NCLEX Review of Maternity Nursing NP07L018 / Version 1.

1 01 Jan 2004
SECTION III. PRESENTATION

1.

Learning Step / Activity 1. Check your mastery of Maternity Nursing

1. Review a. Read the comprehensive nursing content review b. Answer review questions on Maternity Nursing c. Review answers and rationales for each test questions (1) The rationales for correct answers reinforces learning (2) The rationales for incorrect answers corrects knowledge deficits and identifies areas of focus for further study 2. Fetal development a. Terms (1) Zygote-Formed by the union of the sperm and ovum. (2) Embryo-Developing baby from the 3rd week to the end of the 8th week after fertilization. (3) Fetus- From the 9th week after fertilization until delivery, the developing baby is called a fetus. b. Zygote Stage: The Zygote develops in 2 distinct areas, the amniotic cavity and the yolk sac. (1) Amniotic cavity-The walls of this cavity are lined with ectoderm (outer layer of embryonic tissue that develops the skin, hair and nails) and filled with amniotic fluid. (2) Yolk-Sac-Lined with the endoderm (innermost cell layer that develop into the lining of the cavities and passages of the body, and develops into the covering of most internal organs). It supplies nourishment until implantation. (3) Mesoderm-This is a third area where Zygote development occurs. It is located between the 2 germ cells (ectoderm and endoderm) and develops into all types of muscles, connective tissue, bone marrow, blood, lymphoid tissue and epithelial cells. (4) The embryo develops at the location of implantation, where all 3 of the above listed layers (ectoderm, endoderm and mesoderm) meet. This location is known as the trilaminar embryonic disk. c. Embryonic Stage (1) The 3 primary cell layers differentiate into tissue and layers from the placenta and embryonic membranes. (2) Growth is rapid! A simple heartbeat begins and basic forms of all the major organ systems begin. (3) By the end of this stage, the embryo has developed a human appearance.

(4) During this stage, teratogenic agents (drugs, viruses, radiation, infectious agents) can cause serious harm to the embryo. d. Stages of Development of the Embryo (1) Week 3: The first body segments appear: (a) Neural tube forms. (b) Primitive Brain. (c) Primitive Spinal Cord. (2) Week 4: The embryo is now 1/5th inch long, and the head is a third of its total length. The following begins to form: (a) Heart pumps blood. (b) Neural tube closes. (c) Digestive Tract- esophagus and trachea separate; stomach forms. (3) Week 5: (a) The heart starts to pump blood, has 2 chambers. (b) Limb buds appear. (c) Major divisions of the brain can now be discerned. (4) Week 6: (a) Heart has 4 chambers. (b) External ears develop from skin folds. (c) Eyes begin to take shape. (5) Week 7: Development is proceeding rapidly. (a) The face is now formed with eyes, nose, lips and tongue. (b) Tiny bones and muscles appear beneath the thin skin. Even tiny primitive milk teeth can be seen. (6) Week 8: (a) The embryo is now a little more than 1 inch long. (b) Fingers and toes are formed. (c) Purposeful movements occur but mother can't feel these yet. (d) Heart beats at 40-80 beats/minute.

e. The fetus- at 9 weeks the genitalia are well developed and sex of the baby determined. (1) Week 10: The fetus assumes a more human shape as the lower body rapidly develops. (a) Heartbeat detected by Doppler. (b) The first movement begins. (2) Week 16: All organs and structures have been formed, and a period of simple growth begins. (3) Week 20: (a) The fetus is now following a regular schedule of sleeping, turning, sucking, and kicking. (b) May be considered as the point of viability. (c) Lanugo covers the fetal body. (4) Week 24: (a) The fetus now weighs about 820 grams. (b) The eyes are complete, and are capable of opening and closing. (5) Week 28: (a) Fetal weight increases to 1300 grams. (b) Nervous system begins some regulatory functions. (6) Week 32: Fully developed skeletal system is soft and flexible. 3. Fetal vs. Neonatal Circulation a. Fetal circulation provides oxygen and nutrients to the fetus and disposes of carbon dioxide and other waste products from the fetus. (1) Oxygenated blood is brought to the fetus by the umbilical vein and enters the fetal liver, where it branches. (2) The first branch (portal sinus) carries some of the oxygenated blood to the portal circulation and empties, via the hepatic vein, into the inferior vena cava. (3) The second branch (ductus venosus), carries most of the blood directly into the inferior vena cava, where it mixes with blood returning from the lower limbs, abdomen, and pelvis of the fetus to the fetal heart. (4) Blood entering the heart from the vena cava is directed across the right atrium through the foramen ovale to the left atrium. (5) Blood is then ejected from the left ventricle into the aorta and further circulated to the coronary arteries, brain, and upper extremities. (6) Venous blood returning from this region returns to the right atrium through the superior vena cava and is directed downward through the tricuspid valve into the right ventricle. (7) It is then pumped into the pulmonary artery, where the majority of the blood is shunted to the

descending aorta through the ductus arteriosus and perfuses the lower body. (8) Only a small amount of blood enters the fetal lungs as a result of high pulmonary resistance. b. Circulation Changes at Birth (1) With the first breath, the newborn's lungs expand and the fluid within them is absorbed into the pulmonary circulation. (2) With that first breath, pulmonary and right heart pressures fall and systemic pressures begin to rise with the removal of the placenta. (3) The foramen ovale closes as the pressure in the left atrium exceeds the pressure in the right atrium. (4) The ductus arteriosus closes with the increased oxygen content of the newborn's blood. 4. Common Complications of Pregnancy a. Hyperemesis gravidarum-excessive nausea and vomiting, which significantly hinders nutritional status and fluid balance and causes electrolyte and metabolic imbalances. b. Bleeding disorders of early pregnancy. (1) Spontaneous Abortion-pregnancy, which ends before viability (20 weeks gestation) from natural causes. (2) Ectopic Pregnancy- when the fertilized ovum (zygote) is implanted outside the uterus. c. Late pregnancy bleeding (1) Placenta Previa-occurs when the placenta develops in the lower part of the uterus. (2) Abruptio Placentae-is the premature separation of a placenta that is normally implanted. d. Pregnancy induced hypertensio-Elevation of blood pressure in a previously normotensive woman after 20 weeks gestation, proteinuria and generalized edema. (1) Mild Preeclampsia - SBP 140-160 mmHg and DBP 90-100 mmHg. Trace protein in urine and liver enzymes are minimally elevated. (2) Severe Preeclampsia - SBP > 160 mmHg and DBP>110 mmHg on two separate occasions 6 hours apart. Urine protein is >5g/24h. Urine output less than 500cc/24 hours. Liver enzymes are markedly elevated. (3) Eclampsia - Generalized seizures with oliguria (Preeclampsia progresses to eclampsia when convulsions occur). e. . Blood incompatibilities-a condition that occurs after maternal exposure to Rh-positive blood. Occurs between an Rh-negative mother and an Rh-positive fetus, which can result in the mother's antibodies destroying the newborn's red blood cells. 5. Components of the Birth Process a. The powers - forces that cause the cervix to open and that propel the fetus downward through the birth canal.

(1) Uterine contractions (a) Definition - involuntary smooth muscle contractions; women cannot consciously cause them to stop or start. 1) Uterine contractions are the primary power of labor during the first stage. 2) Intensity and effectiveness of contractions are influenced by a variety of factors, such as walking, drugs, maternal anxiety, and vaginal examinations. (b) Effect of contraction - contractions cause the cervix to efface and dilate so that the fetus may descend into the birth canal. 1) Effacement - Thinning of the cervix, described as a percentage. For example, if the cervix is 50% effaced, it is about one-half of its original length. When the cervix is 100% effaced or completely effaced it feels like a thin (paper thin), slick membrane over the fetus. 2) Dilation - Opening of the cervix, is determined by a vaginal examination, and described in centimeters, full dilation being 10 cm. (c) Phases of contractions 1) Increment - the period of increased strength of the contraction. 2) Acme or peak - the period of greatest strength of the contraction. 3) Decrement - the period of decreasing strength of the contraction. (d) Characteristics of contractions 1) Frequency - is the elapsed time from the beginning of one contraction until the beginning of the next contraction. 2) Duration - is the elapsed time from the beginning of a contraction until the end of the same contraction. Duration is described as the average number of seconds for which contractions last, such as 40-60 seconds long. 3) Intensity or strength - is the approximate strength of the contraction. Usually described as mild, moderate, or strong. With mild contractions the uterus can easily be indented with the fingertips; it feels similar to the tip of the nose. Moderate contractions feel similar to the chin and strong or firm contractions feel similar to the forehead. 4) Interval - is the amount of time the uterus relaxes between contractions. NOTE: Persistent contraction intervals shorter than 60 seconds may reduce fetal oxygen supply. Refer to Figure 6-4, p. 126, Leifer. (2) Maternal pushing (a) When the cervix is fully dilated (10 cm) the woman adds voluntary pushing with the contractions. The combined powers of the contraction and the maternal pushing propel the fetus downward through the pelvis. (b) Factors affecting pushing

1) Maternal exhaustion 2) Epidural anesthesia (c) Some women may want to push prematurely due to the fetal head causing rectal pressure. b. The passage (1) Definition - consists of the mothers bony pelvis and the soft tissues (cervix, muscles, ligaments, and fascia) of her pelvis and perineum. (2) Bony pelvis (a) False pelvis - the upper flaring part of the pelvis (b) True pelvis - the lower part of the pelvis, the true pelvis is directly involved in childbirth. The true pelvis is divided into the inlet at the top, the midpelvis in the middle, and the outlet near the perineum, its shaped like a curved cylinder. (3) Soft tissues (a) Cervix, muscles, ligaments, and fascia (b) Women who have had previous vaginal births generally deliver more quickly because their soft tissues yield more readily to the forces of the contractions. (c) Soft tissue may yield less readily: 1) In older mothers 2) After cervical procedures that have caused scarring (cone biopsy, laser surgery) 3) After many years between births c. The passenger (1) Definition - is the fetus, along with the placenta and membranes (2) Fetal head (a) The fetus usually enters the pelvis headfirst. (b) The fetal head is composed of several bones linked together with tough connective tissue, the sutures. (c) Fontanel - a wide area formed where the sutures meet. The fontanels and sutures play an important role in determining how the fetus is oriented within the mothers pelvis. 1) Anterior fontanel - a diamond-shaped area formed by the intersection of four sutures (frontal, sagittal, and two coronal) 2) Posterior fontanel - a tiny triangular depression formed by the intersection of three sutures (the sagittal and two lambdoid) (d) Molding - Sutures and fontanels of the fetal head allow the head to change shape as it passes through the pelvis.

(3) Lie (a) Describes how the fetus is oriented to the mothers spine. (b) Types 1) Longitudinal lie - the fetus is parallel to the mothers spine. This is the most common lie. (99% of births) 2) Transverse lie - the fetus is at a right angle to the mothers spine. May also be called shoulder presentation. 3) Oblique lie - the fetus is between a longitudinal and a transverse lie. NOTE: Refer to Figure 6-6, p. 128, Leifer. (4) Attitude (a) The fetal attitude is normally one of flexion, with the head flexed forward and the arms and legs flexed. (b) Extension of the head, arms and/or legs sometimes occurs. (5) Presentation (a) Refers to the fetal part that enters the pelvis first (b) Types: 1) Cephalic or vertex presentation - the fetal head is the first to enter the pelvis. This is the most common presentation (95% of births at term). 2) Breech presentation - is the second most common presentation (3-4% of term births). There are three variations of the breech presentation. a) Frank breech - (the most common), fetal legs flexed at the hips and extending toward the shoulders. This is the only breech presentation that may be delivered vaginally. b) Full or complete breech - both fetal legs are flexed at the hips and flexed at the knees. c) Footling breech - may be single with one foot presenting, or double, with both feet presenting. NOTE: Refer to Figure 6-7, p. 129, Leifer. 3) Shoulder presentation - the fetus is in a transverse lie with the shoulder entering the pelvis first; with this presentation fetus must be delivered by cesarean section. (6) Position (a) Refers to how a reference point on the fetal presenting part is oriented within the mothers pelvis. 1) Occiput is used to describe how the head is oriented if the fetus is head down. 2) Sacrum is used to describe how a fetus in a breech presentation is oriented within the pelvis.

3) The shoulder and back are used as reference points if the fetus is in a shoulder presentation or transverse lie. (b) The pelvis is divided into four imaginary quadrants: 1) Right anterior 2) Left anterior 3) Right posterior 4) Left posterior (c) Abbreviations describe the fetal presentation and position within the pelvis. Three letters are used for most abbreviations: 1) First letter - is the right or left side of the womens pelvis. This letter is omitted if the fetal reference point is directly anterior or posterior, such as Occiput Anterior (OA). 2) Second letter - is the fetal reference point (occiput, mentum, and sacrum) 3) Third letter - front or back of the mothers pelvis (anterior or posterior). Transverse (T) denotes a fetal position that is neither anterior nor posterior. (d) Classifications of fetal positions 1) Cephalic presentations a) LOA Left Occiput Anterior b) ROA Right Occiput Anterior c) LOP Left Occiput Posterior d) ROP Right Occiput Posterior e) ROT Right Occiput Transverse f) LOT Left Occiput Transverse g) OA Occiput Anterior h) OP Occiput Posterior 2) Cephalic presentations (face): a) LMA- Left Mentum Anterior b) RMA- Right Mentum Anterior c) LMP- Left Mentum Posterior d) RMP- Right Mentum Posterior 3) Breech presentation

a) LSA Left Sacrum Anterior b) RSA Right Sacrum Anterior c) LSP Left Sacrum Posterior d) RSP Right Sacrum Posterior NOTE: To simplify reference to the various positions, the descriptive phrase usually begins with the right or left (of mother's pelvis), then point of reference used (on the fetus) and then adjectives anterior, posterior, or transverse (referring to part of mother's pelvis) toward which a particular point on the fetus is directed. d. The psyche (1) Definition - how the influence of a womens mental state affects the course of her labor (2) Influences: (a) Relaxed and optimistic, better able to tolerate discomfort and work with the labor process. (b) Anxiety can increase her perception of pain and reduce her tolerance of it. (c) Anxiety and fear also cause secretion of stress compounds from the adrenal glands (catecholamines) that inhibit uterine contractions and divert blood flow from the placenta. (d) Individual values influence how the woman views and copes with childbirth. She may or may not feel comfortable with the husbands presence. (e) Cultural influences, include a culture that value stoicism, a woman may quietly endure labor pain without a complaint. Other cultural groups express their feeling openly, these women may respond loudly to labor. 6. Process of Childbirth a. Impending labor (1) Braxton-Hicks contractions - are irregular contractions that begin during early pregnancy and intensify as full term approaches (2) Increased vaginal discharge (a) Fetal pressure causes an increase in clear and nonirritating mucous secretions. (b) Irritation or itching with the increased secretion is not normal and should be reported to the health care provider. (3) Bloody show (a) Thick mucus mixed with pink or dark-brown blood (b) Bloody show occurs: 1) When the cervix undergoes changes in preparation for labor; it softens, effaces, and dilates slightly. When the cervix makes these changes a mucus plug that has sealed the uterus during pregnancy is dislodged from the cervix, tearing small capillaries in the process.

2) If the woman has had a recent vaginal examination. 3) If the woman has recently has sexual intercourse. (c) Bloody show may begin a few days before labor, or a woman may not have bloody show until labor is under way. (4) Rupture of the membranes (a) The amniotic sac (bag of waters) usually breaks during or immediately before labor. (b) The patient should go to the birthing facility as soon as she thinks her membranes have ruptured even if she is not in labor due to the increased risks. (c) Risks of ROM (Rupture of the Membranes) 1) Infection - is a higher risk if many hours elapse between ROM and birth, because the amniotic sac seals the uterine cavity against organisms from the vagina. 2) Cord prolapse - The fetal umbilical cord may slip down and become compressed between the mothers pelvis and fetal presenting part. (5) Energy spurt (a) Nesting - a sudden burst of energy shortly before the onset of labor. (b) The nurse should teach women to conserve their strength, even if they feel a burst of energy. (c) Weight loss - Occasionally the woman may notice that she losses 1-3 pounds shortly before labor begins as hormone changes cause her to excrete extra body water. b. Mechanisms of labor (1) Descent - is the fetus moving downward into the maternal pelvis, this must occur for all other mechanisms to occur and for the baby to be born. Station - describes the level of the presenting part. (a) Station is measured from the level of the ischial spines in the mothers pelvis, if the presenting part of the fetus (usually the head) were even with the ischial spines it would be a zero station. (b) Minus stations are above the ischial spines; plus stations are below the ischial spines. (c) As the fetus descends, the minus numbers get smaller (-2, -1, 0, +1, +2) and the plus numbers get higher. (2) Engagement - occurs when the fetal presenting part is at a zero station or lower (a) Nullipara - Engagement usually occurs before the onset of labor. (b) Multipara - Engagement may not occur until after labor begins. (3) Flexion - To pass most easily through the pelvis, the fetal head should be flexed. As labor progresses, uterine contractions increase the amount of fetal head flexion until the fetal chin is on the chest. (4) Internal rotation - As the fetus is pushed down into the maternal pelvis by contractions, the curved,

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cylindrical shape of the pelvis caused the head to turn until the occiput is directly under the symphysis pubis. (5) Extension - As the fetal head passes under the mothers symphysis pubis, it must change from flexion to extension. (6) External rotation - As the fetal head is born it spontaneously turns to one side as it realigns with the shoulders (restitution). As the fetal head continues to rotate the shoulders turn within the pelvis so that they can be born. (7) Expulsion - The anterior shoulder and then the posterior shoulder are born, quickly followed by the rest of the body. c. Stages of labor (1) First stage (stage of dilation) (a) From the onset of labor until full dilation of the cervix (10 cm) (b) This is the longest stage, averaging 8-10 hours for the nullipara and 6-8 hours for the multipara. (c) Three phases occur within the first stage of labor: 1) Latent phase - from the onset of labor until about 4 cm of cervical dilation a) During the latent phase, contractions gradually increase in strength and intensity, they are mild and infrequent about 5 minutes apart. b) The woman is usually sociable and excited, cooperative but anxious. May complain of lower back pain. 2) Active phase a) The cervix dilates from 5-7 cm. b) Effacement is complete. c) Contractions are moderate to firm; they intensify until they are about 3 minutes apart lasting 45 seconds. d) The woman become less sociable, mentally turns inward and concentrates on the task of giving birth. This is the phase that most laboring women will ask for pain medication. 3) Transition phase a) The cervix dilates from 8-10 cm. b) This is the shortest phase of labor. c) Contractions are firm, 2-3 minutes apart lasting as long as 90 seconds. d) The woman in labor often feels as if she is losing control, may become uncooperative and even hostile. (2) Second stage (stage of expulsion)

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(a) Extends from the time of full cervical dilation until the babys birth (b) The average duration of the second stage is 1.5 hours in the nullipara, and 20-45 minutes in multiparas. (c) Contractions are firm, but may be slightly less frequent and shorter in duration. (d) The woman that has not had regional anesthesia has an involuntary urge to push or bear down with each contraction. (e) The woman usually regains control during this stage and often says that pushing feels good or makes her feel useful. (3) Third stage (placental stage) (a) Extends from the birth of the baby until the placental is expelled (b) Two ways the placenta may deliver: 1) Schultze mechanism - if the shiny fetal side of the placental delivers first 2) Duncan mechanism - if the rough maternal side of the placenta delivers first (c) The uterus must promptly contract and remain contracted after placental expulsion, to control bleeding from the vessels that supplied the placenta before birth. (d) Oxytocin (Pitocin) is usually given in the mothers I.V. fluid, to help the uterus to contract. The infants suckling at mothers breast also stimulates uterine contractions. (e) Pain is usually minimal during the third stage; she may feel some brief cramping. (4) Fourth stage (recovery) (a) One to four hours following birth (b) The uterus should be easily felt through the abdominal wall as a round firm object about the size of a grapefruit. The uterus should be centered at midline, about halfway between the umbilicus and symphysis pubis. (c) There is usually minimal pain during this stage. There may be perineal discomfort from bruising, lacerations or episiotomy. (d) The womans bladder may fill rapidly due to I.V. fluids and loss of retained fluid, full bladder may cause increased bleeding. Be sure the woman empties her bladder. (e) The fourth stage of labor is an ideal time to promote bonding between the family and the new baby. 7. Obstetric procedures a. Amniotomy (1) Definition - is artificial rupture of the membranes (AROM) by using a sterile sharp instrument. (2) Purpose - of the amniotomy is to stimulate contractions or to enhance contractions that have already started.

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(3) Technique (a) To determine if an amniotomy is safe the doctor or nurse-midwife does a vaginal exam to evaluate the cervix and the station of the baby. (b) A disposable plastic hook is passed through the cervix, and the amniotic sac is snagged to create a hole and release the amniotic fluid. (4) Complications (a) Prolapse of the umbilical cord - the cord may slip down with the gush of fluid. (b) Infection - may occur because the membranes no longer block vaginal organisms from entering the uterus. (c) Abruptio Placentae 1) Separation of the placenta before birth. 2) May happen with amniotomy because the uterus becomes smaller with discharge of amniotic fluid, but the placenta stays the same size and no longer fits its implantation site. (5) Nursing Care (a) Identifying Complications 1) The fetal heart rate is recorded for at least 1 minute after an amniotomy. If the rate is outside the normal range (110-160 beats/minute) it is noted, and reported to the charge nurse or doctor. 2) Record the color, odor, and amount of the amniotic fluid. The fluid should be clear and may contain vernix. If cloudy, yellow, or malodorous fluid is noted, it may suggest infection and must be noted and reported. 3) The womans temperature is taken every 2 hours after the amniotic sac is broken. Report the patients temperature if it reaches 100.4 F or higher. It may suggest infection. 4) An increase in fetal heart rate, usually above 160 beats/minute, may suggest infection. 5) Green fluid means that the fetus passed the first stool (meconium) into the fluid before birth. May vary from thin meconium (green-tinged) to thick meconium (pea soup). Thick meconium may be associated with fetal compromise during labor. (b) Promoting Comfort 1) Place several underpads under the womans hips to absorb the fluid. 2) The underpads need to be changed frequent enough to keep patient dry and to reduce the moist, warm environment that favors growth of microorganisms. b. Induction or Augmentation of Labor (1) Definitions (a) Induction of labor - is the initiation of labor before it begins naturally.

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(b) Augmentation of labor - is the stimulation of contractions after they have begun naturally. (2) Indications to induce labor (a) Labor is induced if continuing the pregnancy is more hazardous for mom and fetus than delivery. (b) Reasons may include: 1) Pregnancy - induced hypertension. 2) Ruptured membranes without spontaneous onset of labor. 3) Infection within the uterus. 4) Medical problems in the woman that worsen during pregnancy. 5) Fetal problems. 6) Fetal death. (3) Contraindications - Labor is not induced in these situations: (a) Placenta previa. (b) Umbilical cord prolapsed. (c) High station of the fetus. (d) Active herpes. (e) Abnormal size or structure of the mothers pelvis. (f) Abnormal fetal presentation. (g) Previous classic cesarean incision. (4) Technique (a) Amniotomy may be the only method needed to initiate labor. (b) Cervical Ripening. 1) Prostaglandin gel (Prepidil) is a gel placed on the cervix to soften it before induction of labor. Some women begin labor soon after the gel is placed. 2) Laminaria - is a narrow cone of a substance (seaweed) that absorbs water and swells inside the cervix causing dilation of the cervix. (c) Oxytocin Induction and Augmentation of Labor 1) Pitocin (oxytocin) is the most common method of induction and augmentation of labor. 2) Pitocin is diluted in an intravenous solution. The Pitocin is the secondary line so that it may be shut off quickly while the main IV continues to infuse. 3) Pitocin is regulated with an infusion pump. Start at a very low dose and increase the dose

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according to the doctors orders. 4) Continuous electronic fetal monitoring is the usual method to assess and record fetal and maternal responses to Pitocin. (d) Non-drug Methods to Stimulate Contractions 1) Walking - stimulates contractions, eases pressure of the fetus on the mothers back, and adds gravity to the downward force of the contraction. 2) Nipple Stimulation of Labor - stimulating the nipples causes the womans posterior pituitary gland to secrete natural oxytocin. a) Pulling or rolling the nipples. b) Brushing the nipples with a dry wash cloth. c) Using water in a whirlpool tub or a shower. d) Applying suction with a breast pump. (5) Complications of Oxytocin (Pitocin) (a) The most common complications are related to over-stimulation of contractions, fetal compromise and uterine rupture. (b) Water intoxication sometimes occurs because oxytocin inhibits excretion of urine and promotes fluid retention. (c) Nursing Interventions with Complications of oxytocin. 1) Oxytocin is discontinued or rate is reduced if the fetal heart rate is out of the normal range or if there are excessive uterine contractions. 2) In addition to turning off the Oxytocin the nurse may: a) Increase the non-medicated IV fluid. b) Keep the woman off her back. c) Give the woman oxygen via face mask. (6) Nursing Care- directed by an RN (a) Baseline vital signs and fetal monitor tracing to detect contraindications to induction. (b) Monitor FHR and contractions during induction. Stop oxytocin if either is abnormal. (c) B/P, pulse and respirations every 30-60 minutes. (d) Temperature every 2-4 hours. (e) Intake and output to assess for water intoxication. c. Version

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(1) Definition (a) A method of changing the fetal presentation, usually from breech to cephalic. (b) Types 1) External Version (most common). 2) Internal Version. (2) Contraindications (a) Abnormal uterine or pelvic size or shape. (b) Most cases of previous cesarean birth. (c) Abnormal placental placement. (3) Risks. The fetus may become entangled in the umbilical cord, causing cord compression. (4) Technique (a) External Version 1) Done after 37 weeks gestation. 2) The procedure begins with a nonstress test or biophysical profile. 3) The woman receives a tocolytic medication (terbutaline) to relax the uterus. 4) Using ultrasound to guide the procedure, the doctor pushes the fetal buttocks upward outward and at the same time pushes the fetal head toward the pelvis. (b) Internal Version 1) Is an emergency procedure. 2) The physician performs internal version during vaginal birth of twins to change the fetal presentation of the second twin. (5) Nursing Care (a) The nurse assists the doctor with the procedure. (b) Observe the mother and fetus for 1-2 hours after the procedure. (c) Observe for leaking of vaginal fluid, which may indicate that the membranes are ruptured. (d) Observe for contractions. 1) Report to the doctor if contractions dont stop shortly after the procedure. 2) Teach the patient the signs and symptoms of labor before sending the patient home. d. Episiotomy and Lacerations

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(1) Definitions (a) Episiotomy - the surgical enlargement of the vagina during birth. (b) Lacerations - a tear in the perineum, vagina, or cervix (2) Classifications: (a) 1st and 2nd degree laceration - are usually uncomplicated and heal quickly because they dont affect the rectal sphincter. (b) 3rd degree laceration - extend to the rectal sphincter. (c) 4th degree laceration - extends completely though the rectal sphincter. (3) Indications for Episiotomy (a) Better control over the direction and amount that the vaginal opening is enlarged (instead of tearing). (b) An opening with a clean edge, rather than the ragged opening of a tear. (4) Risks (a) Infection is the primary risk. (b) Risk of extension of the episiotomy with a laceration into or through the rectal sphincter. (5) Technique - Episiotomy is done with blunt-tipped scissors just before birth. (6) Types of episiotomy: (a) Median (midline)--extending directly from the lower vaginal border toward the anus. 1) Easier to repair. 2) Heals neatly. 3) More likely to affect the rectum. (b) Mediolateral - extends from the lower vaginal border toward the mothers right or left. 1) Provides more room. 2) Greater scarring. 3) May cause painful sexual intercourse. (7) Nursing Care (a) Place cold packs on perineum to reduce pain, bruising and edema during the first 12-24 hours. (b) After the first 24 hours apply warm applications; this increases blood flow and promotes healing. (c) Provide mild PO analgesics for pain management.

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e. Forceps and Vacuum Extraction Births (1) Definitions (a) Forceps - instrument with curved blades that fit around the fetal head without compressing it, assists in delivery of the fetus. 1) Forceps may also assist the doctor to extract the fetal head during a cesarean section. 2) Piper forceps are a special type, to deliver the fetal head during a breech delivery. (b) Vacuum Extractor 1) Uses suction applied to the fetal head so that the physician can assist the mothers pushing. 2) The vacuum does not take up the room in the moms pelvis like the forceps do. (2) Indications (a) Mother is exhausted and is unable to push. (b) If the woman has regional anesthesia and is unable to push effectively. (c) Women with cardiac or pulmonary disorders often have forceps or vacuum extraction birth, because prolonged pushing can worsen these conditions. (d) Fetal compromise toward the end of labor. (3) Contraindications (a) These procedures are not done if a cesarean section is less traumatic. (b) They are not done if the fetus is too high in the pelvis. (c) They are not done if the fetus is too big for the pelvis. (4) Risks. Trauma to the maternal and/or the fetal tissues is the main risk. (a) The woman is at risk for lacerations and hematomas in her vagina. (b) The infant may have facial bruising, lesions or abrasions, cephalohematoma, intracranial hemorrhage. (c) The vacuum may cause an area of circular edema, called chignon, where the vacuum was placed. (5) Technique (a) Forceps - After the forceps are applied, the doctor pulls in line with the pelvic curve, an episiotomy is usually done. After the head is born, the forceps are removed and the rest of the body is delivered naturally. (b) Vacuum - the doctor places the cup over the fetal occiput, and suction is increased by a hand pump to hold it in place. (6) Nursing Care

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(a) The nurse places the sterile equipment on the delivery instrument table, to include a catheter to empty the womans bladder. (b) Maternal 1) After birth, place ice to the perineum to reduce edema and bruising. 2) Notify doctor of severe and poorly relieved pelvic or rectal pain, may indicate a vaginal hematoma. (c) Infant 1) Examine the infants head for lacerations, bruising or abrasions. 2) Watch for facial asymmetry, may indicate injury of the infants facial nerves. This usually resolves on its own. 8. Emergencies a. Prolapsed Umbilical Cord (1) Definition - the umbilical cord prolapses if it slips downward in the pelvis after the membranes rupture, it can be compressed between the fetal body and the womans pelvis thus interrupting blood supply to and from the fetus. (a) May happen immediately after the membranes are ruptured. (b) May occur much later in labor. (2) Classifications (a) Complete - the cord is visible at the vaginal opening. (b) Palpated - the cord cannot be seen, but it can be felt as a pulsating structure when a vaginal examination is done. (c) Occult - the prolapse is hidden and cannot be seen or felt, it is suspected on the basis of abnormal fetal heart rates. (3) Risk Factors

(a) Fetus is high in the pelvis when the membranes rupture. (b) Very small fetus. (c) Abnormal presentation (breech). (d) Hydramnios. (4) Medical Treatment (a) Displace the fetus upward to stop the compression. 1) Knee-chest position. 2) Trendelenburg.

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3) The nurse or doctor may push the fetus upward from the vagina. (Do not remove pressure until the baby is born.) (b) The baby is usually delivered by cesarean section. (5) Nursing Interventions (a) Assist with emergency procedures. (b) Calm, quick actions to reduce anxiety in patient. (c) After the birth, explain to the patient and family what happened. b. Uterine Rupture (1) Definition - a tear in the uterine wall that occurs if the uterine muscle cannot withstand the pressure inside the organ. (2) Variations: (a) Complete rupture - there is a hole through the entire uterus, from the uterine cavity to the abdominal cavity. (b) Incomplete rupture - the uterus tears into a nearby structure, such as a ligament, but not all the way into the abdominal cavity. (c) Dehiscence 1) An old uterine scar, usually from a previous cesarean birth, separates. 2) Dehiscence is a common occurrence; there may be no signs or symptoms. (3) Risk Factors

(a) Previous surgery on the uterus. (b) Many previous births. (c) Intense contraction, as with use of Pitocin. (d) Blunt abdominal trauma (Motor Vehicle Accident). (4) Signs and Symptoms (a) May have no symptoms. (b) Shock due to bleeding into the abdomen. (c) Abdominal pain. (d) Pain in the chest, between the scapulae, or with inspiration. (e) Cessation of contractions. (f) Abnormal or absent fetal heart rates.

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(g) Palpation of the fetus outside the uterus, because the fetus is pushed through the torn area. (5) Medical Treatment (a) If fetus is living and/or there is excessive bleeding, surgery is performed to deliver the baby and stop the bleeding. (b) For a large tear a hysterectomy may need to be done. (c) A smaller tear may be repaired. (6) Nursing Interventions (a) If signs or symptoms of uterine rupture occur, notify the physician immediately. (b) Comfort measures to decrease patients anxiety. (c) Uterine rupture is sometimes not discovered until after birth, the nurse should observe for: 1) Bright red continuous bleeding. 2) Rising in pulse. 3) Falling blood pressure. c. Uterine Inversion (1) Definition - occurs if the uterus turns inside out after the baby is born. (2) Risk Factors (a) A boggy uterus, not firmly contracted. (b) More likely to occur if the birth attendant pulls on the umbilical cord when delivering the placenta. (c) May occur during postpartum if the uterus is pushed downward when the uterus is not firm. (3) Medical Treatment (a) The doctor will try to replace the inverted uterus while the woman is under general anesthesia. (b) After the uterus is replaced Pitocin is use to cause the uterus to contract and decrease bleeding. (c) If replacement of the uterus is not successful, the woman needs a hysterectomy. (4) Nursing Interventions (a) During the emergency, two intravenous lines are started to administer fluids. (b) During Recovery Period: 1) Vital signs and assessment every 15 minutes. 2) Place Foley catheter, so uterus can contract well, and can keep a close eye on output. Report output less than 30 cc/hr.

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3) Provide explanations and emotional support to the patient, her partner and family. d. Amniotic Fluid Embolism (1) Definition - an uncommon embolism occurs when amniotic fluid, with its particles such as vernix, fetal hair, and sometimes meconium, enters the womans circulation and obstructs the small blood vessels in her lungs. (2) It is more likely to occur during a very strong labor because the fluid is pushed into small blood vessels that rupture as the cervix dilates. (3) Signs and Symptoms (a) Abrupt and severe respiratory distress and circulatory collapse. 1) Sudden hypotension. 2) Chest pain or dyspnea. 3) Restless and cyanotic. 4) Frothy blood tinged mucus. (b) Coagulation abnormalities (DIC) may occur because amniotic fluid is rich in factors that promote blood clotting. (c) The embolism may occur during or after the infant is born. (4) Medical Treatment (a) Begin immediate cardiac and pulmonary support. (b) Correct clotting defects with appropriate blood factors. (5) Prognosis - The likelihood of death from amniotic fluid embolism is high, especially if there was meconium in the fluid. e. Trauma (1) Trauma during pregnancy may be encountered anywhere, from an accident scene, to the emergency room. (2) Nursing Interventions (a) The priority is management of the womans life-threatening injuries. (b) Once the woman is stabilized the fetus is considered. (c) Place a wedge under one of the womans hips to improve blood flow to the placenta. (d) Remain alert to signs and symptoms that suggest abruptio placentae and uterine rupture. 9. Self-care and recovery a. Fundus

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(1) Report bogginess to primary care provider immediately. (2) May cramp when breast feeding. b. Lochia (1) Report foul smelling, bright red discharge or large clots. (2) If flow increases, rest. If does not subside, report to primary care provider. c. Perineum (1) Sitz baths and cleansing. (2) Tucks for discomfort. d. Breasts (1) Breast feeding (a) Demonstrate proper technique (b) Breast care: air dry, supportive bra and break suction properly when baby done nursing. (2) Dry breasts (a) Supportive bra and ice. (b) Avoid stimulation. e. Nutrition (1) Continue prenatal vitamins until after 6 week check-up (2) Increased needs if breast feeding. f. Sexuality (1) Delay resuming sexual activity until after 6 week check up. (2) Use contraceptives- breast feeding is not protective. g. Exercise (1) Gradually increase activity. (2) No strenuous activity until primary care provider gives okay. h. Emotions (1) Bonding. (2) Postpartum blues. i. Cesarean birth

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(1) Notify primary care provider for signs of infection. (2) No lifting heavier than baby until primary care provider gives okay. j. Report the following to primary care provider: (1) Temperature above 100.4 F. (2) Unexpected change in lochia. (3) Calf pain, tenderness, redness. (4) Signs of mastitis. (5) Urinary urgency, burning or frequency. (6) Severe or incapacitating depression. k. Safety (1) Infant safety. (2) Car seat usage. 10. Postpartum assessment a. Routine assessment- see box 9-1, p. 205, Leifer. Every 4-6 hours unless risk factors exist. (1) Vital signs- report temperature > 100.4 F or abnormal pulse/respirations (2) Fundus- check for firmness, height, and location. See figure 9-2, p. 205, Leifer (3) Lochia- character, color, amount, odor, clots. See figure 9-3, p. 206, Leifer (4) Perineum- hematoma, edema, episiotomy (REEDA- redness, edema, ecchymosis, drainage, approximation), hemorrhoids, degree of discomfort (5) Bladder- fullness, output, burning, pain (6) Breasts- engorgement, nipple tenderness, breastfeeding (7) Bowels- passage of flatus, bowel sounds, defecation (8) Pain- location, character, intensity, relief measures (9) Extremities- signs of thrombophlebitis, ability to ambulate, Homan's sign (10) Emotional state- family interaction, support, signs of depression (11) Attachment- interest in newborn, eye contact, touch contact, response to cries (12) Cultural variations- incorporate into plan of care when appropriate b. Signs and Symptoms of postpartum complications

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(1) Fever >100.4 with or without chills. (2) Foul odor to vaginal discharge. (3) Excessive vaginal discharge. (4) Bright-red bleeding after lochia has changed to serosa or alba. (5) Edema, erythematous or painful legs. (6) Pain or burning with urination or unable to void. (7) Pain, heat, edema or smelly discharge from breasts. (8) Perineal or pelvic pain. 11. Handicaps of preterm newborn a. Inadequate respiratory function (1) Muscles that move the chest are not fully developed (2) Abdomen is distended causing pressure on diaphragm (3) Stimulation of the respiratory center in the brain is immature (4) Gag and cough reflexes are weak because of immature nerve supply (5) Respiratory distress syndrome (RDS) is a result of immaturity of the lungs, which leads to decreased gas exchange (a) There is a deficient synthesis or release of surfactant, a chemical in the lungs. Surfactant begins to appear in the alveoli at approximately 24 weeks gestation and is at a level to enable the infant to breathe adequately at birth by 34 weeks gestation (b) Symptoms of respiratory distress occur after delivery, and may not be apparent for several hours. Symptoms include tachypnea, grunting, nasal flaring, cyanosis and retractions (c) Surfactant may be given to preterm infants via the endotracheal tube NOTE: Oxygen toxicity is a high risk for infants receiving prolonged treatment with high concentrations of oxygen. Bronchopulmonary dysplasia is the toxic response of the lung to oxygen therapy (6) Apnea may occur in the premature infant, defined as the cessation of breathing for 20 seconds or longer. Apnea is related to immaturity of the nervous system (7) Bradycardia, fewer than 100 beats/minute, may occur with apnea, b. Sepsis (1) Generalized infection of the bloodstream (2) Signs of infection include a low temperature, lethargy or irritability, poor feeding and respiratory distress. Maternal infection and complications can predispose the preterm infant to sepsis (3) Treatment includes IV antibiotics, maintenance of warmth and nutrition and close monitoring of vital

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signs c. Poor control of temperature (see ELO D below) d. Hypoglycemia (1) Defined as plasma glucose levels less than 40 mg/dl (2) Increased stress of prematurity (asphyxia, sepsis, RDS) increased glycogen use by the brain, heart and other tissues (3) Hypoglycemia must be treated immediately. May require gavage or IV feedings if preterm infant too weak to suck e. Hypocalcemia (1) Calcium is transported across the placenta throughout the pregnancy, but mainly in third trimester. If infant born early, may have lower calcium (2) Treated with IV calcium. Nurse must monitor for bradycardia f. Increased tendency to bleed (1) More prone to bleeding because blood is deficient in prothrombin (2) Fragile capillaries of head may bleed due to injury during delivery. Nurse must monitor neuro status and report bulging fontanels, lethargy, poor feeding and seizures g. Retinopathy of prematurity (ROP) (1) Condition in which there is separation and fibrosis of the retina (2) Caused by high concentration of oxygen and other problems common to the preterm infant (3) Nurse needs to monitor oxygen saturation with a pulse oximeter. There is no "safe" oxygen level (4) Treatment includes consult with an ophthalmologist and possible cryosurgery h. Poor Nutrition (1) The stomach capacity of the preterm infant is small (2) The sphincter muscles at both ends of the stomach are immature, which contributes to regurgitation and vomiting (3) Sucking and swallowing reflexes are immature (4) Ability to absorb fats is poor (5) Inadequate store of nutrients and need for glucose and nutrients to promote growth and prevent brain damage contribute to the nutritional problems (6) Gavage feedings are required until infant is strong enough to tolerate oral feedings without compromising cardiorespiratory status

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i. Necrotizing enterocolitis (NEC) (1) Acute inflammation of the bowel that leads to bowel necrosis (2) Decreased blood supply to the bowel, related to hypoxia or sepsis, result in a decrease in protective mucous and bacterial invasion (3) Signs include abdominal distention, bloody stools, diarrhea and bilious vomiting (4) Treatment includes antibiotics and parenteral nutrition to rest the bowel. May need to surgically remove necrosed bowel (5) Nursing interventions: Observe vital signs, maintain infection control techniques, measure abdomen and listen for bowel sounds, resume feedings slowly as ordered j. Immature kidneys (1) Dehydration may occur easily (2) Need to weigh diapers to determine urine output (between 1 and 3 ml/kg/hr) (3) Need to observe for signs of over hydration and dehydration. Document status of fontanels, tissue turgor, weight and urine output k. Jaundice (1) See Leifer, p. 312, table 13-1, on neonatal jaundice (2) In preterm infants the normal rise in bilirubin levels is slower than in full-term infants and lasts longer, which predisposes the infant to hyperbilirubinemia (3) Goal of treatment is to prevent kernicterus and reverse the hemolytic processes that cause the bilirubin level to rise (4) An increase in bilirubin levels of more 5mg/dl in 24 hrs requires careful investigation 12. Postterm Newborn a. Physical characteristics of the post-term infant (1) Infant long and thin; looks as if weight has been lost (2) Skin is loose (3) Little vernix; skin is dry (cracks and peels) (4) Nails are long and may be stained with meconium b. Problems associated with post maturity (1) Asphyxia (2) Meconium aspiration (3) Poor nutrition status; depleted glycogen reserves cause hypoglycemia

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(4) Polycythemia; because of intrauterine hypoxia (5) Difficult delivery due to increased size (6) Birth defects (7) Seizures, due to hypoxia c. Nursing care (1) Prepare parents for labor induction or cesarean (2) Observe infant for the following: (a) Respiratory distress (b) Hypoglycemia (c) Hyperbilirubinemia 13. Normal Newborn a. Characteristics of a Newborn's Head and Face (1) Examine head and face for symmetry, paralysis, shape, swelling and movement. (a) Molding- overlapping of the parietal bones caused by compression of the head as it passes through the birth canal. The head may appear elongated and misshapen. Resolves gradually within a day or two. (b) Caput Succedaneum- is commonly seen with molding. It is the result of edema, caused by pressure during labor and delivery, in the soft tissue of the scalp. The tissue feels spongy and may be felt over suture lines. Resolves in a few days and generally disappears without treatment. (c) Cephalohematoma- caused by bleeding within periosteum or a flat cranial bone. It may be seen on both sides of the head, but it is confined to a particular bone and does not cross suture lines. This is usually a result of hard labor. The head may appear elongated and misshapen. The hemotoma may not be apparent immediately after birth; generally appearing 1 to 2 days after birth. Normally resolves within a few weeks without treatment. (2) Examine symmetry of facial movements, eyes, and ears. NOTE: Large hematoma may lead to anemia and jaundice, which require medical intervention. (3) Measure head circumference- 33-35.5 cm (13-14 inches), 1-2 cm larger than chest. Measure just above the eyebrows (frontal) and over the occiput (occipital). (4) Fontanelles- broad area or soft spot consisting of a strong band of connective tissue contiguous with (touching) cranial bones and located at the junction of the bones should be palpable. They protect the head during delivery by the process of molding and allow further brain growth during the next 1-1/2 years. A tough membrane covers these areas, and there is little chance of injury with ordinary care. (a) Enlarged or bulging-may indicate increased intracranial pressure if it occurs while infant is at rest. (b) Depressed or sunken- often indicates dehydration.

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(c) Size 1) Posterior- smaller and triangle-shaped, 1 cm in diameter or may be obliterated because of molding. Generally closes by the end of the 2nd month. 2) Anterior- normally enlarged usually palpable, diamond shaped, 3-4 cm long by 2-3 cm wide. Generally closes in 12-18 months. (5) Sutures- junctions of adjoining skull bones. (a) Overriding- skull bones overlap due to molding during labor and delivery. (b) Separation- extensive separation may be found in malnourished infants and infants with increased intracranial pressure. (6) Eyes (a) May not track properly and may cross (strabismus) or twitch (nystagmus). Not significant unless persists beyond 4 months of age. Are commonly seen as a result of the newborn's immature nervous system. (b) Color- irises of Caucasian neonates are slate blue or grayish brown, dark-skinned races iris may appear darker. True eye color is seldom determined until 3 to 12 months of age. (c) Pupils react (constrict equally) to light. Blinking is an inborn protective reflex. (d) The lacrimal glands function minimally at birth; the newborn infant's cries are characteristically tearless until after 1-3 months of age. (e) Edema of eyelids may result from pressure on the head and face during labor and delivery or from irritation caused by erythromycin installation. (f) Newborns are nearsighted and can see objects best at 8 to 10 inches. Most prefer simple patterns in black and white and human faces. NOTE: It is important for parents to know this, because eye contact with the baby is an important part of bonding. (7) Ears (a) The ears are normally positioned with the upper insertion of the pinna located even with the outer canthus of the eye. (b) May be folded and creased. (c) Neonate usually responds to sound at birth. (d) Low set ears may indicate a congenital anomaly. NOTE: High pitched sounds and the mother's voice generates the greatest attention. It is believed that the fetus becomes familiar with the mother's voice while still in utero. (8) Nose- assess for patency, discharge and septal deviation. (9) Mouth (a) Inspect for pink, moist mucous membranes, midline tongue and movable, and intact soft and hard

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palate. (b) Epstein's pearls- small white glistening cysts found midline on the hard palate. b. Characteristics of the Newborn's Skin and Tissue Turgor (1) Vernix caseosa (a) A yellowish-white cream cheese-like substance that protects the fetus skin from its watery environment. (b) Caused by an accumulation of old cutaneous cells mixed with an early secretion from the oil glands. (c) Sometimes the baby is thickly covered with vernix at birth, and sometimes found in abundance only in the body creases. The more mature the newborn, the less vernix remains. (d) The skin of newborn Caucasian babies is usually pink to slightly reddish in appearance. The skin of African American babies may appear as pinkish or yellowish brown. Newborns of Spanish descent may have an olive tint or slight yellow cast to the skin. (2) Lanugo (a) Long, soft growth of fine hair often observed on the shoulders, back, forehead, and cheeks, but found on nearly all parts of the body, except the palms of the hands, soles of the feet, and the scalp, are commonly noted during the first week. (b) Disappears early in postnatal life. Pre-term infants have more visible lanugo. (3) Tissue Turgor (a) Refers to the hydration or dehydration of the skin. (b) To test tissue turgor (elasticity) the nurse gently grasps and releases the skin. It should spring back to place immediately. (c) When skin remains distorted, tissue turgor is considered poor. (d) Good turgor and tissue elasticity are normally observed. (4) Desquamation (peeling of the skin) of the term infant does not occur until a few days after birth. Its presence at birth is an indicator of postmaturity. c. Characteristics of the Newborn Respiratory System. (1) The lungs are not inflated and are almost completely inactive, until the umbilical cord is clamped and cut. The birth process stimulates a series of events that transform the fluid-filled lungs into organs capable of gas exchange. The lungs then take on the function of breathing oxygen and removing carbon dioxide. (2) The first breath helps to expand the collapsed lungs. (a) Full expansion does not occur for several days. (b) The health care provider assists the first breath by removing mucous from the passages to the lungs.

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(c) The baby's cry should be strong and healthy. (d) The most critical period is the first hour of life, when the drastic change from life within the uterus to life outside the uterus takes place (e) The nurse can assist the newborn to maintain a patent airway by positioning them on their back or side and dressing them in clothing to maintain warmth while allowing full expansion of the lungs. (3) Observe the infant's respiratory effort, rate and color. Auscultate lung fields. (4) Periodic breathing is common. Resumption of respirations should occur within 5-15 seconds. (5) Most common cause of respiratory difficulty in the first few hours of birth is due to the use of sedatives, tranquilizers, analgesics and anesthetics during labor, which pass over the placenta to the baby, making the newborn sleepy, thus, the newborn may require stimulation to elicit spontaneous respirations. d. Characteristics of the Newborn Cardiovascular System (1) Peripheral circulation: Acrocyanosis- hands and feet are typically blue, due to sluggish circulation after birth-blood is shunted to vital organs immediately after birth. (2) Listen to heart sounds throughout heart region for normal "lub-dub" sound. Any slur or slushing sound may indicate a murmur. (a) Murmurs are caused by blood leaking through openings that have not yet closed. (b) Murmurs may be functional (innocent) or organic (due to improper heart formation). (c) Majority of the heart murmurs are not serious. However, notify the physician; murmurs should be examined periodically in order to rule out other possibilities. e. Characteristics of the Newborn Gastrointestinal System (1) The attending physician or Certified Nurse Midwife (CNM) cuts the umbilical cord, which is attached to the placenta at birth. The cord has three vessels with white, glistening tissue and no bleeding: The cord is clamped and inspected to determine if it has two arteries and one vein present. (a) Green cord- meconium staining (b) Red cord- infection (c) 2 vessels- associated with congenital anomalies (2) Abdomen (a) Cylindrical and protrudes slightly. (b) Bowel sounds should be auscultated. (3) Stools (a) Meconium stools- first stools, a mixture of amniotic fluid and secretions of the intestinal glands. Meconium is a greenish-black, tarry, odorless, but very tenacious material. The first stool should occur in 824 hours following birth. The stools gradually change during the first week.

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(b) Transitional stool- Products of ingested milk begin to change the color of the stool, it becomes browner and then yellow green and looser in consistency. It occurs during the first week. (c) Stools of formula-fed babies are characteristically pasty, yellow-brown (almost mustard-like in appearance). Maybe one to four times a day at first, but gradually decreases to one or two stools per day. It is more solid than breast fed babies. (d) Stools of breast-fed babies have a more yellow "cottage cheese curds" like appearance, areusually softer, and during the first few weeks are more frequent. Infant will have 3-6 stools per day. (e) Constipation refers to the passage of hard dry stools a. Newborns differ in regularity b. After the second month of life the infant will increase stool volume and decrease frequency c. Even if 5-6 days pass without a stool, it is not considered constipation if the stool passed is large in volume and soft or pasty in character

d. May be seen when formula is changed e. Increasing water intake may be all that is necessary f. If eating solid foods, increase fruits, vegetables, and whole-grain cereals.

(4) Hiccoughs (a) Appear frequently in newborns and are normal. (b) Most disappear spontaneously (c) Burping the infant and offering warm water may help f. Characteristics of the Newborn Genitourinary System (1) Newborn voids within first 24 hours. (2) Usually 6 wet diapers per day. (3) For newborn males, urethral opening should be located at the tip of the penis. A white cheesy substance called smegma is found under the foreskin. Routine retraction of the foreskin of the newborn for cleansing is not recommended. g. Characteristics of the Newborn Endocrine System (1) Newborn endocrine system is supplemented by maternal hormones that have crossed the placental barrier. These maternal contributions of hormones, when withdrawn from the baby through the act of birth bring about certain phenomena that may cause parents concern and should be explained. (2) Vaginal discharge and/or bleeding may occur in female infants, along with swollen labia. (a) Generally a white mucoid discharge. (b) Bleeding (pseudomenstration) may occur as a result of withdrawal from maternal hormones at the time of birth; usually only a few blood spots seen on the diapers. Usually disappears by 2-4 weeks of age.

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(3) Swelling (engorgement) of the breasts may affect both male and female infants (Gynecomastia). (a) Particularly noticeable about the third day of life. (b) Secretion of milk from the breast may occur. (c) Swelling usually subsides in 2-3 weeks; breasts should not be squeezed. h. Characteristics of the Newborn Musculoskeletal System (1) Bones of the newborn are soft because they are composed mostly of cartilage. (2) Movements of the newborn are random and uncoordinated. Newborn lacks the muscular control to hold the head steady. (3) Tremors of the lips and extremities during crying are normal. Constant tremors during sleep may be pathological. i. Characteristics of the Newborn Nervous System (1) Nervous system of the newborn is immature. (2) Reflex actions present at birth serve the infant until neuromuscular development is improved. (3) Absence of reflex activity often indicates abnormalities of the nervous system. j. Reflexes of the Newborn (1) Rooting- Stimulated by touching the side of the newborn's mouth or cheek. Infant turns head toward that side and opens the lips. (2) Sucking- Stimulated by placing a nipple or gloved finger into the infant's mouth. Suck reflex is very strong in full term newborn. (3) Moro reflex (startle reflex)- Head is brought forward (about 30 degrees) and then allowed to fall back suddenly - abduction of the upper extremities at the shoulder, extension of the elbows, and opening of the hands follow. Disappears after 3 to 4 months. (4) Grasping reflex; Elicited by placing a finger in the newborn's palm. The newborn grasps the fingers tightly. (5) Plantar- Elicited by placing thumb against the ball of the foot. Toes curl down in response to stimulation. (6) Tonic Neck Reflex- When infant's head is quickly turned to one side, arm and leg will extend on that side, and opposite arm and leg will reflex; posture resembles a fencing position. Disappears by 3 to 4 months of age, to be replaced by symmetric positioning of both sides of body. (7) Babinski- When the sole of the foot is stroked along side of sole beginning at heel and then moving across ball of foot to big toe, toes will fan out with dorsiflexion of big toe. (8) Dance or stepping reflex- If infant is held so that sole of foot touches a hard surface, there will be a reciprocal flexion and extension of the leg, simulating walking.

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