colored piss)
o Reflexes
Tonic neck: turn nbn head quickly, arm and leg extend and
sensitive, taste: sweet, smell: recognize mom, habitation: they get used to
things
o Labs: Hgb: 14-28, platelets: 150-300,000, Hct: 44-64%, glu: 40-60, RBC:
4.8 x10^6, bili: 24h: 2-6, 48h: 6-7, 3-5 days: 4-6, leukocytes: 9,000-30,000
Physical Ax: VS q30minx3, qhx2, q8h, inspect umbilical cord, 6-8 h of life
systems begin to stabilize, period of reactivity: nbn awake, alert, active HR, 30
min post birth, relative inactivity: nbn will sleep, HR/RR dec 60-100 min post
birth, second period of reactivity: nbn reawakens, 2-8h post birth, last 10m-
several hrs
Lab tests: heel stick 24h post birth, received formula or BF for at least 24h, all
Care
o Resp: bradypnea: less than 30, tachy: greater than 60, abnormal: grunting,
center of mouth, aspirate mouth, then one nostril, then other nostril
o Identifiation: two, permanent locks, ankle and wrist, foot pints and thumb
prints of mom, ID band verified every time baby is given to mom, photo
to vapor, radiation: loss of heat from the body surface to a cooler solid
o Bathing: begin once temp is stabilized to 97.7 (36.5,) gloves until first
bath
o Sleep: 16-19 hr/day nbns sleep, safe sleep (on the back,) no loose linens or
o Elimination: void once within 24h of life, void 6-8x/day after day 4,
month, at diaper change cleanse area w/ clear water or water w/ mild soap,
pat dry, avoid alcohol, zinc oxide or petroleum jelly on the bottom if you
must
o Infection control: don’t share stuff with other memebrs of family and baby
o Family education: eye contact with baby, provide edu with all nursing
o Umbilical cord: clamp on 24-48h (until dry,) clean cord with water during
initial bath, diaper folded down and away from stump, do not submerge in
and vax if mom is infx within 12h of birth, then heb B vax 1 mo, 2 mo, 12
mo
Nutritional needs: loss of 5-10% birth weight, regain 10-14 days post birth, gain
110-200g/week for first 3 mos, nbns need 100-140 mL/kg/day. 110 kcal/kg/day,
Breastfeeding: 8-12/24hr, every 2-3h, 3hr during day, 4h at night, colostrum has
IgA (first 2-3 days,) interventions: skin-to-skin, let down reflex, uterine cramps,
proper latch, spread few drops across nipple, nose, cheeks, chin will touch breast,
prevent trauma, begin feeding with breast you last stopped with, gaining wgt,
offer formula or pacifier until BF has been established, on back after feedings
mos, deep freezer: 1 yr, thawing mild in fridge is best way to preserve
Formula: 3-4h, follow mixing instructions, boil water and bottles PRN, wash lid
of a can of formula w/ warm, soapy water before opening (shake it, too,) prepared
formula refrigerated 24h, not in supine pstn, 45 degree angle, nipple on top of
6+ wet diapers, BF babies: 3 stools per days, bottle: less, 1 maybe, assess wgt 2-3
Crying: you will learn why they are crying, swaddle, close contact, rhythmic
Sleep: supine, 16-19hr/day, do not five solid food, in 4-5 mos baby will sleep
through the night, keep environment quiet at night, bring them out in the center of
house with noise during the day, teach them what time of day it is (with noise and
stimulation,) put to bed around 2300, keep small night light, don’t startle with
bright lights
Bathing: face, diaper area, skin folds cleaned daily, bathing 2-3x/wk, mild soap,
not done until cord off, circ healed, wash the area around the cord, don’t get it
wet, cleanest to dirtiest, eyes, face and head, chest, arms, legs, groin, not after
feeding, do not leave unattended, move quick baby will get cold, test water with
Feeding/Elimination: baby seen 72h post d/c, lactation consultant, avoid timing
them out
Cord: clamp removed prior to d/c, sponge bath until it’s off, red, moist, foul oder
no vit K IM injection, don’t feed baby 2-3 h before if bottle fed, BF don’t matter,
diaper q4h, petroleum jelly and sterile gauze, keep area clean, yellow mucus not
alcohol
Clothing: washed w/ hot water, mild detergent, dress lightly indoors, dress as you
Home Safety: never leave unattended with pets or children, small objects out of
reach, do not put anything around their neck, slats on crib 5.7cm (2.25 in) apart,
awa from windows, drapery cords, blinds, on inner wall, do not out them on high
surfaces unless adult is within arms reach, fire hazard (fire retardant pajamas,)
Carseat Safety: back sweat, in the middle, rear facing until 2y/o
Checkups: 72 hr post d.c, 1mo, 2mo, 4mo, 6mo, 9mo, 12mo, 15mo, 18mo, 2yr,
Illness: call if: 100.4 temp, less than 97.9, poor feeding, voimiting, decreased
hyperactivity, increased Moro reflec, inc deep tendow reflex, inc muscle tone,
phenobarb: anticonvulsant,
o Alcohol: small eyes, flat face, thin lip, wide spaced eyes, small teeth, cleft
lip, deaf, abnormal palmar creases, irregular hair, heart irregularities (with
septum)
Hypogylcemia: LGA, SGA, preterm, DM, stress @ birth, less than 40 BG, less
than 45 serum BG
Preterm Newborn: born 20 wks-37 wks, late preterm: 34-36, early term newborn
37-38 6/7, cardiac and resp support main priority, complcations: respiratory
SGA: sprase hair, wgt below 10th percentile, dry, loose skin, no fat, dec muscle
from infx
LGA: >4,000 g, shoulder dystocia, plump, full faced, hypoxia, birth trauma,
Postmature Infant: 42 week gestation, dysmaturity (placenta only good for about
loss of SQ, peeling, dry, cracked skin, long thing body, meconium, hair and nails
Trauma: skull: fracture, scalp: caput, IC: epidul or subdural hematoma, spinal:
24h, persistent after day 14, acute encephalopathy: deposited in brain, >25 nbn is
at risk, kernicterus: irreversible, chronic result of bili tox; yellow skin, mucous
membranes, elevated serum bili, eye mask, diaper on, leave skin uncovered, move
ever 2hr, take off lights every 4hr, turn lights off for blood draws,feed early and
frequently