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LEOPOLDS MANEUVER (ABDOMINAL EXAMINATION) Leopolds Maneuvers are a systematic method of observation and palpation to determine fetal position,

presentation, lie and attitude. It is preferably performed after 24 weeks gestation when fetal outline can be palpated Keen observation of abdomen should give data about: 1. longest diameter in appearance (longest diameter (axis) is the length of the fetus) 2. location of apparent fetal movement (the location of the activity most likely reflects the position of the feet) PREPARATION
(1) CARDINAL RULE: Instruct woman to empty bladder first. This will promotes

comfort and allows for more productive palpation because fetal contour will not be obscured by a distended bladder (2) Place woman in dorsal recumbent position, supine with knee flexed to relax abdominal muscles. Place a small pillow under the head for comfort (3)Drape properly to maintain privacy (4)Explain procedures to gain patients cooperation (5) Warm hands first by rubbing them together before placing them over the womans abdomen to aid comfort. Cold hands may stimulate uterine contractions (6) Use the palm for palpation not fingers (7) During the first three maneuvers, stand facing the patients. For the last maneuver, stand facing patients feet THE FOUR MANEUVERS FIRST MANEUVER: Fundal Grip: What fetal pole or part occupies the fundus? -palpation of the fundal area to determine which fetal part is located in the uterine fundus

-to determine the presenting part or presentation (part of the fetus lying over the inlet) PROCEDURES (1)Nurse stands at the side of the bed, facing the client (2)Using both hands, feel for the fetal par lying in the FINDINGS -The nurse-midwife should ascertain what is lying at the fundus by feeling the upper abdomen (fundus) with tips of both hands. Generally, she will find there is a mass, which will either be the head or the buttocks (breech) of he fetus. The nursemidwife must decide which pole of the fetus; it is by observing three points:


Relative consistency- the head is harder/ firmer than the breech

Shape- if the head, it will be round and hard, and the transverse groove of the neck may be felt. The breech has no groove and usually feels more angular 3. Mobility- the head will move independently of the trunk; but the breech moves only in conjunction with the body -If the nurse-midwife feels the head, the fetus is in breech presentation; if the nursemidwife feels the buttocks, it means the fetus is in vertex presentation
2. SECOND MANEUVER: Umbilical Grip: Which side is the fetal back? -to locate/identify the fetal back in relation to the right and left sides of the mother

-to determine the fetal position (the relationship of the presenting part to one of the quadrants of the mothers pelvis PROCEDURES (1)The nurse-midwife places the palmar surfaces of either side of the abdomen. (2)With left palm stationary on the left side of the steady the uterus the right palpates the right side of circular motion from top to lower segment of the gentle but deep pressure to palpate the fetal outline parts (3)The nurse-midwife then reverses her hands. FINDINGS -Small fetal parts (knees and elbows) feel nodular with numerous angular nodulations -Fetal back feels smooth, hard, like a resistant surface THIRD MANEUVER: Pawliks Grip: What fetal part lies above the pelvic inlet? -determine if the presenting part has entered the pelvis (engagement of presenting part)

both hands on abdomen to the uterus on a uterus applying and small fetal

-to find the head at the pelvis and to determine the mobility of the presenting part PROCEDURES (1)Nurse-midwife stands at the side of the bed, facing (2) It should be conducted by gently gras ping the of the abdomen, just above the symphisis pubis, thumb and the two fingers of one hand and then together slightly and make gentle movements from FINDINGS the client lower portion between the pressing side to side

-If the presenting part moves, round, balottable and easily displaced it is not yet engaged. If the presenting part is not movable felts as relatively fixed, knoblike part, it is engaged. -If it is firm, it must be the head. If soft, it could be breech

FOURTH MANEUVER: Pelvic Grip: Which side is the cephalic prominence? Cephalic prominence is part of the fetal head that prevents the deep descent with one hand

-to determines the degree of fetal head flexion or extension -to determine the attitude or habitus (degree of flexion of the fetal body, head and extremities, or the relationship of fetal parts to ach other) -to determine the fetal descent -should only be done if fetus is in cephalic presentation. Information about the infants anteioposterior position may also be gained from this final maneuver PROCEDURES (1)The nurse-midwife faces the feet of the client (2)Place one hand each on either side of the lower uterus (3)Palpate the fetal head by pressing downward about the inguinal ligament (4)Use both hands FINDINGS -If descended deeply, only a small portion of the fetal head will be palpated. -If cephalic prominence or brow or the baby is on the same side of the small fetal parts, the head is flexed -If the cephalic prominence is on the same side of the fetal back, the head is extended Age of Gestation Nageles Rule: -3 calendar months and +7 days Ex. LMP= May 15, 2006 or 5-15-06 LMP: 5 15 Formula: - 3 + 7 EDC: 2 22 or February 22, 2007 McDonalds Rule: Ht fundus/4 (AOG wks) 1. Measure in cms the length from the symphysis to the level of fundus 2. Lunar months: Fundal Height (cms) x 2/7 3. Weeks of pregnancy: Fundal height (cms) x 8/7 Ex. Fundal Height = 14 cms Lunar Month: 14cms x 2 = 28 / 7 = 4 months Weeks Pregnant: 14 cms x 8 = 112 / 7 = 16 weeks AOG Bartholomews Rule: based on position of fundus in abdominal cavity 3rd month = above symphysis 5th month = umbilical level 9th month = below xiphoid process) Fetal Length: pole of the 2 inches above

Haases Rule: 1st half of pregnancy square number of months Example : 2 months = 2x2 = 4 cm 2nd half of pregnancy number of months multiplied by 5 Example: 7 months x 5 = 35 cm Fetal Weight: Johnsons Rule: Fundic Ht n x k ( k=155; n = 11 not engaged/12 engaged) Example for a not engaged fetus Fundic Height given = 35 cms n = 11 (standard for not engaged fetus) k= 155 gms. (9 standard) Solution: 35 cms 11 = 24 x 155 =3,720 g STRUCTURE OF THE FETAL SKULL Fetal skull is the largest anatomical pary of the fetus through the birth canal, usually if the head can pass, the rest of the body can be delivered Consists of 7 bones 2 frontal presenting part 2 parietal presenting part 2 temporal not a presenting part 1 occipital Suture lines of the skull 1. Sagittal suture a membranous interspace, joins the 2 parietal bones of the skull 2. Coronal suture is the line of the junction of the frontal bones and the 2 parietal bones 3. Lambdoidal suture is the line of junction of the occipital bone and the 2 parietal bones Closed anterior fontanelle (diamond) 12-18 months posterior fontanelle (triangular) Fontanelles 1. Anterior fontanelle (Bregma) - is at the junction of the 2 parietal bones and the two fused frontal bones - diamond-shaped - normally closes at age 12-18 months measures 2 cm to 3 cm and 3 cm to 4 cm in length 2. Posterior fontanelle - is at the junction of the parietal bones, and occipital bones triangular-shaped - normally closes by age of 2 months - measures approximately 2 cm across its widest part FETAL PRESENTATION - denotes the body parts that will first contact the cervix or deliver first - determined by fetal lie, or the degree of flexion or the attitude or habitus 3 Types of fetal presentation 1. Cephalic presentation means that the head is the body part that 1st contacts the cervix and it is the most frequent type of presentation 4 Types of Cephalic Presentation 1. Vertex head is sharply flexed, making the parietal bones or the space between the fontanelles and the presenting part 2. Brow head moderately flexed, the presenting part is the brow

3. face head is extended, presenting part is the face 4. sinciput the head is completely hyperextended, the head is nor flexed, the presenting part is the sinciput 2. Breech presentation - means either the buttocks or feet are the first body parts to contact the cervix 3 Types of breech presentation 1. Complete thighs tightly flexed on the abdomen, the presenting part are both the buttocks and tightly flexed feet 2. Frank the hips are flexed but the knees are extended to rest on the chest, the presenting part is the buttocks alone. 3. Footling (incomplete breech presentation) neither the thigh nor the lower legs are flexed, presenting part is the foot - single footling breech one foot is present - double footling breech both feet is present 3. Shoulder presentation - fetus is lying horizontally in the pelvis so that its long axis is perpendicular to that of the mother, presenting part is the shoulder acromion process iliac crest, elbow, hand ATTITUDE / DEGREE OF FLEXION - term used to describe the degree of flexion the fetus assumes or the relation of fetal parts to each other Four types 1. Complete flexion (normal fetal position) - the spinal column is bowed forward, the head is flexed forward, the chin touches the sternum, arms are flexed and folded on the chest, thighs are flexed on the abdomen and the calves of the legs are pressed against the posterior aspect of the thighs 2. Moderate flexion (military position) sinciput - the chin is not touching the chest (frank, sinciput) 3. Partial extension (brow presentation) - presents the brow of the head to the birth canal 4. Complete extension (face presentation/incomplete footling) - presents the face and the back is arched, the neck is entended FETAL LIE - is the relationship between the long axis of the featl body and the long axis of the womans body 1. Transverse lie fetus is lying horizonally. Ex. Shoulder presentation 2. Longitudinal lie fetus is lying vertically POSITION - is the relationship of the fetal presenting part to the maternal bony pelvis - is determined by locating the presenting part in relation to the pelvis Means of assessing fetal position 1. Leopolds maneuver method of palpating the maternal abdomen to determine information about the fetus such as presentation, engagement and rough estimate of fetal size 2. Vaginal examination 3. Auscultation of FHT 4. Sonography diagnostic tool that is helpful in assessing a fetus for general size and structural disorders or internal organs and limbs 6 Most Common Fetal Positions 1. LOP FHT heard in LLQ 2. LOT LLQ 3. LOA LLQ

4. ROP RLQ 5. ROT RLQ 6. ROA RLQ Most Common Fetal Position 1. Left occipito anterior (LOA) - occiput of the fetus points to the left side of the maternal pelvis and towards front, face down 2. left occipito posterior (LOP) - occiput of the fetus points to the left side of the maternal pelvis and towards rear or face up 3. Left occipito transverse - occipot of the fetus is parallel to the left maternal pelvis 4. Right occipito anterior - occiput of the fetus points to the right side of the maternal pelvis, towards front face down 5. right occipito posterior - occiput of the fetus points to the right side of the maternal pelvis and toward the rear or face up 6. Right occipito transverse (ROT) - occiput of the fetus is parallel to the right maternal pelvis Position measured in numeric terms: Station- is the relationship of the presenting part of the fetus to the level of the ischial spines 0 station presenting part is at the level of the ischial spines (engagement) -1 to 4 cm presenting part is above the ischial spines +1 to +4 cm presenting part is below the ischial spines +3 to +4 cm presenting part is at the perineum (crowning) Other terms to denote station: High presenting part not engaged Floating presenting part freely moveable in inlet Dipping entering pelvis Fixed no lnger moveable in inlet but not engaged Engaged bipareital plane is passed through the pelvic inlet Engagement - refer to the settling of the presenting part of the fetus (midpoint of the pelvis) - largest diameter / widest diameter of the presenting part - usually take place two weeks before labor - maybe assessed by Leopolds maneuver, vaginal / rectal examination / cervical examination GRAVIDA >the # of pregnancies including the present & abortion NULLIGRAVIDA =woman who has never been pregnant PRIMIGRAVIDA =woman w/ first pregnancy MULTIGRAVIDA = woman w/ 2nd pregnancy or more PARITY > refers to past pregnancies (not the # of babies) that reached viability whether or not born alive (abortion & miscarriages not included) NULLIPARA = woman who has not carried a pregnancy to viability PRIMIPARA = woman who carried one pregnancy to viability MULTIPARA = woman who had 2 or more pregnancy that reached viability GRANDMULTIPARA= woman who has had 6 or more viable pregnancies

GTPALM SYSTEM: G > the # of pregnancies including the present TERM > the # of full term birth born @ 38-40 wks. Gestation PRETERM > the # of preterm birth born @ 20-37 wks. Gestation ABORTION > the 3 of abortion LIVING > the # of living children MULTIPLE > the # of multiple pregnancy 20 wks. Below > considered abortion 20-37 wks. > preterm 38-40 wks. > term 42 wks. Up > post-term NORMAL LABOR a. Intra-partum care - refer to the medical and nursing care given to a pregnant woman and her family during labor and delivery Intra-partum period - extends from the beginning of contractions that cause cervical dilatation to the 1st 1-4 hours after delivery of the newborn and placenta Labor / parturition - is the process by which the fetus and products of conception are expelled as the result of the regular, progressive and strong uterine contractions - is the last few hours of human pregnancy characterized by thunderous uterine contractions that affect dilatation of the cervix and the force of the fetus through the birth canal - myometrial contractions of labor are painful that is why pains is used to describe labor B. Factors affecting labor / components of labor 1. passageway refers to the adequacy of the pelvis and birth canal in allowing fetal descent Factors include: a. type of pelvis b. structure of pelvis c. pelvic inlet diameters d. pelvic outlet diameters e. ability of the uterine segment to distend the cervix and dilate and the vaginal canal and introitus to distend 2. passenger refers to the fetus and its ability to move through the passageway which is based on the following: a. size of the fetal head b. fetal presentation c. fetal attitude d. fetal position 3. power refers to the frequency, duration, strength of uterine contractions to cause complete cervical effacement and dilatation 4. placental factors refers to the site of placental insertion 5. Psyche refers to the clients psychological state, available support system, preparation for childbirth, experiences and coping strategies

C. Signs and symptoms of impending labor / premonitory signs of labor 1. Lightening is the descent of the fetus and uterus into the pelvic cavity 2-3 weeks before the onset of labor 2. Braxton Hicks contractions are irregular, intermittent contractions that have occurred throughout the pregnancy, becomes uncomfortable and produce a drawing pain in the abdomen groin 3. Cervical changes include softening, ripening and effacement of the cervix that will cause expulsion of the mucous plug (bloody show) 4. Rupture of amniotic membranes may occur before the onset of labor. If the woman suspects that her membranes have ruptured, she should contact her OBGyne and go to the labor suite immediately so that she may be examined for prolapsed cord a threatening condition for the fetus * Premature rupture of membranes 5. Burst of energy or increased tension and fatigue may occur right before the onset of labor 6. Weight loss of about 1 3 lbs may occur 2-3 days before the onset of labor Characteristics of false labor 1. Contractions are irregular, occur at irregular intervals decreased frequency and intensity, longer intervals between contractions 2. contractions located chiefly in the abdomen - intensity remains the same or variable - intervals remain long 3. Walking does not intensify contractions and often gives relief - either no effect or decreases contractions 4. bloody show usually not present. If present, usually brownish in color 5. There is no cervical changes 6. Contractions disappear while sleeping 7. Sedation decreases or stops contractions 8. Discomfort in lower abdomen and groin Characteristics of true labor 1. Contractions occur at regular intervals 2. Contractions start at the back and sweep around to the abdomen - increased intensity and duration or progressive - shortened intervals between contractions 3. Walking (activity) intensifies contractions 4. Bloody show present (pink-tinged mucus released from the cervical canal and as labor starts) 5. Contractions continue while sleeping 6. Cervix becomes effaced and dilated. -progressive thinning and opening of the cervix 7. Sedation does not stop contractions 8. Discomfort begins in the back and radiates to the abdomen Length of labor a. 1st stage nullipara 8-12 hrs multipara 6-8 hrs b. 2nd stage nullipara 1-2 hrs multipara 30 minutes

C. 3rd stage nullipara 5-60 minutes multipara 5-60 minutes Separation of placenta 5 to 6 minutes Cardinal movements of normal delivery (DFIERE) 1. descent 2. flexion 3. internation rotation 4. extention 5. restitution (external rotation) 6. expulsion STAGES OF LABOR 1. 1st stage of labor - begins with the onset of regular contractions which cause progressive cervical dilatations and effacement and it ends when the cervix is completely effaced and dilated N.A. due vaginal examination to detect if there is cervical dilatation - frequency of vaginal exam: once every 4 hours

3 Phases of the 1st stage of labor a. Latent phase this phase begins with the onset of regular contractions and effacement and dilatation of the cervix to 1 to 3 cms. Contractions become increasingly stronger, shortened and more frequent lasting for abour 20 to 40 seconds occurring approximately 3-5 minutes intervals - walking is recommended - effacement and dilatation 1 to 3 cm - contractions last for 20-40 seconds (duration) - contraction interval 3-5 minutes (frequency) b. Active phase - dilatation from 4 7 cm -contractions lasts 40 60 seconds - contractions becomes stronger, more frequent, longer and more painful c. Transition phase - the culmination of the 1st stage of labor is the transition phase during which the cervix dilates from 8 to 10 cm - intensity, frequency and duration of contractions peak and there is an irresistible urge to push lasting for about 60-90 seconds -dilatation 8-10 cm - contractions lasts 60-90 seconds -intervals of 2-3 minutes 2. 2nd stage of labor (expulsive stage, including episiotomy) - this phase begins with the complete dilatation of the cervix and ends with delivery of the newborn -woman feels the urge to bear down a. contractions are severe at 2-3 minutes intervals, with a duration of 50 seconds or less - membranes rupture spontaneously b. newborn exits into the birth canal with the help of the mechanism of normal labor or cardinal movements

c. crowning occurs when the newborns head or presenting part appears at the vaginal opening d. Episiotomy surgincal incision of the perineum, may be done to facilitate delivery and avoid laceration of the perineum e. Clamping the umbilical cord. The cord is but between 2 clamps placed 4 to 5 cms from the fetal abdomen and later on an umbilical cord clamp is applied 2-3 cm from the fetal abdomen MECHANISMS OF NORMAL LABOR / CARDINAL MOVEMENTS 1. Descent 1st requisite for birth of the infant, brought about by one or more four forces: a. pressure of the amniotic fluid b. direct pressure of the fundus upon the breech c. contraction of the abdominal muscles d. extension and straightening of the fetal body 2. Flexion a movement which the chin is broight about into more intimate contact with the fetal thorax 3. Internal rotation turning of the head in such a manner that the occiput gradually moves from its original position anteriorly toward the symphysis pubis 4. Extension back of neck pivots under s.p. allows head to be born by extension 5. Restitution (external rotation) head returns to normal alignment with shoulders, presents smallest diameter of shoulders to outlet 6. Expulsion borth of neonate completed (3rd stage) EPISIOTOMY a surgical procedure or an incision performed to facilitate the delivery of the infant Rationale: 1. surgical incisions reduces laceration 2. heals more easily than lacerations 3. protects infants head from pressure exterted by resistance 4. protect infants from signs of fetal distress 5. gives sufficient progress of delivery 6. shortens the 2nd stage of labor Side effects of episiotomy 1. infections 2. longer healing time Types / degree of lacerations / perineal tear / birth canal 1. 1st degree involves the fourchette, perineal skin and vaginal mucous membrane but not the underlying faschia and muscle 2. 2nd degree skin and mucous membrane, the faschia and muscle of the pernial body but not the rectal spinchter thus forming triangular injury, usually can be sutured under local anaesthesia 3. 3rd degree extends to the skin, mucous membrane and perineal body and involved the anal spinchter can be sutured by an expert obstetrician. Complications: fecal incontinence and fistulas 4. 4th degree extends to the rectal mucosa to expose the lumen of the rectum and it bleeds profusely Health teachings 1. cold packs to the perineum 2. sitz bath 3. using medication

Two types of episiotomy 1. Midline 2. Mediolateral Comparison Characteristics Midline Mediolateral 1. surgical repair easy more difficult 2. faulty healing rare more common 3. post-operative pain minimal common 4. anatomical results excellent occasionally faulty 5. blood loss less more 6. dyspareunia rare occasional 7. extensions common* uncommon * only disadvantage of midline NURSING MANAGEMENT OF THE NEWBORN IMMEDIATELY AFTER BIRTH 1. ensure patent airway 2. suction with bulb syringe 3. maintain body tempterature 4. identify infant 5. prevent eye infection 6. facilitate prompt identification 7. intervention in hemolytic problems of the newborn (vit. K) 3. 3rd Stage of labor Placental Stage - this phase begins with the delivery of the newborn and ends with the delivery of the placenta. Some bleeding is inevitable during this stage. It occurs in two phases - 5-6 minutes gap before placenta comes out - order oxytocin 10 in (IM) or IV push - increased blood loss if placenta comes out after 30 minutes a) Signs of placental separation 1. Uterus becomes globular or firmer. It is the earliest sign to appear. Calkins Sign 2. Sudden gush of blood from the vagina 3. Lengthening of the imbilical cord, 1-5 minutes after delivery of the infant 4. Fundus rises up in the abdomen b) Placental expulsion 1. Placenta is deliver by natural bearing down effort of the mother 2. Credes maneuver is performed by the doctor or nurse by gentle pressure over the contracted uterine fundus 3. Duncan placenta / mechanism as the placenta separates, the blood from the implantation site may escape into the vagina immediately. It looks raw and red in color - edges, meaty, everted, maternal side Hysterectomy 3,000 3,500 ml blood loss 4. Schultzes placenta / mechanism concealed behind the placenta and membranes until the placenta is delivered, appears shiny and glistening from the fetal membranes (fetal side) -NSD blodd loss = 500 ml to less than 1,00 ml -CS blood loss = 1,000 ml to 1,400 ml 4. 4th stage of labor (recovery or bonding stage) a. This stage lasts from 1-4 hours after birth of the newborn b. The mother and newborn recover from the physical process of birth c. The maternal organs undergo initial readjustment to the nonpregnant state d. The newborn body systems begin to adjust to extrauterine life and stabilize

e. The uterus contracts in the midline of the abdomen with the fundus midway between the umbilicus and symphysis pubis NURSING CARE OF THE WOMAN IN THE 1ST 24 HOURS POSTPARTUM 1. Provide pain relief for afterpains 2. Relieve muscular aches 3. Give episiotomy care 4. Promote perneal exercises 5. Administer sitz bath 6. Provide perineal care 7. Promote perineal self-care Postpartum warning signs to report to the physician 1. Increased bleeding, clots or passage of tissue 2. bright red vaginal bleeding anytime after birth 3. pain greater than expected 4. temperature elevation to 110.4 F 5. Feeling of full bladder accompanied by inability to void 6. enlarging hematoma 7 feeling restless 8. pain, redness and warmth accompanied by a firm area in the calf 9. difficulty breathing, rapid HR, chest pain, cough, feeling of apprehension, pale, cold blue or blue skin color Postpartum sexual activity 1. sexual intercourse may be resumed at 2-3 weeks after birth 2. Sexual intercourse should not resume until vaginal bleeding has stopped and the episiotomy has healed 3. sexual arousal may cause milk to leak from the breast 4 longer periods of foreplay will encourage lubrication 5. when the infant is weaned from the breast, sex drive will usually return to normal 6.the contraceptive meethid of choice should be used as directed, at the initiation of sexual Activity APGAR SCORING One of the standardized assessments done to evaluate the newborn quickly at birth is the Apgar Scoring. This assessment is done at the first 1 minute and 5 minutes after birth, newborns are observed and rated according to an Apgar score, an assessment scale used since 1958. Heart rate, respiratory effort, muscle tone, reflex irritability and color of the infant are each rated 0, 1, or 2; the five score are then added. Score interpretation as follows: A newborn whose total sore is less than 4 is in serious danger and needs resuscitation. A score of 4-6 means that the infants condition is guarded and the baby may need clearing of the airway and supplementary oxygen. A score of 7-10 is considered good, indicating that the infant scored as high as 70% to 90% of all infants at 1 to 5 minutes (A score of 10 is the highest score possible).

The Apgar score standardizes infant assessment at birth and serves as the baseline for future evaluation. There is a high correlation between a 5-minute Apgar scores and mortality and morbidity, particularly neurologic morbidity.

APGAR SCORING CHART SIGN Heart rate Respiratory effort Muscle tone Reflex irritability Response to catheter in nostril or Slap to sole of foot Color 0 Absent Absent Flaccid 1 Slow(<100) Slow, irregular, weak cry Some flexion of extremities Grimace Grimace 2 >100 Good, strong cry Well flexed

No response No response

Cough or sneeze Cry or withdrawal of foot Normal skin coloring (completely pinkish)

Blue, pale

Body normal pigment (pinkish), Extremities blue (acrocyanosis)

The following points should be considered in obtaining Apgar rating: Heart rate. Auscultating a newborn heart rate with a sensitive stethoscope is the best way to determine heart rate; however, heart rate also may be obtained by observing and counting the pulsations of the cord at the abdomen if the cord is still uncut. Respiratory effort. Respirations are counted by watching respiratory movements. A mature newborn usually cries and aerates the lungs spontaneously at about 30 seconds after birth. By 1 minute, he or she maintains regular, although rapid, respirations. Difficulty with breathing might be anticipated in a newborn whose mother received a large dose of analgesia or a general anesthesia during labor or birth. Muscle tone. Mature newborns hold their extremities tightly flexed, simulating their intrauterine position. Muscle tone is tested by observing their resistance to any effort to extend their extremities. Reflex irritability. One of two possible is used to evaluate reflex irritability in a newborn: response to suction catheter in the nostrils and response to having the soles of the feet slapped. A baby whose mother was heavy sedated will probably demonstrate a low score in this category. Color. All infants appear cyanotic at the moment of birth. They grow pink with or shortly after the first breath, which makes the color of the newborns correspond to how well they are breathing. Acrocyanosis (cyanosis of the hands and feet) is common in newborns that a score of 1 in this category can be thought of normal.

NURSING MANAGEMENT OF THE NEWBORN AFTER DELIVERY a. assessment - mucus in nasopharynx, oropharynx - note and record apgar score - # of vessels in the umbilical stump - passage of meconium stool, urine - general physical appearance b. analysis / ND 1 ineffective airway clearance related to excessive nasopharyngeal mucus 2. ineffective breathing pattern related to CNS depression secondary to intrauterine hypoxia and prematurity 3. impaired gas exchange related to respiratory distress 4. fluid volume deficit related to birth trauma, hemolytic jaundice 5. impaired skin integrity related to cord stump 6. high risk for injury related to impaired thermoregulation (incubation & drop light) 7. ineffective thermoregulation related to environmental condition c. NCP / implementation - ensure patent airway - suction with bulb syringe - maintain body temp - identify infant - prevent eye infection - facilitate prompt identification / vigilance for potential neonatal complications 1. history of pregnancy 2. history of delivery - facilitate prompt identification / intervention in hemolutic problems of the newborn NURSING ACTIONS DURING THE 4TH STAGE OF LABOR a. assessment - every 15 minutes, 4 times, then every 30 minutes, 2 times or until stable - to monitor response to physiologic stress of labor / birth 1. vital signs 2. location and tone of fundus - midline - firm & slightly lower than the umbilicus 3. perineum edema / rectal pain 4. bladder initial nursing action is to alternate warm & cold packs - fullness of bladder 5. rate of IV, I&O 6. interactions between parents, newborn, signs of bonding 7. assess for signs of postpartal emergencies - hemorrhage - uterine atony Nursing care plan - comfort measures 1. maternal position supine 2. pad change 3. perineal care 4. ice pack to perineum as ordered

- nutritional hydration offer oral fluid, 4-6 hours -urinary elimination - promote bonding - health teachings - signs to report to physician 1. uterine cramps 2. increased vaginal bleeding, passage of large clots 3. nausea, dizziness (Kegel exercise eliminate urination) 4. pain greater than expected 5. temp elevation at 110.4 F 6. enlarging hematoma 7. feeling of full bladder accompanied by inability to void POSTPARTUM (puerperium) - six weeks after delivery or beginning with the termination of labor and ending with the return of the reproductive organ to its non-pregnant state - sometimes called as 4th trimester of pregnancy Uterus contracts firmly, reducing its size by more than half Lochia discharge from the uterus during the first 3 weeks of delivery 3 types of lochia = RSA 1. Lochia rubra color dark red duration 1-3 days after delivery composition blood, epithetial cells, erythrocytes, leukocytes & fragments of decidus odor characteristic odor 2. locahia serosa color pinkish to brownish duration 3-10 days after delivery composition blood, decidus, erythrocytes, leukocytes, cervical mucus & microorganisms odor strong odor 3. lochia alba color colorless to creamy yellowish duration 10 days to 3 weeks after composition leukocytes, decidus, epithelial cells, fat, cervical mucus, cholesterol crystals & bacteria odor no odor Fundal height & consistency after delivery 1. after birth / delivery - fundus is palpated halfway between the umbilicus & symphysis pubis, or @ the level of the umbilicus, size & consistency of firm grapefruit 2. day 1 (first 12 hours) - one firngerbreath (1 cm) below the umbilicus 3. descends by 1 fingerbreath daily until day 10 4. day 10 to 14 - palpated behind symphysis pubis, non-palpable abdominally 5. 4-6 weeks - returns to its non-pregnant size

6. 6-7 weeks - to heal site of placental attachment GOALS of post-partum care 1 promote normal involution & return to the non-pregnant state - involution of the uterus pregressive changes of the uterus after delivery 2. prevent or minimize post partum complications - profuse bleeding -puerpera infection - mastitis - thrombophebitis - UTI - sub-involution 3. promote comfort & healing of pelvic, perianal and pernienal tissues 4. assist in restoration of normal body function 5. increased understanding of physiologic & psychological changes 6. facilitate new born care & self-care of the mother 7. promote the new borns successful integration into the family unit 8. support parenting skills & parent-newborn attachment 9. provide effective discharge planning including appropriate referral for home-care follow up Post-partum psychological adaptation 3 phases of puerperium 1. taking-in phase 2. taking-hold phase 3. letting go phase Taking-in phase - occurring 1-2 days after delivery - time for reflection talkative - mother typically passive & dependent - review her labor & delivery experience frequently Taking-hold phase - extending 2-4 days after delivery - time for initiating action - expressed little interest in caring for her child - strives to master newborn care skills Letting go phase - this phase generally occirs after the new mother returns home - time of family reorganization; time for a new role - assumes responsibility for newborn care - adapt to the demands of newborn dependency - post partum depression most commonly occur during this phase Post partum depression - a let down feeling after giving birth related to the magnitude of the birth experience & doubts about the ability to cope effectively with the demands of childrearing - begins 2-3 days after delivery & resolving pain within 1-2 weeks

Post-partum blues - also known as baby blues - due to hormonal changes - evidenced by tearfulness, feelings of inadequacy, moody, anorexia & sleep disturbance - serious depression, postpartal psychosis requiring formal counseling or psychiatric care Rooming-in - the infant stays in the room with the mother rather than staying in the central nursery Two types of rooming-in - implies that the mother & the child are together 24 hours a day 2. partial - in which the infant remains in the mothers room for part of the time

Type Isotonic

Intravenous Solution Dextrose 5% in water (D5W) 0.9% sodium chloride (Normal Saline) (NaCl)



Lactated Ringers (LR)

Fluid Comparison Uses Special Considerations Fluid loss Dehydration Use cautiously in renal and cardiac patients Hypernatremia Can cause fluid overload Shock Can lead to overload Hyponatremia Use with caution in Blood patients with heart failure transfusions or edema Resuscitation Fluid challenges DKA Dehydration Burns Contains potassium, Lower GI dont use with renal fluid loss failure patients Acute blood Dont use with liver


0.45% sodium chloride (1/2 normal saline)

loss Hypovolemia due to third spacing Water replacement DKA Gastric fluid loss from NG or vomiting Later in DKA treatment Temporary treatment for shock if plasma expanders arent available Addisons crisis Water replacement Conditions where some nutrition with glucose is required

disease, cant metabolize lactate

Use with caution May cause cardiovascular collapse or increased intracranial pressure Dont use with liver disease, trauma, or burns Use only when blood sugar falls below 250 mg/dL Dont use n cardiac or renal patients


Dextrose 5% in normal saline Dextrose 5% in normal saline



Dextrose 10% in water

Monitor blood sugar levels

Risks of intravenous therapy Infection Any break in the skin carries a risk of infection. Although IV insertion is an aseptic procedure, skin-dwelling organisms such as Coagulase-negative staphylococcus or Candida albicans may enter through the insertion site around the catheter, or bacteria may be accidentally introduced inside the catheter from contaminated equipment. Moisture introduced to unprotected IV sites through washing or bathing substantially increases the infection risks. Infection of IV sites is usually local, causing easily visible swelling, redness, and fever. If bacteria do not remain in one area but spread through the bloodstream, the infection is called septicemia and can be rapid and life-threatening. An infected central IV poses a higher risk of septicemia, as it can deliver bacteria directly into the central circulation. Phlebitis Phlebitis is inflammation of a vein that may be caused by infection, the mere presence of a foreign body (the IV catheter) or the fluids or medication being given. Symptoms are warmth, swelling, pain, and redness around the vein. The IV device must be removed and

if necessary re-inserted into another extremity. Due to frequent injections and recurring phlebitis, scar tissue can build up along the vein. The peripheral veins of intravenous drug addicts, and of cancer patients undergoing chemotherapy, become sclerotic and difficult to access over time, sometimes forming a hard venous cord. Infiltration Infiltration occurs when an IV fluid accidentally enters the surrounding tissue rather than the vein. It is characterized by coolness and pallor to the skin as well as localized swelling or edema. It is usually not painful. It is treated by removing the intravenous access device and elevating the affected limb so that the collected fluids can drain away. Infiltration is one of the most common adverse effects of IV therapy and is usually not serious unless the infiltrated fluid is a medication damaging to the surrounding tissue, in which case the incident is known as extravasation. Fluid overload This occurs when fluids are given at a higher rate or in a larger volume than the system can absorb or excrete. Possible consequences include hypertension, heart failure, and pulmonary edema.

A blood clot or other solid mass, as well as an air bubble, can be delivered into the circulation through an IV and end up blocking a vessel; this is called embolism. Peripheral IVs have a low risk of embolism, since large solid masses cannot travel through a narrow catheter, and it is nearly impossible to inject air through a peripheral IV at a dangerous rate. The risk is greater with a central IV. Air bubbles of less than 30 milliliters are thought to dissolve into the circulation harmlessly. Small volumes do not result in readily detectable symptoms, but ongoing studies hypothesize that these "micro-bubbles" may have some adverse effects. A larger amount of air, if delivered all at once, can cause lifethreatening damage to pulmonary circulation, or, if extremely large (3-8 milliliters per kilogram of body weight), can stop the heart. One reason veins are preferred over arteries for intravascular administration is because the flow will pass through the lungs before passing through the body. Air bubbles can leave the blood through the lungs. A patient with a heart defect causing a right-to-left shunt is vulnerable to embolism from smaller amounts of air. Fatality by air embolism is vanishingly rare, in part because it is also difficult to diagnose.

Electrolyte imbalance Administering a too-dilute or tooconcentrated solution can disrupt the patient's balance of sodium, potassium, magnesium, and other electrolytes. Hospital patients usually receive blood tests to monitor these levels.

Extravasation Extravasation is the accidental administration of IV infused medicinal drugs into the surrounding tissue which are caustic to these tissues, either by leakage (e.g. because of brittle veins in very elderly patients), or directly (e.g. because the needle has punctured the vein and the infusion goes directly into the arm tissue). This occurs more frequently with chemotherapeutic agents and people who have tuberculosis.


DRUG COMPUTATION Formulas: 1. Clarks RuLE : Childs dose = Adult dose x weight ( lbs.) _____________________ 150 2. Youngs Rule: Childs Dose = Adult dose x age ______________ Age + 12 3. Ideal Body weight ( ages 2-10 years) Weight ( lbs.) = age in years x 5 +18 4. Ideal body weight ( ages 2-10 years ) Height ( inches) = age in years x 2 + 32 5. Fahrenheit to Celsius: 0c = 5/9 x ( 0F 32 ) 6.Celsius to Fahrenheit: 0F = (9/5 X 0C ) + 32 EXAMPLE: 1. A patient is to receive 100,000 U of an oral suspension of Penicillin QID. A bottle containing 300,000 U penicillin in 5 cc of solution is to be used to prepare the ordered dose. How much solution will contain the ordered dose. 100,000 U: x cc = 300,000 U: 5 cc 3000, 000x = 500,000 X = 500,000 _______ 300,000 X= 1.5 cc OF THE STOCK= 100,000 U 2. The doctor orders Lanoxin for patient. The dose ordered is 0.08 mg. Lanoxin is available in a solution with 0.05 mg./ml. How much do u prepare? 0.08 mg: x ml = 0.05 mg: 1 ml 0.05x = 0.08 X = 0.08

_____ 0.05 X = 1.6 ml of the stock = 0.08 mg. 3. The doctor orders insulin 25 U OD. The available stock is 40 U/cc. How much insulin should be drawn up in a minim? Formulas: 25 U : x cc = 40 U : cc 40 x = 25 X = 25 ___ 40 X = .625 cc 1 cc = 15 16 minutes .625 cc X 15 minims _____________ 3125 625 9.375 = 10 minims 4. The doctor orders atropine so4 gr. 1/300 IM preop. The vial reads : Atropine 0.4 mg./ml How much should the nurse administer? First step: 60 mg. = 1 grain 1/300 gr. : x mg = 1 gr. : 60 mg. X mg = 1/300 x 60 X mg = 60/300 X mg = 0.2 mg. = 1/300 gr.

Second step:

.2 : x ml = .4 mg : 1 ml 0.4x = 0.2 X = 0.2/0.4 X = 0.5 ml of the stock = gr. 1/300 5. The doctor orders ASPIRIN 150 mg. QID PRN. You have on hand aspirin 1 tab = 11/4 gr. How many tablets should you give? First step: 60 mg =1 gr. 1.25 gr. : x mg. = 1 gr. : 60 mg. X = 1.25 x 60 = 75 mg. = 1 gr. Second step: 150 mg : x tabs = 75 mg. : 1 tab Formulas: 75 x = 150 X = 150/75 X = 2 tablets of the 150 mg. Stock 6. A patient is to receive 5 % dextrose and LR, 1000 ML IV in 24 hrs. The drop factor of the mini dropper is 60/ml. The nurse should regulate the IV to run at? Total ml. To be infused x drop factor Total time to infuse ( in minute ) 1000 x 60 = 6000 = 41. 6 mcgtts/min = 42 ______________________________________ 24 x 60 = 1,440