Maternal and

Child health Nursing

rnursingnotes
 Male Reproductive System
External genitalia

Penis - reproductive and urinary elimination Prostate: muscular gland that surrounds the first part
of the urethra as it exits the urinary bladder.
Scrotum - External sac that houses testes

The alkaline fluids secreted by these glands are

Protects the testes from trauma & testicular
nutrient plasmas with several key functions, including
temperature regulation.
the following:

Internal reproductive organs Enhancement of sperm motility (i.e., ability to

move)
Testes: produce male sex hormone and from
spermatozoa Nourishment of sperm (i.e., provides a ready
source of energy with the simple sugar fructose)
Ductal system: “ vas deferens” the tube in which
sperm begin the journey out of the body. Protection of sperm (i.e., sperm are maintained
in an alkaline environment to protect them from
Accessory glands: The seminal vesicles are the acidic environment of the vagina) (Hatfield
paired glands that empty an alkaline, fructose- 51)
rich fluid into the ejaculatory ducts during
ejaculation.
 Female Reproductive system
External genitalia Fallopian tubes: The paired fallopian tubes (also
known as oviducts) are tiny, muscular corridors that
mons pubis arise from the superior surface of the uterus near the
labia majora and minora fundus and extend laterally on either side toward the
Clitoris ovaries.
Vestibule The fallopian tubes have three sections
perineum Isthmus
Ampulla
infundibulum
Internal reproductive organs
Uterus: uterus, or womb, is a hollow, pear-
Vagina: muscular tube that leads from the vulva to the
shaped, muscular structure located within the
uterus
pelvic cavity between the bladder and
the rectum.
Cervix: dips into the vagina and forms fornices, which
are arch-like structures or pockets. The uterus is divided into four sections.
cervix
Ovaries :two sex glands homologous to the male uterine isthmus
testes, are located on either side of the uterus. (Hatfield corpus
55) fundus
 Menstrual Cycle Two main components:
Ovarian Cycle
Uterine Cycle

Ovarian cycle Uterine cycle:

Cyclical changes in the ovaries occur in changes that occur in the inner lining of the
response to two anterior pituitary hormones: uterus. These changes happen in response
to the ovarian hormones estrogen and
- follicle-stimulating hormone (FSH) progesterone.
and luteinizing hormone (LH).
There are four phases to this cycle:

There are two phases of the ovarian cycle, each Menstrual

named for the hormone that has the most control Proliferative
over that particular phase. Secretory
ischemic.
The follicular phase controlled by FSH,
encompasses days 1 to 14 of a 28-day cycle.

LH controls the luteal phase ,which includes days 15 to

28
 Assessment
Admission Prenatal visits
Birth imminence Ist visit:
Fetal status
Maternal status Family History, Medical Surgical History, Social
Risk assessment History, Teaching, Avoiding teratogenic, substance
ingestion, Alcohol, tobacco, illegal drugs, etc., Diet,
nutrition, and exercise, Infection control
Assessment of reproductive history Medication use

Gravida: Number of pregnancies the woman has Determining due dates

had regardless Naegele's rule
of outcome Add seven days to the date of the first day of the
LMP, then subtract three months (and add a year)
Nulligravida: never been pregnant
Pelvic examination
Multigravida: more than one pregnancy Practitioner sizes the uterus to estimate term
Obstetric sonogram: High frequency sound waves
Parity: the client communicates outcome of
reflect off fetal and maternal pelvic structures,
previous pregnancies
allowing structure measurement
 Components of Assesmment

Obstetric history Current labor status

Number and outcomes of previous
pregnancies in GTPAL (gravida,
term, preterm, abortions, living) Time of contraction onset
format
Estimated delivery date Contraction pattern including
frequency, duration, and intensity
History of prenatal care for current
pregnancy
Status of membranes
Complications during pregnancy
Dates and results of fetal surveillance Description of bloody show or
studies, such as ultrasound or bleeding
nonstress test (NST)
Fetal movements during the past 24
Childbirth preparation classes
hours
Previous labor and birth experiences
Medical-surgical history Social history Desires/Plans for Labor and Birth

Chronic illnesses Marital status Presence of a partner,

Support system coach, and/or doula
Current medications
Pain management
Prescribed Domestic violence screen
preferences
Over-the-counter Cultural/religious
Other personal
Herbal remedies considerations that affect preferences affecting
care intrapartum nursing care
Amount of smoking during Presence of a birth plan
pregnancy Desires/Plans for Newborn
Drug and alcohol use Plans for feeding—breast
or formula
during pregnancy
Choice of pediatrician
Circumcision preference, if
the infant is male
Rooming-in preference

Tips! If a woman presents with c/o bleeding ask her how man
sanitary napkins she has saturated in an hour.
 Fetal heart tones
Condition Cause Grade

Infection
Mild: > 5 BPM from baseline
Dehydration
Moderate: 6-25 BPM from
Fever baseline
Fetal hypoxemia Severe: < 25 BPM from
Fetal Tachycardia Anemia baseline
Prematurity Absent: No fluctuation in
Terbutaline fetal heart rate
Caffeine
Epinephrine
Theophylline
illicit drugs

Maternal hypotension Mild: > 5 BPM from

Supine hypotensive baseline
syndrome Moderate: 6-25 BPM from
Fetal bradycardia Fetal decompression baseline
Late fetal hypoxia Severe: < 25 BPM from
Cord compression baseline
Abruptio placenta Absent: No fluctuation in
Vagal stimulation fetal heart rate
 Variability
FHR drops from baseline then recovers, usually jagged and erratically shaped. Can happen
at anytime during contraction

Nursing interventions:

Left Side
IV bolus of fluids
O2 6l mask Memory Trick
Notify HCP
A great way to remember this is L.I.O.N
V: variable deceleration C: cord compression
E: early deceleration H: head compression
Decreased or absent variability: Non reassuring, acute A: acceleration O: ok
treatment and monitoring are indicated. Late deceleration Placental insufficiency
Wandering baselines with no variability could indicate

- Congenital defects
- Metabolic acidosis

The nurse should administer 02 and the baby needs to be

delivered as quickly as possible.
 Accelerations &
Fetal decelerations
Decelerations
Early decelerations::
Accelerations: must be 15 BPM above the FHR baseline
for 15 seconds 15x15 window
A decrease in FHR during uterine contraction
mirrors uterine contractions . caused by uterine
Decelerations: A decrease in FHR during uterine contraction ”
squeeze
mirrors contractions usually a U shape
FHR slows as the contraction begins
Period changes: variations that occur during a contraction. Lowest point coincides with the highest point
ACME of the contraction
Reassuring periodic changes: must be 15 BPM
Deceleration ends with the contraction
above the FHR baseline for 15 seconds ( 15x15
window) Late decelerations:
Benign periodic changes: Early decelerations
occurs after the peak of contraction due to uteroplacental
occur in association with medication insufficiency, pitocin, HTN, diabetes, placental abruption.
Episodic changes:
administration or analgesia Too many decelerations will indicate a need for
C-section
Decreased or absent medications, narcotics, mag sulfate Prepare for fetal resuscitation
variability: (preeclampsia, preterm),
Variable decelerations:
terbutaline, fetal sleep (normally 20
minute cycles), prematurity, fetal Measures to clarify NONreassuring FHR patterns:
hypoxemia. Fetal stimulation
Fetal scalp sampling
Fetal scalp oximetry
 Signs of Pregnancy
Presumptive Probable Positive
least indicative not a definite Pregnancy signs that the nurse or Definite diagnosis for
diagnosis for pregnancy doctor can observe pregnancy

Period absent Positive (+) pregnancy test (high levels of

Fetal movement palpated by a
(Amenorrhea) the hormone: hCG)
doctor or nurse

Really tired Returning of the fetus when uterus is

Electronic device detects heart
pushed w/ fingers (ballottement)
tones
Enlarged breasts
Objective
The delivery of the baby
Sore breasts
Braxton hicks contractions
Ultrasound detects baby
Urination increased (urinary
Seeing visible movements
frequency) A softened cervix (Goodell's sign)

Movement perceived Bluish color of the vulva, vagina, or cervix

(quickening) (Chadwick's sign)

Emesis & nausea Lower uterine segment soft (Hegar's sign)

Enlarged uterus
Usual diagnostic exam prescribed in
pregnant women

General test Selective test

Pregnancy test
Blood typing Blood glucose / HbA1C
RBC antibody screen Testing for women at risk
Papsmear test and HPV testing for
Urine screen for glucose Type 2 diabetes
CBC TSH for women with
Immunity to Rubella hostory of thyroid disease
HIV screening TORCH panel if exposure
Gonorrhea, Chlamydia, Syphilis
to infection is suspected
screening
Varicella zoster
Hepatitis B screening Urine culture for
Bacterial vaginosis test
asymptomstic bacteriuria
Test for abnormalities Blood tests

First trimester screening Iron level

Chorionic villus sampling Blood glucose level
Cell free fetal DNA Rh factor
Pap smear

Standard prenatal care visits

Monthly 6 months

Every 2 weeks 36 weeks

Every week 37 weeks - delivery

2 hormones that affects
the cervix
-Dilates the cervix
-Released before ovulation: 14th day
-Mucus is watery, clear, stretchy
-Spinnbarkheit: 6-12 cm
Estrogen
-Unsafe period
-13th day of the 28th day cycle
-For 3-5 days
-Ph: 8

-Closes the cervix

-Released on the 16th day
-Mucus is decreased in amount, sticky, cloudy
-Spinnbarkheit: 3 cm
Progesterone -Safe Period
-Ph: 6
-Hormone that protects the baby
-Dec. progesterone (AP) = Inc. oxytocin (PPG)
 What to avoid
Danger Signs during
Vaginal bleeding
pregnancy?
Persistent vomitting

Chills & fever TERATOGENIC DRUGS

Sudden escape of fluid from vagina

Thalidomide Third element (lithium)
Epileptic medications Oral contraceptives
Abdominal pain
Retinoid (vit A) Warfarin (coumadin)
Ace inhibitors, ARBS Alcohol
Chest pain
Sulfonamides & sulfones

PIH
TORCH INFECTIONS
- rapid weight gain
- swelling of the face and fingers TORCH infections are a group of infections that cause
- difficulty opening the eyes in the morning fetal abnormalities. Pregnant women should avoid these
- visual disturbances infections!
- continues headache Toxoplasmosis
Par O Virus-B19 (fifth disease)
Increase and decrease fetal movement Rubella
Cytomegalovirus
Herpes simplex virus
Naegele's Rule → Used for estimating the expected date of
delivery (EDD) based on LMP (last menstrual
period)

Date of Last Menstrual Period – 3 Calendar Months + 7 Days + 1 Year

1st day of last period: September 2, 2015

Minus 3 calendar months: June 2, 2015
Remember: Plus 7 days:
Plus 1 year:
June 9, 2015
June 9, 2016
How many days
are in each month?
Sample
→

FACTS ABOUT NAEGELE'S RULE

30 days hath
September, April, Bases calculation on a woman who has a 28-day cycle (most
June & November. women vary)
All the rest have 31, The typical gestation period is 280 days (40 weeks)
except February alone First-time mothers usually have a slightly longer gestation
(28 days) period
 Signs of labor
Lightening

Increased vaginal discharge (bloody show)

Labor Return of urinary frequency

Moving the fetus, placenta, Cervical ripening

& the membranes out of the
uterus through the birth Rupture of membranes "water breaking"
canal
Persistent backache

Stronger Braxton Hicks contractions

Days preceding labor

- Surge of energy
- Weight loss (1- 3.5 pounds) from a fluid shift

rnursingnotes
 True vs False labor
False labor True labor
Occur regularly
Contractions

- Stronger
Irregular
- Longer
Stops with walking / position change
- Closer together
Felt in the back or the abdomen above the
More intense with walking
umbilicus
Felt in lower back -> radiating to the lower portion of the
Often stops with comfort measures
abdomen
Continue despite the use of comfort measures

May be soft • Progressive change

Cervix

• NO significant change in.... - Softening

- Effacement
- Effacement
- Dilation
- Dilation signaled by the appearance of bloody show
• No bloody show
• In posterior position - Moves to an increasingly anterior position
(baby's head facing mom's front of belly) (baby's head facing mom's back)

• Presenting parts become engaged in the pelvis

• Increased ease of breathing more room to breathe)
Presenting part is usually not
Fetus

• Presenting part presses downward &

engaged in the pelvis
compresses the bladder = urinary frequency
 Mcdonald's Rule
Using tape measure to get fundic height
in cm x 8 / 7

= AOG in weeks

Usually higher

Fundal height matches the number of

weeks between the 20th and 36th

Mechanisms of labor
Engagement
Decent Extention
Flexion External
Internal Rotation
Rotation Expulsion
Assessment of uterine contractions
• Lasts 45 - 80 seconds
Beginning of the contraction to • Should not exceed 90 seconds
Duration the END of that same contraction Only measured through external
monitoring

• 2 - 5 contractions every 20 minutes

Number of contractions from the
Frequency BEGINNING of one contraction to the
• Should not be more FREQUENT
then every 2 minutes
BEGINNING of the next
Only measured through external
monitoring

• 25 - 50 mm Hg
• Should not exceed 80 mm HG
Intensity Strength of a contraction at its PEAK Can be palpated
Mild - nose
Moderate - chin
Strong - forehead

TENSION in the uterine muscle • Average: 10 mm HG

Resting tone between contractions (relaxation • Should not exceed 20 mm HG
of the uterus = fetal oxygenation Can be palpated
between contractions) Soft = good
Firm = not resting enough
The four P'S of labor Fetal presentation
Foremost part of the fetus that enters the
Passageway: Pelvic shape pelvic inlet
Passenger: fetus Three main presentations
Powers: contractions Head: Cephalic presentation
Psyche Feet or buttocks: Breech presentation
Shoulder: Shoulder presentation

Fetal lie
Longitudinal lie: Long axis of the fetus is
Fetal attitude
parallel to maternal long axis
Relationship of fetal parts to one another
Oblique lie: Between longitudinal and Flexion (ovoid shape):Most favorable for
transverse lie vaginal delivery
Military (no flexion or extension)
Transverse lie: Long axis of fetus is
Brow or frontum (partial extension)
perpendicular to maternal long axis Face (full extension)
Maternal adaptation to labor
Maternal physiologic adaptation
Increased respiratory rate
Increased demand for oxygen during the first stage of labor
Gastrointestinal and urinary systems are affected
Increased heart rate Laboratory values impact
Increased cardiac output

Fetal adaptation to labor

Increase in intracranial pressure Edema: Swelling
Placental blood flow temporarily interrupted at peak of uterine
contractions Caput succedaneum:
Stresses cardiovascular system; results in slowly decreasing pH
serosanguinous, subcutaneous,
throughout labor
extraperiosteal fluid collection with poorly defined
Passing through the birth canal is beneficial in two ways
margins caused by the pressure of the presenting
Stimulates surfactant production; helps clear respiratory
part of the scalp against the dilating cervix
passageways
(tourniquet effect of the cervix) during delivery.

Cephalohematoma:
Ecchymosis
is a traumatic subperiosteal haematoma that occurs
underneath the skin, in the periosteum of the
infant's skull bone. Cephalohematoma does not
a discoloration of the skin resulting from pose any risk to the brain cells, but it causes
bleeding underneath, typically caused by unnecessary pooling of the blood from damaged
bruising. blood vessels between the skull and inner layers of
the skin.
 Stages of labor
First stage:
Goals, expected outcomes
Begins with the onset of true labor and ends
with full dilation of the cervix at 10 cm. Goal: The woman and fetus remain free from
injury
1. Early labor Goal: The woman’s anxiety is reduced
2. Active labor Goal: The woman’s pain is manageable
3. Transition Goal: The woman and partner have adequate
knowledge of labor process
Latent Phase (Early Labor):
Active labor
Contractions during early labor are typically
five to 10 minutes apart, last 30 to 45
contractions occur every two to five minutes, last 45 to 60 seconds,
seconds, and are of mild intensity. The
and are of moderate to strong intensity. The cervix should dilate
cervix is dilated from 1 to 3 cm, and
progressively from 4 to 8 cm.contractions are regular moderate and
effacement has begun. Possible
strong. Rapid effacement. Fetal
spontaneous rupture of membranes
descent begins.
Assessment
Assessment
Assess FHR and contractions at least once Assess woman’s psychosocial
every hour state
Assess maternal status Assess labor progress
Assess status of fetal membranes Assess fetal status
Assess maternal status
Assess the woman’s psychosocial state
Second stage of labor Expulsion of the Fetus

Assessment

Monitor the blood pressure, pulse, and respirations every 15 to 30 minutes

Assess the contraction pattern every 15 minutes
Assess fetal status
Assess the woman’s report of an uncontrollable urge to push
Check the FHR every 15 minutes for the low-risk woman, every five minutes for woman at risk for labor complications

Third stage of labor Delivery of Placenta

Assessment

Assess the woman’s psychosocial state after she gives birth

Monitor for signs of placental separation

Selected nursing diagnoses

Risk for deficient fluid volume related to blood loss in the intrapartum period
Risk for trauma: Hemorrhage, amniotic fluid embolism, retained placenta, or uterine inversion related to delivery of
the placenta
 Fourth stage of labor Recovery

Assessment

Continue to assess for hemorrhage

Assess the lochia: Color, quantity
Monitor for signs of infection
Monitor for suprapubic distention
Assess comfort level
Assess mother’s psychosocial state during the fourth stage
Assess initial bonding behaviors of the new family

Pushing
Vigorous pushing:

take a deep breath, hold the breath, and push while counting to 10. She is encouraged to complete
three “good” pushes in this manner with each contraction.

Open-glottis pushing:

method of expelling the fetus that is characterized by pushing with contractions using an open glottis
so that air is released during the pushing effort.
Urge-to-push method,
in which the woman bearsdown only when she feels the urge to do so using any technique that
feels right for her
 Pain management during labor
Factors influencing pain General concepts of pain
Physiologic
Psychological Pain threshold
Emotional Level of pain necessary for an individual to
Environmental perceive pain
Sociocultural
Pain tolerance

Ability of an individual to withstand pain, once

recognized

Principles of pain relief during labor

Women are more satisfied when they have control over the pain experience
Caregivers commonly underrate the severity of pain
Women who are prepared for labor usually report a more satisfying experience than do women
who are not prepared
 Opoids
Medications with opium-like properties (also known as narcotic
analgesics); the most frequently administered medications to provide
analgesia during labor. (ex.:Demerol IV, IM)

Advantages Disadvantages

Frequent occurrence of uncomfortable side

Increased ability for a woman to cope effects
with labor
Nausea and vomiting; pruritus;
Medications may be nurse- drowsiness; neonatal depression
administered
Pain not completely eliminated

Possible overdose
Non Pharmacological pain interventions
Continuous labor support
Comfort measures

Relaxation techniques Complications of anesthesia

Patterned breathing Hypotension

Attention focusing/concentration Total spinal blockade (rare)
Movement and positioning Inadvertent injection into the bloodstream
Touch and massage Spinal headache
Water therapy; hypnosis,Intradermal water injections Pruritus
Acupressure and acupuncture Respiratory distress

Fatal complications of anesthesia

Anesthesia
Failed intubation
Local: Used to numb the perineum just before birth, Aspiration
allowing for episiotomy and repair Malignant hyperthermia: is a disease that
causes a fast rise in body temperature and
Regional: Blocks a group of sensory nerves, supplying severe muscle contractions when someone
a particular organ or body area
with the disease gets general anesthesia. It is
passed down through families.
General:Not frequently used in OB due to risks
involved
 Delivery
Getting ready for the newborn Birthing the placenta
If the urinary bladder is full, the birth attendant may request that nursing care focuses on monitoring for placental separation and
you perform a straight cath providing physical and psychological care to the woman.
bed is “broken”—the lower part of the bed is removed to allow
room for the birth attendant to control the delivery. the fundus rises in the abdomen, the uterus takes on a globular
place the woman’s feet on foot pedals or stirrups shape, blood begins to trickle steadily from the vagina, and the
clean the woman’s perineum with an antiseptic solution umbilical cord lengthens as the placenta separates from the
Position the instrument table close to the birthing bed and uncover uterine wall.
it.
Eye shields, gowns, and gloves may be necessary for protection
from contact with bodily fluids.

Recovery
The new mother is at highest risk for hemorrhage during the first two to four
Monitor for signs of infection. The temperature may be
hours of the postpartum period.
elevated slightly, as high as 100.4°F, because of mild
Monitor the woman’s vital signs, and palpate the fundus for position and
dehydration and the stress of delivery.
firmness.
The woman should void within six hours after delivery.
The fundus should be well contracted, at the midline, and approximately one Assess cramping from uterine contractions (referred to as
fingerbreadth below the umbilicus immediately after delivery. “afterbirth pains”) and perineal pain from edema or
Assess the lochia (vaginal discharge after birth) for color and quantity. The episiotomy repair
lochia should be dark red and of a small to moderate amount. If she saturates ibuprofen to be given every six to eight hours
more than one perineal pad in an hour, palpate and massage the fundus, ice pack to the perineum.
 Bleeding complication
Ectopic pregnancy
First trimester
Abortion

Second trimester Hyatidiform mole/molar

pregnancy

Placenta previa
Third trimester
Abruptio placenta

rnursingnotes
 Abortion
Signs & symptoms Management
Threatened Abortion- cervix is still closed Complete bed rest
Vaginal bleeding/spotting Soft diet: Prevent constipation; prevent straining
Painless Sedatives - stress can predispose the abortion of
baby
Inevitable/ Imminent Admission in hospital only for observation to observe
Fetus and clot expelled for further bleeding
Vaginal bleeding may be heavy, pain Cerclage
on abdominal area and radiates to the - McDonald’s- temporary (12-14 weeks)
back - (NSD)
Contractions - Shirodkar-bar- permanent
Cervix dilated - Purse String
- Delivery by CS
D&C
Safe all the tissue that passes out for histopathology
Might scar endometrium possible placenta previa on
the next pregnancy
Help cervix dilate (induction of Labor)
Abortion Loss of pregnancy before fetus is viable (<20 weeks)
Early Abortion- before 16 weeks AOG
Late abortion- after 16 weeks AOG
- More dangerous
- Possible DIC

Types of abortion

Also known as miscarriage; 15- 30% of abortion

Chromosomal abnormality
Infection that damages organs of the baby
Spontaneous abortion Endocrine disturbance
(Hyperthyroid)
Trauma
Incompetent cervix – dilates w/o uterine contraction

Induced Abortion/
Performed to save the mother
Therapeutic
Ectopic pregnancy

Habitual Abortion 3 consecutive times or more abortions

 Fetus is expelled
Incomplete Abortion Placenta retained
Management- D&C, suction curettage

All products of conception expelled

Complete Abortion
Mgt: methergine, antibiotic (pennicillins), pain meds (mefenamic)

Threatened Abortion Painless spotting with not effect on fetus

2 weeks rest: Complete bed rest; soft diet given sedatives to prevent stimulus for
contractions; sex resume after 2 weeks

Fetus dies in utero and is retained

No caesarean section
Missed Abortion Drugs to contract the uterus
Laminaria – dried seaweed that is sterilized, absorb the fluids, expand and
painlessly expand, then given misoprostol (Cytotec) intravaginally and Oxytocin
(Pitocin) per IV
D&C to remove the placenta
 Management Home Management
Laminaria- seaweed introduced into the cervix; Restriction at home for 2 weeks
will swell if absorbed water -- cervical dilation Can have sex after 2 weeks
Can go back to work after 2 weeks
Misoprostol (Cytotec)- prostaglandin that
increases blood supply to the cervix (more 50% of threatened abortions lose their babies
dilatable) -- softening of the cervix Causes
Genetic defect in the baby
Oxytocin (Pitocin/Syntocinon) contraction of
Endocrine factors
uterus
Hyperthyroidism
Dead baby can be expelled
DM (rare)
Placenta removed through D&C
Possible DIC to mother Infection
Systemic disorders
Psychological factors
Medical Therapeutic for Spontaneous Abortion - Medications can be terratogenic
Incompetent cervix
1. Ultrasound
2. Bed rest Can be managed surgically
3. Intravenous fluids Dilates without uterine contraction
4. Possible blood transfusions Frequent dilation- D and C
5. D&C Habitual Abortion
6. RhoGAM given within 72 hours post-delivery, post
amniocentesis and after D&C Complication: Missed Abortion - DIC
Classical CS incision - forever CS
 Ectopic Pregnancy Pregnancy outside the uterus

Manifestations

Bluish discoloration in the

Cullen’s Sign umbilicus – hematoma
because of the bleeding
underneath the peritoneum

Fallopian Cul-de-sac mass

Normally it is hollow
If in isthmus - more bloody (closer to uterus); can be
expelled vaginally 70% tubal
Referred pain
If in ampulla- chronic bleeding (more dangerous)
Shoulder pain Compression of the
Acute – on the isthmus; bleeding form rupture may go
phrenic nerve
to the uterus and manifest outside
Side of implantation
Chronic – on the ampulla; bleeding form rupture goes
back and goes to the cul- de- sac (Cullen’s Sign)
Unilateral, lower not ruptured), sharp
- may compress phrenic nerve; shoulder pain upon respiration; quadrant, on and of
one- sided pain
same side with ruptured colicky pain
(rupture)
 Ovarian Ectopic Rhythmic contractions of the fallopian tube pushes the zygote backward to the ovary

Hypermotility of the zygote then implants itself in the cervix - IUD

Cervical Ectopic Cervix has low blood supply cannot fully nourish the baby
Remove the portion of with the fetus then cerclage is done

Abdominal Laparotomy done to get the baby

Placenta is retained in the attached organ

Medical Treatment for Ectopic Pregnancy Risk Factors: Abnormal thickening of the endometrium
due to hormonal imbalance
Administration of methotrexate IM History of PID
(prevent multiplication)
Estrogen
IUD
Surgical treatment – salpingostomy
Management- androgen (male hormones)
via laparoscope Abnormal tube

Can damage the liver

Endometriosis

Given Depo-Provera

40% of young women are at risk

Abruptio Placenta
Sudden complete/partial separation of a normally implanted
placenta after 20th weeks AOG
OBSTETRIC EMERGENCY

Risk factors Assessment

Sharp like abdominal pain
HPN
Board-like abdominal pain (Couvelaire)
History of placental
Changes in the shape of the uterus
abruption Usually w/ vaginal bleeding - Dark red (not fresh blood)
Multipara Middle of pad- scant
Substance Abuse Fully saturated pad- 30 ml of blood
1/3 pad- 10 ml
S/Sx of shock fetal distress (bradycardia)
Assess abnormal coagulation
99% of babies die

Types
Partially or Completely Separate
Management
Concealed Position on modified trendelenburg
- Separation at the middle - Blood from the extremity will go to more important organs
- More dangerous Keep patient warm
- Blood will not b able to come out sink - Cover her with several layers of sheets
into muscles -- board-like rigidity (internal Monitor CVP
bleeding) - Right pressure of the heart
- Shultz, Couveaire - If increased- slow down the IVF to KVO
Apparent – separation from marginal Fluid volume deficit
area where blood mixes with amniotic - Priority nursing intervention
fluid - Then altered perfusion
Abruptio placenta Placenta Previa
Sudden separation Low implantation
With or without bleeding Bright red
Painful Painless
Couvelaire uterus Soft uterus
Hyatidiform mole/molar pregnancy
Gestational trophoblastic disease - proliferation of the trophoblasts (bigger
than age of gestation); no embryoblast
Trophoblast > formation of amniotic fluid > elevated HCG
Benign - precursor of choriocarcinoma (malignancy)
Inc. FH, No FHT, hyperemesis, red or brownish vaginal bleeding which may
also include vesicles (diagnostic!)
Degeneration of the chorion into the fluid-filled grape like chorionic
epithelioma
NO KNOWN CAUSE

Risk factors Manifestations

Extremes of age - very young Increase in fundic height
and very old Increased hCG
Genetic - Asian women Hyperemesis
Low protein diet No fetal heart tones
Use of Clomid – stimulate Red, brown vaginal mdischarge
excretion of egg cell that is Ultrasound reveals mass without fetal skeleton
empty (fertility drug) Snowstorm pattern
 Hysterectomy
Management Monitor level of hCG for 1 year after surgery
Teach the patient to delay pregnancy for 1 year
Suction evacuation of the mole hCG monitored after Follow up for choriocarcinoma
Curettage - if she still wants to become pregnant Provide emotional support
Labs drawn – serial hCG monitoring (blood) Methotrexate- drug of choice for choriocarcinoma
CXR – to establish if metastasis is seen Since it is folic acid antagonist, free from folic acid diet
Birth control for minimum of one year since it will neutralize the effect
If mole is cancerous – chemotherapy (methotrexate) Chest x-ray
To determine if there was metastasis to another area
Lungs- most lymphatic organ
Use birth control (Combined birth control)

Placenta Previa
Low lying placenta/ attachment in the lower uterine segment

Risk factors Manifestations:

Uterine abnormalities Painless

No invasive History of uterine surgery bright red bleeding from the placenta
soft uterus

Causes Diagnosis
Unfavorable deciduas
Ultrasound
Multiparity
Twins (dizygotic/fraternal) – different placenta
 Types Management

Low lying - placenta is very near the cervix but does not
cover it No IE in suspected previa treatments
May be NSD, may have minimal bleeding, double set Only through CS (partial and total)
up when bleeding occurs NSD (marginal and low lying)
Double set-up: NSD and CS
Marginal - 1 cm before you touch the placenta

Partial – placenta covers 50% of the cervical ox Complication

Complete/Total - placenta covers the entire cervical O Bleeding because area of

Excessive bright red bleeding with no pain, not in attachment (lower part of uterus)
bleeding does not contract
Directly CS
 Fetal Station
Fetal station

Where the baby's presenting part is located in

the pelvis?

PRESENTING PART?
-Head, foot, butt

Measured in centimeters Engagement

-Find the ischial spine = zero
Fetal station zero = baby is "engaged"
-Above the ischial spine (-)
Presenting parts have entered down into the pelvis inlet &
-Below the ischial spine (+)
is at the ischial spine line (0)
+4 / +5 = birth is about to happen
When does this happen?
-First time moms: 38 weeks
-Already had babies: can happen when labor starts
 Emergency Implementation for Bleeding in Pregnancy

Alert the health team to provide maximum coordination of care

Place woman on modified trendelenberg or left side lying (minimal bleeding)
Begin IV with a gauge 18-19 needle in anticipation of blood infusion
NPO in anticipation of surgery
Administer oxygen PRN at 2-4 L/min to provide adequate fetal oxygenation despite
decreasing circulating volume of blood
Assess blood loss (weigh pads), FHR, VS, I and O, Uterine contractions
Omit vaginal or rectal exam
Order type and cross match 2 “U” whole blood to restore maternal circulating blood
Assist with placement of CVP (assess pressure of blood that goes to the heart)
Pulmonary wedge pressure (pressure that leaves the heart)
- Rise in CVP – put to KVO
- Low in CVP – hasten delivery
Set aside 5 ml of blood in a test tube and observe if it will clot in 5 mins. If it did not clot,
suspect DIC
Maintain a positive attitude towards fetal outcome to maintain bonding
 Pregnancy induced hypertension/
Toxemia
Risk
Seen on 20-24 weeks
Accompanying symptoms are hypertension, edema, and Primipara - highest
proteinuria Young and old
Eclampsia - convulsions (+) HPN in hypertension
BP will be normal after 6 weeks Low socioeconomic group
Noted in the second trimester Low protein diet

Manifestation
Edema – generalized anasarca
Proteinuria
HTN
Has convulsion
Corrected within 6 weeks after delivery
Cause is unknown; due to hormonal change
 Stage 1 (Pre-eclampisia)
Mild Severe

BP 140/90 BP 160/110 or above

Edema of finger and ace Anasarca – third spacing edema
Proteinuria +1 (<2g/day) – less than Proteinuria + 3 or 4 (more than 2g/day)
2 g of protein per liter Epigastric pain (aura)
Visual disturbances – inc ICP
Altered sensory and perceptual function
Management
Altered perfusion
Bed rest on left side Altered sensory and perceptual function (priority) –
Diet alterations: High protein, low fat, low promote quiet, non stimulating environment
salt Room of patient is 20 feet away from the nurses
Normal CHO to avoid use of protein for station
energy Limit visitors to visiting time to promote rest and sleep
Monitor fetal status – times two of normal No TV and close eye work
visit High protein, low salt, low fat
Twice a week on the last month Bed rest anticonvulsant medications
Fluid and electrolyte replacement
Corticosteroids are given: bethamethasone
Anti HTN meds
 Stage 1 (Pre-eclampisia)
Magnesium Sulfate (TL: 4-8 mg/dl) Corticosteroids

Anticonvulsant Stimulates Surfactant production for the baby

IM bolus, Buttocks, Deep IM, Z- track Given for possible preterm birth
Check DTR,RR, BP, FHR, Injection within 2 days before birth
I&O(released through the kidneys; monitor I&O; Betamethasone – better but
maintain expensive ( 2 injections)
30 ml before giving next dose) before giving first Dexamethasone – cheaper (4 doses)
dose Epigastric Pain (aura for seizure)
Prepare calcium gluconate; max of 8 hours - Grand mal
May be replaced by - With loss of consciousness
Hydralazine (vasodilator) - Tonic-clonic
Potassium sparing (non-thiazine) because loss Delivery: CS
of potassium can affect the heart Given epidural if NSD to anesthesize -
12 gms- respiratory distress prevent seizures
>12 gms- circulatory collapse Greatest risk for convulsion
If IV- use soluset - over a period of 20 minutes 1st 24 hours after delivery because of loss of
Stinging to the tissue - lidocaine is added to fluid-- increased BP to compensate for the
decrease pain fluid loss
Magnesium sulfate first before lidocaine
Eclampsia Grand mal (generalized tonic clonic seizure w/ loss of consciousness)

Post-ictal
Stages
Coma/Resuscitation
Oxygen first before suction
Invasion
Reorient the client to prevent anxiety
- When VS is fluctuating, restless
which may cause another seizure
Antianxiety medication (Valium)
Aura (warning) – epigastric pain! (may signal HELLPS
– hemolysis, elevated liver enzymes (DIC), decreased *Status epilipticus – may cause death
platelet)
- Protect the tongue Nursing Care
- Side-lying position (DO THIS FIRST!)
- Tongue depressor is NOT safe, use mouth gag Mild preeclampsia
- Tongue blade (rubber) Bed rest on the left side
Diet alteration
Tonic-clonic / Contraction Monitor for fetal status
20 sec tonus (muscle contraction) before clonus
Severe preeclampsia
(alternate contraction and relaxation) Bed rest
Prevent self-inflicted injuries: Time the duration of Anticonvulsant medication
seizure to know how much time brain lost oxygenation Fluid and electrolyte replacement
Lock jaw Corticosteroids are given: bethamethasone to increase surfactant
production antiHPN meds
Prepare for safe environment; padded side rails
Do not restrain or stop Mgt:
Forceps assisted, analgesia to prevent stimulation
 Gestational Diabetes
Dx:
Human placental lactogen (HPL) – counteract
effect of insulin Not diagnosed in the 1st trimester
Estrogen and progesterone – antagonist of Diagnosed in 2nd trimester- 5th month
insulin OGTT (glucose challenge)
Placental insulinase – enhances degradation of - Ability to use glucose in the body
insulin - Get FBS – baseline; if abnormal, patient is diabetic
Placental insufficiency – Maternal insulin - Intake of 50 gms of oral glucose
utilization - Check blood glucose 1 hour after
- <7.8mmol, 140 mg/dl or less
Effect on baby
- 7.8 mmol of less - normal
- >7.8, 140- abnormal
Macrosomia – wide shoulders,
If abnormal, ingest 100 gms of oral glucose
fractured clavicle
Check blood glucose 3 times for every hour
Organomegaly – heart, liver
- 2 positive- (+) for GDM
Preterm delivery
Hypoglycemia – due to
Management
hyperinsulinism inside the mother
Only INSULIN is given – 2nd trimester
Effect on mother - Later half of pregnancy more insulin requirement
No OHA
More prone to infection; UTI – sugar is increase - Crosses placental barrier, teratogenic
in urine - Further aggravate insulin production in baby
Greater incidence of PIH and eclampsia Insulin
- Last trimester (increased demand)
Inc incidence of hydramnios
- Lab or- will have insulin pump
Distocia – CS management - Postpartum- at risk for hypoglycemia
Atony of uterus after delivery - hemorrhage Postpartum- 6 weeks, diabetes should resolve
 BUBBLE-HE/8 - Point assessment tool
Breast
Lochia
3rd day woman will start to release milk (colostrum)
Engorgement in 2-3 days in multipari; primi in 5 days postpartum bleeding, is a normal discharge of blood
First time – 7 mins max (primi)/ 12 mins max (multi) and mucus from the uterus after childbirth
Marmet’s technique - gently pull the nipple twice if inverted nipple
Football hold - benefits CS -- no pressure in abdomen
Uterus decends 1-2cm fingerbreaths per day (involution) Episiotomy
In 10 days, uterus is not palpable
R – redness
Uterus E- edema
E – ecchymosis
Firm and contracted
D – discharge
Fundus
A – approximation
- After birth, midway between the umbilicus and pubis Needs order form MD, perineal prep, must be 12
- Fundus goes down by 1-2cm (fingerbreadths) a day inches away
- About 1oth day, uterus is not palpable anymore
Major sign of sepsis – low grade fever/chills

Bladder
Homan's sign emotion
First 24 hours urine = 2500-3000ml
May have dehydration; inc temp
Lochia By the second day after giving birth, sloughing of decidual tissue results in a
vaginal discharge termed as lochia. It contains erythrocyctes, WBC,
shredded decidua, epithelial cells, and some bacteria.

Lochia Rubra
3-4 days after birth
bright/dark red
may have small clots
flow similar to heavy menstrual period

Lochia Serosa
4-12 days
pinkish/brown loss
flow moderate to small amount

Lochia Alba
12 days to 3 weeks
yellow/white discharge
gradually reducing/disappearing
 The newborn
Neonatal Resuscitation

Neonatal Resuscitation Program (NRP)

Must be able to initiate resuscitation and assist throughout process
First 6 to 12 hours after birth are a critical transition period for the newborn
Must be alert to early signs of distress: Bluish color of the skin and mucous membranes (cyanosis),Brief stop in breathing
(apnea), Decreased urine output. Nasal flaring. Rapid breathing. Shallow breathing. Shortness of breath and grunting
sounds while breathing.
Must be ready to intervene quickly to prevent complications and poor outcomes

Assessment

Heart and respiratory rates at least every 30 minutes during the first two hours of transition.
Monitor the axillary temperature every 30 minutes until it stabilizes in the expected range between 97.7°F and 99.5°F
Be alert for signs of hypoglycemia.
A full physical assessment including gestational age assessment is completed within the first few hours of life.

Birth
the newborn cries vigorously: Palpate the base of the umbilical cord and count the pulse for six seconds and
multiply x 10
Pulse above 100 bpm and a vigorous cry are reassuring signs
Give constant attention to the airway.
Newborns often have abundant secretions.
A bulb syringe is used to suction the mouth first and then the nose.
Keep the bulb syringe with the newborn, and teach the parents how and when to suction the baby.
Complication

If the newborn doesn't cry immediately: Transport him or her to a preheated radiant warmer for prompt resuscitation
Dry him or her quickly to prevent heat loss
Bag and mask connected to 100% oxygen are used to provide respiratory support
Most newborns do not require resuscitation, and the ones who do generally respond well to a short period of positive
pressure ventilation with a bag and mask.
However, a very small number of infants require chest compressions, intubation, and medications
Give constant attention to the airway
Position newborn on side; bulb syringe is used to suction mouth first, then nose

Thermoregulation
Critical to protecting the newborn from chilling
Cold stress increases amount of oxygen and glucose needed
Can quickly deplete body’s glucose and develop hypoglycemia( < 40 mg/ dl )
Easily develop respiratory distress and metabolic acidosis if exposed to prolonged chilling ( PH < 7.20 )
Dry the newborn while on the mother’s abdomen
Swaddle him snugly, and apply a cap to prevent heat loss
Kangaroo care

Hypoglycemia

Ideal glucose range 40-60 mg/dL

Perform a heel stick Glucose level of less than 50 mg/dL requires confirmation (see hospital protocol)Immediately
initiate treatment ( 20-30 mg/dl start a line, 30-40 mg/dl give sugar bottle)
If the mother is breast-feeding, encourage early and frequent feedings.
If the newborn is to be bottle-fed, initiate early feedings.
Brestfeeding Campaign
Unique Characteristics of Breastmilk

B – best for baby

R – reduced allergic reaction
E – economical
A – always available
S – safe
T – temperature always right
F – fresh always
E – emotional bonding
E – easily established
D – digestible
I – immunity
N – nutritious
G – GIT disorder decreased
Breast feeding
Nutrition requirements for breastfeeding

Approximately 500 kcal/day above her prepregnant needs

Plenty of fluids
Rest
Newborns features that facilitate breast-feeding Eat a balanced diet
Multivitamin each day
Newborn facial anatomy
Assessing breast-feeding readiness
Designed uniquely for breast-feeding
Flat or inverted nipples
Nose breathers History of breast surgery
Attitudes toward breast-feeding
Rooting and sucking reflex Quality of support for breast-feeding
Present at birth Refer to lactation consultant if special needs exist
The breast and lactation
Education
Unique organ designed to provide newborn nourishment
via lactation Relieving common maternal breast-feeding problems

Sore nipples
Consists of 15 to 20 lobes containing milk-producing
Engorgement
alveoli Makes milk in response to several different stimuli Plugged milk ducts
Physical emptying of breast Mastitis
Hormonal stimulation Breastfeeding amenorrhea
Sensory stimulation Return of woman’s menstrual cycle occurs between six
and 10 weeks post delivery
Physical control of breastfeeding
Ovulation can occur in absence of a menstrual period,
When the breast is emptied, it responds by replenishing the milk supply and she can become pregnant
If emptied incompletely, it will decrease milk supply By end of third day of life at least six wet diapers and
Hormonal control of lactation about three bowel movements per day
Pituitary gland releases prolactin and oxytocin Monitor the newborn’s weight daily during the hospital
Lactogen stay
 What is Breast Milk?
Unique substance that commercial formulas cannot duplicate, especially immunologic
factors
Colostrum
Higher in antibodies; lower in fat; higher in protein
Milk appears approximately three to five days after birth

Breast milk supplies 20 calories per ounce Breastfeeding Positions

Foremilk: the breast milk your baby gets at the beginning of each
feeding when your breasts are full. Foremilk is high in lactose
(milk sugar) and low in fat and calories. It's thin, watery, and it
looks white or bluish.

Hindmilk: the high-fat, high-calorie breast milk that your baby

gets toward the end of a feeding. It's richer, thicker, and creamier
than foremilk, the breast milk that your baby gets when he first Cross cradle
Cradle position Football hold
starts to breastfeed. The color of hindmilk is creamy white. position

When the baby isn't feeding well

Dry mouth
Not enough wet diapers per day
Difficulty rousing the newborn for feeding
Not enough feedings per day
Difficulty with latching on or sucking Laid-back position Side-lying position
 Factors that affect feeding
Culture Sociodemographic

Acceptability of breast-feeding in public

Amount and quality of family and community Breast-feeding rates differ by age, amount of
support for breast-feeding education, and socioeconomic status
When a woman initiates breast-feeding Past experiences of a woman and her
How many times per day a woman breast-feeds support system
Whether or not a woman supplements The feeding experiences and attitudes of the
When a woman stops breast-feeding individuals who compose a woman’s support
–In the United States system strongly influence a woman’s choice
–83% (highest): Asian or Pacific Islander descent of feeding method
–59% (lowest): Non-Hispanic African American Intent to return to work or school
women Plays an important role in a woman’s feeding
–Hispanic or Latino: Higher initiation rates (81%) choice
than white women at 77% Nursing considerations
–Hispanic women are more likely to breastfeed if Provide education
they are of Mexican descent and have not Support the woman
completely acculturated
 Infection control of the neonate

Umbilical cord stump

Use strict aseptic technique when caring
for the cord
Umbilical cord healing

Triple dye, bacitracin ointment, or povidone-iodine used

initially to paint the cord to help prevent the development
of infection.

Prevent opthalmia neonatorum

a severe eye infection contracted in the birth canal
of a woman with gonorrhea or chlamydia.

0.5% erythromycin
 Newborn Nutrition
Principles Feeding types

At birth, the passive intake of nutrition ends and Two main types of nourishment suitable for the healthy
the newborn must actively consume and digest term newborn:
food
Breast milk
Newborn has unique nutritional needs
Commercial formula
Healthy term newborn requires 80 to 100
mL/kg/day of water to maintain fluid balance Two delivery methods:
and growth Breast
100 to 115 kcal/kg/day to meet energy needs Bottle
for growth and development
Feeding method choices:
Breastfeed exclusively
Breastfeeding Breastfeed and supplement with expressed breast
milk in a bottle
Recommended method for feeding newborns
Breastfeed and supplement with formula
Breast milk is nutritionally superior to commercial formulas
Formula-feed exclusively
The American Academy of Pediatrics (AAP) recommends
Exclusive breast-feeding until 6 months of age
Continuation of breast-feeding until at least 12 months of age
Healthy People 2020 goals
Increase proportion of women who breastfeed their babies
 Newborn Nutrition
Maternal advantages Newborn advantages

More rapid uterine involution, less bleeding in the postpartum

Breast milk contains substances that facilitate critical
period
periods of growth and development, particularly in the
Stress levels decrease; may enhance immune function
brain, immune system, and gastrointestinal tract
More sleep at night; weight loss is faster on average
Breast milk provides immunologic properties
Long-term advantages
Lower incidences of otitis media, diarrhea, and lower
Decreased incidence of ovarian and premenopausal breast
respiratory tract infections
cancers
No physiologic disadvantages to either the woman or
Potential osteoporosis protection
the newborn
Additional research needed

Disadvantages

Maternal conditions or situations in which breast-feeding is contraindicated

Illegal drug use

Active untreated tuberculosis Galactosemia
Human immunodeficiency virus (HIV) infection Phenylketonuria
Chemotherapy treatment Other medical conditions
Herpetic lesions on the breast Mother producing insufficient breast milk
Newborn contraindications
APGAR Scoring
Indicator 0 Points 1 Points 2 Points

Apperance Pink body; Blue

Blue; Pale Pink
(Skin color) extremities

Pulse Absent Below 100 bpm Over 100 bpm

Grimace Minimal response to Prompt response to

Floppy
(relflex irritability) stimulation stimulation

Activity
Absent Flex arms and legs Active
(muslce tone)

Respiration Absent Slow and irregular Vigorous cry

 Newborn Assessment
Vital signs General characteristics

Respiratory rate: 30-60 BREATHS / MIN Head 32-39 cm

circumference 14-15 inches
measure above the eyebrows
110-160 BPM
Heart rate: 180 if crying
100 if sleeping Chest 30-36 cm
Take apical pulse for 1 full min. circumference 12-1 inches
measure above the nipple

Temperature: 36.5 - 37.5 C

44-55 cm
Length
17-22 inches
not done routinely
Blood pressure:
Systolic: 60 -80 mmHg
Weight 2,500-4,500g
Diastolic: 40 - 50 mmHg
 Signs of respiratory distress

Retractions Initial goals

Nasal flaring
1st Priority = AIRWAY
Grunting
Suction with bulb syringe / deep
suction
Umbilical cord Newborns are obligatory nose
Should have: breathers
2 Arteries & 1 Vein 2nd Priority = WARMTH
Should be dry, no odor, & no drainage
Dry with a blanket or place
in warmer.
Head

Caput Succedaneum
edema
Circulatory system
crosses the suture lines

Blood flow from umbilical vessels & placenta stop at

Molding
birth
abnormal head shape that results from pressure (normal)
Acrocyanosis
- Blueness of hands and feet (normal during the first
Fontanelles
24 hrs of life)
Bulging: increase ICP or hydrocephalus
Closure of:
Sunken: dehydration
- Ductus arteriosus
- Foramen ovale
Cephalohematoma
- Ductus venosus
birth trauma
- Transient murmurs are normal
does not cross the suture lines
 Cesarean Section Delivery
Indication Increasing concerns regarding malpractice
History of previous cesarean birth or other uterine incision litigation
Labor dystocia (failure to progress in labor)
Nonreassuring fetal status Increased prevalence of multiple gestations
Fetal malpresentation Increased prevalence of maternal obesity
Active herpes, prolapsed cord( emergency) New phenomenon of cesarean by demand (women
ruptured uterus(emergency) asking for planned cesarean without medical
placenta previa indications)
abruptio placenta.

ons for induced l

e rise of c-section ndicati abor
Th s I
Change in perception of risk by physicians and patients
Postdate pregnancy: pregnancy that has gone past the
Increase in the percentage of pregnant
due date
women who are carrying their first child
Premature rupture of membranes (PROM)
Rise in the number of older pregnant women
Chorioamnionitis: infection of the fetal membranes
More labor inductions for nonmedical reasons
Gestational hypertension
Almost universal use of continuous electronic fetal monitoring,
Preeclampsia
which carries with it high false-positive indications of fetal
Severe intrauterine fetal growth restriction
compromise
Maternal medical conditions
Return to the adage “once a cesarean, always a cesarean”
A decrease in VBAC attempts
 Con traindications for
Cesarean Birth
induced labor
Maternal contraindications for induced labor Maternal risks

Major surgery risks and risks of birth itself

Complete placenta previa: placenta covers the cervix
Increases maternal risk of death
History of vertical uterine incision: This mom will
Thrombophlebitis, laceration of uterine artery,
never have a vaginal birth due to risks of uterine
bladder, ureter, bowel
rupture and risk of hernia. this incision carries an
Hemorrhage, infection, pneumonia, etc.
increased risk of dehiscence
❖
Structural abnormalities of the pelvis Invasive
cervical cancer Fetal risks
Medical conditions (e.g., active genital herpes): A
herpes outbreak can cause the baby to go blind and/ Inadvertent delivery of premature fetu (miscalculation
or cause sores of the mouth of dates)
Increases incidence of neonatal respiratory distress
Scalpel cutting through the uterine wall can nick the
Fetal contraindications for induced labor baby.
The fetus can become wedged in
Certain anomalies, such as hydrocephalus
the pelvis after a prolonged second stage with
Certain fetal malpresentations
the woman pushing, which can make for a mdifficult
Fetal compromise
extraction leading to bruising and possibly other
injuries.
National goal to decrease the cesarean delivery
 Labor Readiness
Ripening of the cervix Methods of cervical ripening

- A “Ripe” cervix: Prerequisite for successful

induced labor. Bishop score is most often Mechanical methods
used to determine readiness for labor
Membrane stripping
Five factors evaluated, each factor Inserting a catheter into the cervix and inflating the
scored 0 to 3 balloon holds 30-80cc of fluid
Score ≥8: Associated with successful Laminaria: Cervical dilators “seaweed”
oxytocin-induced labor
Score ≤5: “Unripe” cervix or Pharmacologic methods
unfavorable
Prostaglandin E2 (dinoprostone)
Never schedule an induction without
Cervidil (string)( tampon like)
asking the bishop score.
Prepidil (gel)
Prostaglandin E1 (misoprostol) ( can cause rough labor)
Cytotec

rnursingnotes
Assisted Delivery Vacuum-assisted delivery: RN assisted: Suction cup
connected to fetal head; suction is applied, used to guide
delivery
Episiotomy: Perineal surgical incision to enlarge the
vaginal opening immediately pre birth Can be hazardous to infant, causing
Scalp trauma, stop vacuum after 3 pop offs
Subgaleal and intracranial hemorrhage
Death

Forceps: Instruments with curved, blunted

blades are placed around the head of fetus to
facilitate rapid delivery
Potential complications of operative vaginal delivery
Low, outlet forceps are more
common than mid forceps Neonatal cephalohematoma; retinal, subdural, and subgaleal
Maternal indications: Fatigue; hemorrhage occur more frequently with vacuum extraction than
certain chronic conditions; with forceps
prolonged second stage of labor Facial bruising, facial nerve injury, skull fractures, and seizures:
Nonreassuring fetal strip More common with forceps
monitor for skull fracture, Potential maternal complications
bruising, and hypoxia Extension of episiotomy into anal sphincter
Uterine rupture, perineal pain, lacerations, hematomas, urinary
retention, anemia, and rehospitalization
 Fetal readiness labor indicators

The Fetus should be mature. There are several ways to Potential complications of oxytocin
assess maturity: induction iv pitocin

≥38 weeks’ gestation

Potential risk for C-section doubles
Fetal lung maturity is major point of consideration
Primigravidas versus multi gravidas
Measuring the lecithin/sphingomyelin (L/S) ratio
Hyperstimulation of uterus leading to one contraction after
via amniocentesis assesses lung maturity. An L/S
another without substantial rest periods in between : can
ratio greater than 2 indicates fetal lung maturity.
blow the uterus. Give 02 10-12L via mask. IV bolus

Induction of labor Water retention may cause

Hyponatremia
Artificial rupture of membranes (AROM) – amniotomy Confusion; convulsions
Causes release of prostaglandins, which enhance labor
Coma
Congestive heart failure; death
Nursing interventions
Observing, documenting amniotic fluid color
Monitoring fetal heart rate Nursing actions
monitoring mother and baby during
Oxytocin induction of labor pharmacologic induction interventions
IV oxytocin (Pitocin) is the most common agent used Assist with pelvic examination in mechanical ripening of
IV line initiated: Infusion pump required cervix or ROM
Baseline fetal heart assessment before induction Document fetal heart rate before and after ROM
Communicate changes as needed
The RN can titrate the PIT until fetal distress
occurs, however they must call the HCP to obtain
an order to decrease the PIT
 Uterine Rupture
What is it?
A serious but rare complication of childbirth. Characterized by tearing of a previous uterine scarn from
cesarean section. The myometrial wall becomes breached causing hemorrhage into the peritoneum.

Causes Types
Pressure of baby moving through the birth
Incomplete: rupture only goes through the endometrium and the
canal against a previous uterine scar.
myometrium only, with the peritoneum still intact.
abnormal presentation
prolonged labor
Complete: rupture goes through the endometrium, myometrium,
multiple gestation
and peritoneum, and then the contractions would immediately stop.
mproper use of oxytocin
traumatic effects of forceps use or traction.
Assessment
Nursing Intervention Dramatic onset of fetal bradycardia or deep variable decelerations
Reports by the woman of a “popping” sensation in her abdomen
The nurse should prepare IV fluid Excessive maternal (possibly referred) pain
replacement. Unrelenting uterine contraction followed by a disorganized uterine pattern
IV oxytocin administration Increased fetal station felt upon vaginal examination
Laparotomy to control the bleeding and repair Vaginal bleeding or increased bloody show
the rupture. Easily palpable fetal parts through the abdominal wall
Cesarean hysterectomy or tubal ligation Signs of maternal shock
 Pregnancy Physiology
Hormones Musculoskeletal Skin
Striae - Stretch marks (abdomen, breasts,
Prolactin: Allows for breast milk production
Estrogen: Growth of fetal organs & maternal Lordosis: center of gravity shifts forward hips, etc)
leading to inward curve of spine Chloasma -Mask of pregnancy
tissues
Low back pain - Brownish hyperpigmentation of the skin
Progesterone & Relaxin: Relaxes smooth
Carpal tunnel syndrome Linea Nigra -“Pregnancy line” dark line that
muscles
Calf cramps develops across your belly during pregnancy
hCG: Produced by placenta, prevents
Montgomery glands / Tubercles -Small
menstruation
Oxytocin: Stimulates contractions at the start of Cardiovascular rough / nodular / pimple-like appearance of
the areola (nipple)
labor
↑ Cardiac output

Respiratory (↑ Heart rate + ↑ stroke volume) Gastrointestinal

Blood pressure stays the same or a slight
↑ Basal metabolic rate (BMR) decrease ↑ in plasma volume Pyrosis ↑ Progesterone = LOS to
↑ O2 needs q Enlarges (May develop systolic murmurs) relax = ↑ heartburn
Respiratory alkalosis (MILD) Constipation & hemorrhoids ↑

Pituitary Progesterone = ↓ gut motility

Renal ↓ FSH/LH due to ↑

Progesterone
Pica (Non-food cravings such as
ice, clay, and laundry starch)
↑ GFR from ↑ plasma volume
Smooth muscle relaxation of the
↑ Prolactin
↑ Oxytocin Thyroid
uterus = ↑ risk of UTI’s!
↑ Urgency, frequency & nocturia Hematological ↑ Thyroxine
•May have moderate enlargement
EDEMA FIBRINOGEN - Non-pregnant levels: 200-400 mg/dL of the thyroid gland (goiter)
ANEMIA - Pregnant levels: up to 600 mg/dL ↑ Metabolism & ↑ appetite
 The hormone that promotes development of endometrium
Progesterone It relaxes smooth muscle of the uterus

The hormone that promotes growth of the uterus and breasts during
Estrogen
pregnancy
Renders connective tissue in the pelvic region more flexible

15-20% by term Pregnancy metabolic rate

Glucose Primary energy source of fetus

Fats Primary energy source of the mother

doubles (2nd tri) Plasma volume during pregnancy

Hemodilution Result of increase plasma volume

Dilution of the blood
 increases Glomerular filtration rate during pregnancy

low birth weight

Consequences of inadequate weight gain during pregnancy
SGA status

SGA Infant born at a lower weight than expected for length of gestation

<5.5 lbs at birth Low birth weight

25-35 lbs. NORMAL weight gain (preg)

28-40 lbs. UNDERWEIGHT weight gain (preg)

15-25 lbs.
OVERWEIGHT weight gain (preg)

11-20 lbs. OBESE weight gain (preg)

 Terms and conditions:
By purchasing, you agree with the following terms and conditions:
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course material and teacher instruction in nursing school

2. These study guides are not intended to be used as medical advice or clinical practice,
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References:
Brown Trial Firm (n.d.). APGAR Score. Retrieved from https://browntrialfirm.com/birth-injury-
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MSD Manual (2021). Leopold maneuver. Retrieved from https://www.msdmanuals.com/en-
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