Obstetric Nursing Study Guide

Maternal-Child
Exam Final Review

Anatomy and Physiology of Pregnancy (pg. 178)
Reproductive System
Uterus
o Shows progressive growth throughout pregnancy
o Braxton hicks contractions: false contractions
Irregular, generally painless contractions
May occur throughout pregnancy
May be felt through the abdominal wall beginning at the fourth month of pregnancy
In later months may be perceived as real contractions
Clinical tip: beginning in early pregnancy, have the woman feel her uterus periodically so that she
becomes familiar with its size and the way it feels
As her pregnancy progresses, she will then be more likely to identify Braxton hicks
contractions and preterm labor if it occurs
Cervix
o The endocervical glands secrete a thick, sticky mucus that accumulates to form the mucus plug
Seals the endocervical canal and prevents the ascent of organisms into the uterus
Expelled at the onset of labor or before when cervical dilation occurs
o Increased cervical vascularity also causes both the softening of the cervix and bluish discoloration
Ovaries
o Stop producing ova during pregnancy but hormones are produced for 6-8 weeks
th
Progesterone is produced until the 7 week of pregnancy maintains the endometrium until the
placenta takes over
Vagina
o Estrogen causes:
Thickening of the vaginal mucosa
Loosening of the connective tissue
By the end of pregnancy, the vagina and perineal body are sufficiently relaxed to permit the
passage of the infant
Increase in the vaginal secretions Leukorrhea
Thick, white, and acidic (pH 3.5-6.0)
Helps prevent bacterial infection but favors the growth of yeast infection
o Pregnant women are more susceptible to candida infection Urinary Tract
Infections
o Blood flow to the vagina is increased vagina may show the same blue-purple color as the cervix
Breasts
o Enlarge and become more nodular as the glands increase in size and number in preparation for lactation
o Superficial veins become more prominent
o Nipples become more erectile
o Areola darken
o Montgomery tubercles, sebaceous glands, enlarge
o Striae reddish stretch marks that slowly turn silver after childbirth
o Colostrum an antibody-rich yellow secretion
May leak from the breast during the last trimester
Gradually converts to mature milk during the first few days after childbirth
High in protein
Respiratory System
Increased maternal oxygen requirements
Occasional dyspnea
Respiratory effort increases
Diaphragm is elevated
o Enlarging of the uterus presses on the diaphragm causing difficulty breathing
Especially in the second trimester
Nasal stuffiness and epistaxis (nosebleeds) may also occur as a result of the following:
o Estrogen-induced edema
o Hypersecretion of mucus
o Vascular congestion of the nasal mucosa

Cardiovascular System
Blood volume progressively increases beginning in the first trimester until about 30-34 weeks
o Plateaus until birth
Cardiac output increases early in pregnancy and peaks at 25-30 weeks gestation
The pulse may increase by 10-15 beats per minute at term
The enlargement of the uterus puts pressure on the pelvic and femoral vessels interfering with returning blood flow
stasis of blood in the lower extremeties
o May lead to the following:
Dependent edema
Varicosity of the veins
Legs
Vulva
Rectum Hemorrhoids
o Advise mother not to sit for long periods of time
Increased blood volume in the lower legs may also make the woman prone to postural hypotension
Supine Hypotensive Syndrome the enlarging uterus presses on the vena cava while lying supine
o Reduces blood flow to the right atrium
o Lowers blood pressure
o Causes the following s/s:
Dizziness
Pallor
Clamminess
o Enlarging uterus may also press on the aorta and its collateral circulation
o Can be corrected by having the woman lie on her left side or by placing a pillow wedge under her right hip
Physiologic anemia of pregnancy because the plasma volume increase is greater than the increase in RBC production,
the hematocrit decreases slightly leading to a pseudo anemia
Increase in RBC = Increased demand for iron
o Even though the GI absorption of iron is moderately increased during pregnancy it is usually necessary to add
supplemental iron to the diet to meet the expanded RBC and fetal needs
o Women are advised to take iron and folic acid during pregnancy to prevent anemia and spina bifida to baby
Leukocyte production increases slightly
3
o 5,600 12,200/mm
3
o 25,000/mm or higher during labor or early postpartum
o both are normal findings
Both fibrin and plasma fibrinogen levels increase during pregnancy
Pregnancy is a hypercoagulable state
o Clotting factors VII, VIII, IX, and X increase
o The previously stated changes coupled with venous stasis in late pregnancy increases the womans risk for
developing a venous thrombosis
Gastrointestinal System
N/V are common in the first trimester and may result from several factors:
o Elevated human chorionic gonadotropin hCG levels
o Relaxation of smooth muscle of the stomach
o Changed carbohydrate metabolism
Morning sickness is common in the first trimester
Hyperemesis Gravidarum
o Persistent and severe nausea and vomiting
o Occurs after 12 weeks
o Can cause the following:
Weight loss
F &E imbalances
Ketonuria
Dehydration
Dehydration may lead to a miscarriage
o Must be hospitalized
IV fluids
OB Final Exam Review

2
Antiemetic meds
Gum tissue may soften and bleed easily
Secretion of saliva may increase
o Ptyalism excessive salivation
Elevated progesterone levels cause smooth muscle relaxation
o Delayed gastric emptying
o Decreased peristalsis
o Prolonged emptying time for the gallbladder
If cholesterol levels are high risk for gallbladder formation
Bloating and constipation
o As a result of the delayed gastric emptying and decreased peristalsis
These s/s are aggravated as the enlarging uterus displaced the stomach upward and the intestines are moved laterally
and posterior
The cardiac sphincter also relaxes
Heartburn pyrosis
o Reflux of gastric contents
Hemorrhoids
o Develop late in pregnancy from constipation and from pressure on the vessels below the level of the uterus
Decrease venous return
Urinary Tract
Urinary frequency due to changing position of the fetus
o First trimester: present
The enlarging uterus is still a pelvic organ and presses on the bladder
o Second trimester: disappears
o Third trimester: present
When the presenting part descends on the pelvis and again presses on the bladder
Reduced bladder capacity
Hyperemia increased blood to an organ
Irritating the bladder
The glomerular filtration rate increases to meet the increased need of the circulatiory system increased cardiac
output
Renal tubular absorption also increases
Glycosuria
o Occurs because of the kidneys inability to reabsorb all the glucose filtered by the glomeruli
o May be normal or may indicate gestational diabetes
Always warrants further testing
Women must increase fluid intake
Skin & Hair
Changes in skin pigmentation commonly is stimulated by increased
o Estrogen
o Progesterone
o Melanocyte stimulating hormone
Linea nigra
o The skin in the middle of the abdomen may develop a pigmented line which usually extends from the pubic
area to the to the umbilicus or higher
Facial Chloasma: a darkening of skin over the forehead and around the eyes
o Mask of pregnancy
o Fades after child is born
Musculoskeletal System
No changes occur in teeth
o Only if oral hygiene is inadequate
o Especially if woman has problems with bleeding gums or N/V
Waddling gait
As the center of gravity gradually changes, the lumbar spine becomes accentuated Lordosis
Pressure of the enlarging uterus on the abdominal muscles on the abdominal muscles may cause the rectus abdominis
muscle to separate diastasis recti
If separation is severe and muscle tone is not regained postpartum, future pregnancies will not have adequate
support
Metabolism
Most metabolic functions increase during pregnancy because of increased demands of the growing fetus and its
support system
Weight gain
o Recommendations
Normal weight before pregnancy: 25-35 lbs
Overweight: 15-25 lbs
Obesity: 11-20 lbs
Underweight: 28-40 lbs
Water metabolism
o Increased water retention
Endocrine System
Human Chorionic Gonadotropin: stimulates progesterone and estrogen production by the corpus luteum to maintain
the pregnancy until the placenta takes over
Human Placental Lactogen:
o An antagonist of insulin
o Increases the amount of circulating free fatty acids for maternal metabolic needs
o Decreases maternal metabolism of glucose to favor fetal growth
Estrogen: stimulates uterine development to provide a suitable environment for the fetus and develops the ductal
system in the breasts for lactation
Progesterone: maintains the endometrium and inhibits spontaneous uterine contractility prevents early
spontaneous abortion
Relaxin: inhibits uterine activity
o Diminishes strength of uterine contractions
o Aids in the softening of the cervix
o Long-term effect of remodeling connective tissue needed to accommodate pregnancy
Prostaglandins
o Maintains reduced placental vascular resistance
o Decreased levels may contribute to to hypertension and preeclampsia
o May also contribute in labor
Prostaglandins E & F
Obstetric/ Prenatal History (pg. 195)
Pregnancy
o First day of last normal menstrual period
Is she sure of the dates or uncertain?
Do her cycles normally occur every 28 days or do her cycles tend to be longer?
o Presence of cramping, bleeding, or spotting since LMP?
o Womans opinion about when the time when conception occurred and when infant is due
o Womans attitude towards pregnancy
Was this pregnancy planned/wanted?
o Results of pregnancy test, if completed
o Any discomforts since LMP?

Past pregnancies
o Number of pregnancies
o Number of abortions
spontaneous or induced
o Number of living children
o History of previous pregnancies
Length of pregnancy
Type of birth
Vaginal
Forceps or vacuum
assisted birth
C-section
Length of labor and birth
Location of birth
Type of anesthesia

Womans perception of the

experience
Neonatal status of the previous children
Apgar scores
Birth weights
General development
Complications
Feeding patterns
Loss of a child
What was the cause of loss?
o Miscarriage
o Elective or medically indicated
abortion
o Stillborn
Complications at any stage of

pregnancy
o
o
o
Breast milk
Formula
Both
Neonatal death
Relinquishment
Death after neonatal period
What coping skills helped?

How did the partner respond?
o Blood type and Rh factor
If negative, was Rh immune globulin received after birth/miscarriage/abortion
o Prenatal education classes and resources
Knowledge about pregnancy, childbirth, and pregnancy
Gynecologic history
Current medical history
o General health
o Previous and present use of alcohol,
o Blood type and Rh factor
caffeine, or tobacco
o Medications and use of herbal medications
o Illicit drug use
o Allergies
Family medical history
Genetic history
o Mother, father, and other family members
Religious, spiritual, and cultural history
Occupational history
Partners history
Personal history
o Age
o Relationship status
o Education
o Race housing
o Economic level
o Acceptance of pregnancy
o Any history of abuse
o
o
o
o
o
History of emotional or mental health

problem
Support system
Personal preference for birth
Plans for care of child after birth
(circumcision for boys)
Feeding preference for baby

G
T
P
A
L
Obstetric History Tool

Gravida: the total number of pregnancies including the current one
Term: the number of infants born at term (38 weeks gestation or more)
Preterm: the number of infants born after 20 weeks gestation and before 38 weeks gestation
Abortion: the number of pregnancies that ended in either therapeutic or spontaneous
abortion (before 20 weeks)
Living: the number of currently living children

Subjective Presumptive Changes (pg. 183)
The subjective changes of pregnancy: what the woman experiences and reports
Because they can be caused by other conditions, they cannot be considered proof of pregnancy
Amenorrhea the absence of menstruation
o The earliest s/s of pregnancy
Missing more than one menstrual period especially for a woman who is ordinarily regular is an especially
useful diagnostic clue
Morning sickness nausea and vomiting early in the day during the first trimester
Excessive fatigue may be noted within a few weeks after the first missed menstrual period and may persist throughout
the first trimester
Urinary frequency is experienced during the first trimester as the enlarging uterus presses on the bladder
Changes in the breasts
o Tenderness and tingling sensations
o Increased pigmentation of the areola and nipple
o Changes in the Montgomery glands
o Veins become more visible and form a bluish pattern beneath the skin
Quickening the mothers perception of fetal movement
o Occurs 18-20 weeks after the last menstrual period in a woman who is pregnant for the first time
As early as 16 weeks for someone who has been pregnant
o A fluttering sensation in the abdomen that increases in intensity and frequency
o

Objective Probable Changes (pg. 184)
An examiner can perceive the objective changes that occur in pregnancy
o These changes can have other causes does NOT confirm pregnancy
Changes in the pelvic organs: caused by increased vascular congestion
o Goodells sign: softening of the cervix
o Chadwicks sign: a bluish, purple, or deep-red discoloration of the mucus membranes of the cervix, vagina, and
vulva
o Hegars sign: a softening of the isthmus of the uterus the area between the cervix and the body of the uterus
o McDonalds sign: an ease in the flexing the body of the uterus against the cervix
o Uterine enlargement: general enlargement
th
Can be noted after the 8 week of pregnancy
The fundus of the uterus is palpable:
Just above the symphysis pubis at 10-12 weeks gestation
At the level of the umbilicus at 20-22 weeks gestation
Enlargement of the abdomen
Braxton hicks contractions: false labor
th
o Most common at the 28 week
Uterine souffl
o May be heard during auscultation over the uterus
Soft blowing sound that occurs at the same time as the maternal pulse
Caused by the increased uterine blood flow and blood pulsating through the placenta
Changes in pigmentation
o Nipples and areolae may darken
o Linea nigra
o Facial chloasma
o Striae
Fetal outline may be identified by palpation after 24 weeks gestation
Ballottement passive fetal movement elicited when the examiner inserts 2 gloved fingers into the vagina and pushes
against the cervix
o This pushes the fetal body up and as at it falls back the examiner feels a rebound

Pregnancy tests
o ELISA Enzyme-Linked Immunosorbent Assay
Can detect hCG 5 days before the first missed period
o FIA Fluoroimmunoassay
Uses an antibody tagged with fluorescent label to detect serum hCG
Takes 2-3 hours to perform
Extremely sensitive
Used to follow hCG concentrations
o Home pregnancy tests
ELISA test
Performed on urine
Detect even low levels of hCG
Follow instructions carefully
If the results are negative, the woman should repeat the test in one week if she hasnt started her period
Diagnostic Positive Changes (pg 184)
These positive signs of pregnancy are completely objective, cannot be confused with pathologic state, and offer conclusive
proof of pregnancy
Fetal heartbeat
o Can be detected with an electronic Doppler device as early as 10-12 weeks of pregnancy
Fetal movement
th
o Actively palpable by a trained examiner after about the 20 week of pregnancy
Visualization of the fetus by ultrasound examination
o Confirms pregnancy
o Gestational sac can be observed by 4-5 weeks gestation 2-3 weeks after conception
o Fetal parts and movement can be seen as early as 8 weeks gestation
o Transvaginal ultrasound has been used to detect vaginal sac as early as 10 days after implantation
Management of Discomfort of Pregnancy Per Trimester (pg 224)
Management of Discomfort: First Trimester
Symptom of Discomfort
Influencing Factors
Self-Care Measures
Nausea & Vomiting
Increased levels of hCG
Avoid odors or causative factors
Changes in carbohydrate
Eat dry crackers or toast before
metabolism
getting up in the morning
Emotional factors
Have small but frequent meals
Fatigue
Avoid greasy or highly seasoned
foods
Take dry meals with fluid in
between meals
Drink carbonated beverages
Urinary Frequency
Pressure of uterus on bladder in Void when urge is felt
both first and third trimesters
Increase fluid intake during the
day
Decrease fluid intake ONLY in the
evening to decrease nocturia
Fatigue
Specific causative factors
Plan time for a nap or rest period
unknown
daily
May be aggravated by nocturia
Go to bed earlier
due to urinary frequency
Seek family support and
assistance with responsibilities so
that more time is available to rest
Breast Tenderness
Increased levels of estrogen and Wear well-fitting, supportive bras
progesterone
Increased Vaginal Discharge
Hyperplasia of vaginal mucosa
Promote cleanliness by daily
and increased production of
bathing
mucus by the endocervical glands Avoid douching, nylon
due to the increase in estrogen
underpants, and pantyhose;
levels
cotton underpants are more
absorbent
Powder can be used to maintain
dryness in not allowed to cake
Nasal Stuffiness and Epistaxis
Elevated estrogen levels
May be unresponsive but, cool air
Nosebleeds
vaporizer may help
Avoid use of nasal sprays and
decongestants
Pytalism
Specific causative factor is
Use astringent mouthwashes
Excessive Salivation
unknown
Chew gum
Suck hard candy

Management of Discomfort: Second & Third Trimester
Symptom of Discomfort
Influencing Factors
Self-Care Measures
Pyrosis Heartburn
Increased production of
Eat small and frequent meals
progesterone, decreasing GI
Use low sodium antacids
motility and increasing relaxation Avoid overeating, fatty and fried
of cardiac sphincter,
foods, lying down after eating,
displacement of stomach by
and sodium bicarbonate
enlarging uterus, thus
regurgitation of acidic gastric
contents into the esophagus
Ankle Edema
Prolonged standing or sitting
Practice frequent dorsiflexion or
feet when prolonged sitting or
Increased levels of sodium due to
standing is necessary
hormonal influences
Elevate legs when sitting or
Circulatory congestion of lower
resting
extremities
Increased capillary permeability Avoid tight clothing
Varicose veins
Varicose Veins
Venous congestion in the lower
Elevate legs frequently
veins that increases with
Wear supportive hose
pregnancy
Avoid crossing legs, standing for
Hereditary factors (weakening of
long periods of time, garters, and
walls of veins, faulty valves)
hosiery with constrictive bands
Increased age and weight gain
Hemorrhoids
Constipation
Avoid constipation
Increased pressure from uterus
Apply ice packs, topical
on the hemorrhoid veins
ointments, anesthetic agents,
warm socks, or sitz baths
Gently reinsert rectum as
necessary
Constipation
Increased level of progesterone
Increase fluid intake, fiber in the
general bowel sluggishness
diet, and exercise
Pressure of enlarging uterus on
Develop regular bowel habits
the intestine
Use stool softeners as prescribed
by physicians
Iron supplements
Diet, lack of exercise, and
decreased fluids
Backache
Increased curvature of
Use proper body mechanics
lumbosacral vertebrae as the
Practice the pelvic tilt exercise
uterus enlarges
Avoid uncomfortable working
Increased levels of hormones
heights, high-heeled shoes, lifting
which causes softening of the
or heavy loads, and fatigue
cartilage in body joints
Fatigue
Poor body mechanics
Leg Cramps
Imbalanced calcium/phosphorus Practice dorsiflexion of feet to
stretch affected muscle
Increased pressure of the uterus
on the nerves
Evaluate diet
Fatigue
Apply heat to affected muscles
Poor circulation to the
Rise slowly from rested position
extremities

Pointing the toes
Faintness
Postural hypotension
Avoid prolonged standing in
warm or stuffy environments
Sudden change in position
causing venous pooling in
Evaluate hemoglobin and
dependent veins
hematocrit
Standing for long periods of time

in warm areas
Anemia
Decreased GI motility leading to
delayed emptying time
Pressure of growing uterus on
large intestine
Air swallowing
Compression of median nerve in
carpal tunnel of wrist
Aggravated by repetitive hand
movements
Flatulence
Carpal Tunnel Syndrome
Avoid gas forming foods

Chew food thoroughly
Get regular daily exercise
Maintain normal bowel habits

Avoid aggravated hand
movements
Use splint as prescribed
Elevate affected arm
Danger Signs During Pregnancy (pg. 211)

Symptom
Gush of Fluid from Vagina
Danger Signs in Pregnancy

Potential Problem
Preterm labor, preterm rupture of membranes,
miscarriage
Other Possible Causes

Leaky bladder, watery mucous
No Fetal Movement
Fetal distress, Fetal Demise, Maternal

medications, Obesity
Slowed movements, anterior placenta
Pelvic or Abdominal Pain
Miscarriage, ectopic pregnancy, abruption
Cyst, uterine growth, ligament pain
Persistent Back Pain
Miscarriage, preterm labor
Kidney/bladder infection, cyst, normal

pregnancy pain
Regular Contractions prior to 37

Weeks
Preterm labor
Gastric upset
Severe Headaches, Blurry Vision
Gestational Hypertension, Ecclampsia
Swelling of the Hands/Face
Gestational Hypertension
Swelling
Vaginal Bleeding
Miscarriage, placental abruption, placenta

previa
Hormonal bleeding, Implantation bleeding

Estimated Date of Delivery (pg. 208)
Ngeles Rule
o Subtract 3 months and add 7 days to the first day of the LMP
o Unreliable in irregular periods
Uterine Assessment
o When a woman is examined in the first 10 12 weeks of her pregnancy
and her uterine size is compatible with her menstrual history, uterine size
may be the single most important clinical method for dating her
pregnancy
o McDonalds method: a tape measure is used to measure the distance in
cm from the top of the symphysis pubis to the top of the uterine fundus
Fundal height in cm correlates well with the weeks of gestation
between 22-34 weeks
The woman should have voided within one half hour of the examination and should lie in the same
position each time
A lag in progression of measurements of fundal height from month to month and week to week
may signal intrauterine growth restriction IUGR
A sudden increase in fundal height may indicate twins or hydraminos excessive amount of
amniotic fluid


9
Assessment of Fetal Development (pg. 209)

Fetal Heartbeat
o The ultrasonic Doppler device is the primary tool used for assessing fetal heartbeat
o It can detect fetal heartbeat, on average, at 8-12 weeks gestation
o The normal range for fetal heart tones is 110-160 beats/min
o An ultrasound should be completed if the nurse is unable to auscultate between 10-12
weeks because there may be:
Discrepancy in the EDD
Twins
Missed abortion
Ultrasound (pg 280)
Use of intermittent high frequency waves to create an image of the
fetus.
Indications for use
o Fetal heart activity
o Gestational age
o Fetal growth
o Fetal anatomy
o Fetal genetic disorders and physical anomalies
o Placental position and function
In the first trimester, transabdominal ultrasound can detect:
o A gestational sac as early as 4-5 weeks after the LMP
o Fetal heart activity by 6-7 weeks
o Fetal breathing movements by 10-11 weeks
Crown to rump measurements can be made to assess fetal age from 4 days until about 12 weeks until head can be
visualized clearly
Transabdominal Ultrasound
o The transducer is moved across the womans abdomen
o Often scanned with a full bladder to assesses other structures in relation to the bladder vagina and cervix
o Woman is advised to drink 1-1.5 quarts of water 2 hours before
If bladder is not full she is asked to drink 3-4 cups of water (8 ounces each) and rescanned 30-45 minutes
later
o Transmission gel is spread over the abdomen
o 20-30 minutes for the procedure
o elevate upper body during test
Transvaginal Ultrasound
o A probe is inserted in the vagina

Daily Fetal Movement Count DFMC (pg 278)
Assessment of fetal activity by the mother.
Also called kick counts
Have mother keep journal and record daily kick count
Frequently used in conditions that may affect fetal oxygenation
Count fetal activity two or three times a day for 60 minutes each time.
Fewer than 5 fetal movements within 1 hour warrants further evaluation.
May not be present during sleep cycle.
Maternal Assays Alpha-fetoprotein (AFP)
Maternal serum levels screened for neural tube defects (NTDs)
80% to 85% of open NTDs and abdominal wall defects can be detected early
Recommended for all pregnant women
18-20 weeks gestation

10
Amniocentesis (pg 287)

A procedure used to obtain amniotic fluid for the following reasons:
o Genetic testing early in pregnancy between 15-16 weeks
gestation
o Fetal abnormalities
rd
o Determine fetal lung maturity in the 3 trimester
Insertion of a needle transabdominally into the uterus to obtain amniotic.
Indications for use:
o Genetic concerns
o Congenital anomalies- Neural Tube Defect
o Fetal maturity
o Fetal hemolytic disease
Maternal risk factors
o Hemorrhage
o Abruptio placentae
o Feto-maternal hemorrhage
o Damage to intestines or bladder
o Infection
o Amniotic fluid embolism Most dangerous
o Labor
o
Fetal risk
o Death
o Injury from needle
o Hemorrhage
o Miscarriage or preterm labor
o Leakage of amniotic fluid
o Infection (amnionitis)

Percutaneous Umbilical Blood Smpling (PUBS) or Cordocentesis
Direct access to fetal circulation
Insertion of needle directly into a fetal umbilical vessel under ultrasound guidance

Chorionic Villus Sampling CVS (pg 289)
Earlier diagnosis and rapid results
Performed between 10 and 12 weeks of gestation
Removal of small tissue specimen from fetal portion of placenta
o Chorionic villi originate in zygote
o Tissue reflects genetic makeup of fetus

Biophysical Profile BPP
Real-time sonography coupled with external fetal heart rate and uterine contraction monitoring.
Assessment of 5 biophysical profile to assess fetus risks.
o breathing movements
o body movement
o muscle tone
o amniotic fluid volume
o reactivity of FHR (non stress test)
Each variable is given a score of 0 or 2.
o Total range 0-10.
o A score of 10/10 or 8/10 is considered reassuring.
Useful in women with decreased fetal movements, IUGR, DM, PROM, post term.

Modified Biophysical Profile (MBPP)
Combines the NST with the Amniotic Fluid Index AFI
Advantages
o Decrease time for completion
o Relative ease of completion
11
The AFI measures the sum of the deepest amniotic fluid pocket in each of the four quadrants of the uterus
AFI indicative of long term function of the placenta
AFI greater than 5 cm represents adequate volume of amniotic fluid
MBPP is abnormal if the AFI is less than 5 cm, regardless of the reactivity of the non-stress test

Non-Stress Test
Typically initiated after 26-28 weeks, is usually done to assess FHR reactivity.
Usually done for post-term or high-risk pregnancies
A health provider monitors the fetus heart rate in response to its movement to
make sure the baby is appropriately responding to stimulus

Contraction Stress Test
Is performed at the doctors discretion, usually only if the Non-stress Test or a
biophysical profile reveals abnormal results
Determines the effect of contractions on the babys heart rate by stimulating the
uterus with pitocin, a synthetic version of a hormone secreted during childbirth
Pitocin causes mild contractions, during which the fetus heart rate is monitored
Usually given during the third trimester.
Can induce premature labor
Test results of the CST may be:
o Negative (normal) 3 contractions in a 10-minute period.
No slowing (or late decelerations) of the fetal heart rate in response to contractions.
o Positive - Late decelerations of the fetal heart rate in response to contractions.
This may indicate a problem that requires further testing or delivery.
o Equivocal - The fetal heart rate response to contractions may be hard to interpret or occurred too infrequently.
These tests are usually repeated the next day.

Bleeding Disorders During Pregnancy (pg 325)
Abortion
o Major cause of vaginal bleeding during the first and second trimester
Causes:
o Chromosomal abnormalities
o Maternal infections
o Placental abnormalities
o Faulty implantation
o Teratogenic drugs
o Weakened cervix
Bleeding During 1st and 2nd Trimester
o Abortion is the expulsion of the fetus prior to viability, which is 20 weeks gestation
o Abortions are either:
Spontaneous or miscarriage (occurring naturally)
Induced ( occurring as a result of medical or surgical intervention)
Medical management
o Bed rest
o Sometimes hospitalization
o IV therapy/blood transfusions
o Dilatation and curettage (D&C)
o RhoGAM administered within 72 hours if woman RH negative and not sensitized
Nursing Assessment
o Assess vital signs
o Amount and appearance of bleeding
12
o Determine FHR with Doppler if pregnancy is 10-12 weeks or more

o Assess coping mechanisms
Spontaneous Abortions
o Threatened abortion
Unexplained bleeding
Cramping and backache
Cervix is closed
o Complete abortion
All the products of conception are expelled

Incomplete abortion
Some of the products of conception are retained, most often the placenta
Internal OS dilated
o Missed abortion
Fetus dies, but not expelled
Diagnosed by ultrasound
No bleeding or cramping
Cervix is closed
If the fetus is retained beyond 6 weeks, the breakdown of fetal tissues results in the release of
thromboplastin
DIC may develop
o Habitual abortion
Abortion occurs consecutively in three or more pregnancies
o Septic abortion
Infection present
It may occur with prolonged, unrecognized rupture of the membranes, pregnancy with an intrauterine
device, or attempts by unqualified individuals to end the pregnancy
Ectopic Pregnancy (pg 327)
o Implantation of the fertilized ovum in the site other than the uterus
o

Causes
o Tubal damage from Pelvic Inflammatory
o Endometriosis
Disease
o Previous ectopic pregnancy
o Previous tubal surgery
o Presence of Intrauterine Device
o Congenital anomalies of the tube
Signs and symptoms
o Sharp unilateral pain and syncope
o Referred shoulder pain
o Lower abdominal pain
o Vaginal bleeding
Medical / surgical therapy
o Single shot of Methotrexate injection to treat unruptured ectopic pregnancy
o Salpingostomy
o salpingectomy
13
Nursing assessment
o Monitor the amount of vaginal bleeding
o Monitor vital signs for developing shock
o Assess pain level
o Assess emotional state
o If surgical intervention, complete the appropriate ongoing assessment postoperatively

Gestational Trophoblastic Disease Hydatidiform Mole (pg328)
Molar pregnancy
Proliferation of the trophoblastic tissue
Abnormal development of the placenta
Results in loss of pregnancy
Classified as two types
o Complete
Develops from anuclear ovum that contains no maternal
materal
o Partial
Two sperms fertilizing an apparently normal ovum
Clinical Manifestations
o Vaginal bleeding
o Anemia
o Uterine enlargement
o No FHR
o Elevated serum hCG
o Gestational hypertension before 24 weeks
Diagnostic & Treatment
o Suction evacuation of the mole and curettage of the uterus
o Possible hysterectomy
o Follow up to monitor hCG levels for about one year
o Increase levels may indicate choriocarinoma
Chemotherapeutic agent-methotrexate
Nursing Care
o Monitor vital signs
o Monitor for signs of hemorrhage
o Assess for abdominal pain
o Assess coping ability
o Have typed and crossmatched blood available for surgery
o Administer oxytocin as ordered to keep uterus contracted to prevent hemorrhage
o Stress importance of follow-up visits

Incompetent Cervix
Premature dilatation of the cervix, usually in the 4th or 5th month of Pregnancy
Associated with repeated second trimester abortions
Possible causes:
o Cervical trauma
o Infection
o Congenital cervical or uterine anomalies
o Multiple gestation
Diagnosis: Positive history of repeated second trimester abortions
Treatment- Surgical procedure
o Shirodkar procedure (cerclage)
o Purse-string suture is placed in the cervix in the first trimester or early
in the second trimester
o Suture cut at term and vaginal delivery permitted

genetic
14
Gestational Diabetes (pg 294)

Carbohydrate intolerance is developed or recognized for the first time during pregnancy
o 4% is women experience GD
Maternal risk
o Previous history
o Obesity
o Previous birth of LGA infant
o Increase maternal age
o Hx. of stillbirth or spontaneous abortion
o HTN
o Family hx. of type 2 diabetes
Fetal Risk
o Macrosomic (LGA)
o IUGRInfants
o Hypoglycemia
o Jaundice
o Polycythemia Complications
o Forceps delivery
o Shoulder dystocia
o Cesarean section
Screening
o 50g random test at 24- 28 weeks
o Results > 140 require further testing
Management
o Diet (Nutritionist)
o Glucose monitoring
o Insulin management
o NST - evaluate fetal well-being
o Education
s/s of hypoglycemia, hyperglycemia
o Obstetrician
o Endocrinologist
o Social worker
Hypertensive Disorder (pg 331)
Classification
o Gestational (or transient )hypertension
o Preeclampsia- eclampsia
o Chronic hypertension
o Chronic hypertension with superimposed preeclampsia or eclampsia
Preeclampsia (pg 331)
Preeclampsia is defined as gestational hypertension with a blood pressure of 140/90 or higher X 2 at least 6 hours apart
accompanied by proteinuria
Sudden onset of edema
The most common hypertensive disorder in pregnancy, occurs in 2% to 7% of nulliparous
o Higher (14%) in twin pregnancies
o Previous history 18%
CNS changes
o Hyperreflexia
o Headache
o Seizures
Maternal Risk
o Renal failure
o Pulmonary embolism
o HELLP syndrome ( Hemolysis, Elevated Liver
o Abruptio placentae
enzymes, and Low Platelet count)
o DIC
o Ruptured liver
o Cause is unknown, but birth is the cure
Known risk factors include:
o Obesity
o 1st pregancy
15
o
o
Age
Family hx, pt. hx
o
o
o
Multifetal pregnancy
Chronic renal disease
DM
FetalNeonatal Risk
o Small for gestational age (SGA)
o Premture
o Hypermagnesemia ( due to administration of magnesium to mother)
o Increased morbidity and mortality
Clinical Manifestations and Diagnosis
o Mild preeclampsia
BP 140/90 mm hg or higher
+1 proteinuria may occur
Liver enzymes may be elevated minimally
Edema may be present
o Severe preeclampsia
BP 160/110mm hg or higher 6 hours apart
Proreinuria 5 g in a 24-hour urine collection
Dipstick urine protein 3+ - 4+ on 2 random samples
Samples must be obtained at least 4 hours apart
Visual or cerebral disturbances
o Eclampsia
Grand-mal convulsions
May occur antepartum, intrapartum, or postpartum
Management
o Home care ( mild preeclampsia)
o Hospital care (mild preeclampsia)
o Client monitor BP
o Bedrest
o Daily weights and test protein in urine daily
o Diet
o NSTs done daily or bi-weekly
o Fetal evaluation
o Instructed to report a worsening in
condition
Severe preeclampsia
o Fluids and electrolyte replacement
o Bedrest
o Corticosteroids
o Diet
o Antihypertensives
o Anticonconvulsants
Eclampsia
o Anticonvulsants: Bolus of
o Digitalis
o Strict I&Os
o Adjunct anticonvulsants: Dilantin
o Diuretics Lasix
Ongoing Nursing Care
o Assess the following:
Vital signs, FHR
Urinary output, urine protein,
urine specific gravity
Pulmonary edema
Deep tendon reflexes
Placental separation
Headache
Visual disturbances
Epigastric pain
Laboratory blood test

LOC
Emotional response and level of
understanding
Magnesium sulfate if drug of
choice to prevent convulsions
should be continued postpartum
Antidote- calcium gluconate
Deep Tendon Reflexes

o 0: absent reflex
o 1+: trace, or seen only with reinforcement
o 2+: normal
16
o
o
o
3+: brisk
4+: nonsustained clonus (i.e., repetitive vibratory movements)
5+: sustained clonus

HEELP Syndrome (pg 332)
Increased risk for:
o Placental abruption
o Hepatic hematoma
o Acute renal failure
o Ruptured liver
o Pulmonary edema
o Fetal/maternal death
Management
o Bp measurements
o Assess for edema (dependant or pitting)
o Assess DTRs CBC, clotting studies, blood chemistry, Type and screen

Rh Alloimmunization (pg 347)
Rh-negative woman carries Rh + fetus
Fetal red blood cells cross into maternal circulation
Antigen-antibody response occurs
1st child not affected
Affects subsequent pregnancies
Rh antibodies enter the fetal circulation
Hemolysis of fetal red blood cells and fetal anemia
Fetal and Neonatal Risk
o Anemia
o Fetal hemolytic anemia
o Jaundice
o Hydrops fetalis (severe fetal edema)
o Hepatosplenomegaly
o Stillbirth
Clinical Presentation (varies with disease severity)
Rh Alloimmunization Prevention
o Screening
o Identify if woman is sensitized
o Administer 300mcg Rh immune globulin
o History
(RhoGAM)
o Identification
o Antibody screen ( indirect Coombs test)
Give RhoGAM in the following cases:
o Pregnant Rh- woman who have no antibody titer
o At 18 weeks gestation
o Baby father is Rh + or unknown
o With in 72 hours after each abortion
o Amniocentesis and placenta previa
o Invasive procedures that may cause bleeding
ABO Incompatibility (pg 349)
Mother has type o blood and the infant has A, B, or AB
Maternal antibodies cross placenta
Hemolysis of fetal RBCs
Unlike Rh incompatibility, the 1st infant is involved
No relationship between the appearance of the disease and repeated sensitization from one pregnancy to the next
No antepartal treatment required
o Hyperbilirubinemia in the infant
o Hyperbilirubinemia treated with phototherapy
After birth:
o Assess newborn carefully
o Assess for Hyperbilirubinemia
Surgery During Pregnancy (pg 340)
Surgery complicates about 1 in every 500 pregnancies
First trimester surgeries increase the incidence of abortion
Increased incidence of fetal mortality
17
And low birth weight infants (less than 2500g)

Increase incidence of preterm labor
Increase incidence of intrauterine growth restrictions
Inability to perform some diagnostic procedures may hinder diagnosing of the disease
Trauma During Pregnancy (pg 340)
Types of trauma
o Blunt
o Gunshot wounds
o Penetrating injuries
o MVA most common
Causes
o Maternal shock
o Placental abruption
o Premature labor or spontaneous abortion
o Traumatic separation of placenta
o Maternal mortality
o Fetal mortality
o Premature birth and ROM
o head trauma or hemorrhage
Battered Pregnant Woman (pg 341)
Incidence 4% to 8%
May result in loss of pregnancy
Preterm labor
Low birth weight infant
Fetal death
Abused women have higher rates of complications
o Anemia
o Low weight gain
o Infection
o Bleeding in the 1st and 2nd trimester
Management
o Early detection
Ask about abuse at several prenatal visits
May not disclose until she becomes familiar with caregivers
Assess old scars
Be alert for signs of bruising
Target areas
o Breast
o Genitalia
o Abdomen
How to Help
o Accepting, nonjudgmental environment
o Listen and allow her to express her concerns
o Provide list with community resources and emergency numbers
o Client has to make decision to seek help
Perinatal Infections affecting the Fetus (pg 342)
Toxoplasma gondii a protozoan parasite
Contracted by ingestion or handling undercooked meat or handling cat feces
Early maternal infection results in congenital toxoplasmosis, leading to spontaneous abortion
Caution about cooking meet thoroughly
Avoid handling cat feces
Use gloves while gardening
Treatment with spiramycin as soon as possible
Education for woman and family
Rubella (pg 342)
Transmission- Across the placenta to fetus
Congenital rubella syndrome (CRS) may result
Treatment: Prevention
Vaccination
1st trimester greatest risk for heart damage, cataracts, mental retardation
2nd trimester- permanent hearing impairment, microcephaly, retardation
Neonate clinical signs- CHD, IUGR, cataracts
Nursing care- focused on prevention
Rubella- Virus
18
STDS (pg 343)

Herpes, Syphilis, Gonorrhea, Chlamydia
o STDs are most common in the reproductive years
o Viral STIs are hard to treat; may have the virus for life
o Client should be asked about risk factors, previous STIs and sexual activity
o Physical examination
o Treatment of bacterial infections should be tailored to situation
o Education regarding safety
Cytomegalovirus (CMV) (pg 343)
Most common cause of congenital neurologic impairment
Acquired during gestation can result in:
Stillbirth or miscarriage
IUGR
Congenital anomalies or other infections
Infants appear asymptomatic at birth but develop sensorineural problems
Risk
o Contact with infected children in daycare centers
Prevention
o Proper handwashing
o No treatment exist, provide supportive counseling
Hepatitis B
Transmitted sexually, IV drug use
Infection can occur during birth
Symptoms
o Fever
o Malaise
o Rash
o Weakness
o Decreased appetite
o Jaundice
o Abdominal pain
o Enlarged liver
o Aching
Prevention/treatment hepatitis B vaccine

Group B Streptococcus GBS (pg 344)
Incidence 1.8 per 1000 live births
Major cause of neonatal morbidity and mortality
Usually asymptomatic
Newborn infections results from vertical transmissions
Risk- preterm labor, previous hx, ROM longer than 18 hours
Prenatal care
o vaginal/rectal swab at 35 37 weeks gestation
Treatment
o Intrapartal antibiotics at least 4 hours before birth, until after birth
Infant monitoring
o Risk of transmission higher in the 1st 24 hours
o Education should be given to monitor infant for up to seven days
HIV (pg 309)
Because of improvements in treatments some HIV infected women are choosing to become pregnant
Most pediatric transmissions are acquired perinatally
Transmission rate without treatment is 25%
HIV testing with consent
Treatment should be started during pregnancy
Minimized vaginal exams
Prolonged ROM increase risk of HIV transmission
Antibiotic therapy should be started at least 4 hours before birth
Cesarean birth is the option to decrease perinatal transmission
Provide emotional, nonjudgmental support
19
Infant -HIV testing and administration of antiviral drugs

Intrapartum Nursing Assessment (pg. 377)
Data collection
Physical assessment
Evaluation of progress of labor
o Contraction assessment: may be assessed by palpation or continuous electronic monitoring
Palpation
Assess contractions for frequency, duration, and intensity by placing one hand on the uterine
fundus
Keep the hand relatively still excessive movement may stimulate contractions or cause
discomfort
Assess at least three successive contractions to gain enough data to determine contraction
pattern
Electronic Monitoring of Contractions
Provides continuous data
External monitor: Tocodynamometer or Toco
Internal monitor: Intrauterine Pressure Catheter IUPC
o Accurate measurement of contraction intensity
Fetal Assessment (pg. 383)
Inspection
Palpation
o Leopolds Maneuvers
A systematic way to evaluate the maternal abdomen
May be difficult on a woman who is obese or on a woman who has excessive amniotic fluid hydraminos
Have the woman empty her bladder and lie on her back with her feet on the bed and her knees bent

o Vaginal Examination and ultrasound
Auscultation of Fetal Heart Rate FHR
o Handheld Doppler ultrasound a device that operates using ultrasound waves that transmit sounds made by the
fetal heart rate
used to auscultate the FHR between, during, and immediately after uterine contractions
o May be useful to perform Leopolds maneuver first
Indicates the probable location of the FHR
Determines the presence of multiple fetuses, fetal lie, and fetal presentation
In cephalic presentation: the FHR may be heard in the lower quadrant of the maternal abdomen
After the FHR is located, it is usually counted for 30 seconds and then multiplied by 2
Check the womans pulse against the fetal sounds
If the heart rates are the same, readjust the Doppler or fetoscope

OB Final Exam Study Guide
20
Fetal Monitoring (pg.384)

Baseline: 110-160 bpm
Tachycardia > 160 bpm
o Marked Tachycardia is 180 beats/min or above
o Causes include the following:
EARLY fetal hypoxia
Amnionitis fetal tachycardia
Maternal hypoxia
may be the first sign of developing
Maternal dehydration
an intrauterine infection
Sympathomimetic beta drugs
Fetal anemia
Maternal- Hyperthyroidism
o Characterized by late decelerations
o If associated with maternal fever antibiotics and antipyretics
Bradycardia < 110 bpm during a 10 minute period or longer
o Causes include the following:
LATE profound fetal hypoxia
Abruptio placentae
Maternal hypotension
Uterine rupture
Prolonged umbilical cord
Vagal stimulation in the second
compression
stage
Fetal arrhythmia
Congenital heart block
Uterine hyperstimulation
Maternal hypothermia

o When bradycardia is accompanied by decreased long-term variability and late decelerations, it is considered a sign
of non-reassuring fetal status
Accelerations (pg. 389)
Transient increases in the FHR normally caused by fetal movement
A sign of fetal well-being and adequate oxygen reserve
NORMAL
15bpm x 15 seconds
Decelerations (pg.389-390)
Periodic decreases in FHR from the normal baseline
Defined by the following characteristics
o Early: Occurs before the onset of the contraction
Uniform in shape
Usually considered benign
NO INTERVENTION REQUIRED
When the fetal head is compressed, cerebral blood flow is decreased central vagal stimulation
early decelerations
o Late: Uteroplacental insufficiency resulting from decreased blood flow oxygen transfer to the fetus
Uniform in shape that tends to reflect uterine contractions
Non-reassuring sign but does not mean immediate birth is necessary
If late decelerations continue, C-section may be indicated
Most common causes:
Maternal hypotension from administration of epidural anesthesia
Uterine hyperstimulation associated with oxytocin infusion
o Variables Occurs if the umbilical cord becomes compressed
Blood flow is reduced from placenta to fetus
21
Managing Decelerations (pg. 391)

Early decelerations:
o No intervention necessary
o The nurse may choose to reposition the patient
Late and variable decelerations:
o Reposition to left lateral
o Administer oxygen via face mask
o Give IV fluids (bolus)
o TURN OFF PITOCIN
o Notify physician as need

Maternal Responses to Labor (pg. 369)
Cardiovascular
o Increased CO when mother lays on her side
o Decreased CO when mother lays supine
o BP rises during contractions
First stage: systolic increases by 35 mmHg and diastolic 25 mmHg
Second stage: further increase during pushing
Respiratory
o O2 demands increase
o Hyperventilation
Gastrointestinal
o Gastric motility and absorption decreases
o Gastric emptying time prolonged
Genitourinary and Renal
o Bladder pushed forward and upward when engagement occurs
o Impaired blood and lymph drainage edema
Immune and other blood values
o WBC counts increase to 25,000 30,00 during labor and early postpartum
o Decreased blood sugar
Pain
o Everyone has pain and copes with it differently
Psychosocial
22

The Family in Childbirth: Needs and Care (pg. 402)
Nursing responsibilities
Cultural beliefs
o First stage
Admission
Pain
Family expectations
modesty
o Second stage
Promoting comfort
Birthing positions
Assisting during birth
Labor support

o Third stage
Initial care of the newborn
Apgar
Umbilical cord
Warmth
Newborn identification
Collection of cord blood
Newborn assessment

o Fourth stage
Bonding
Safety
Non-pharmacologic Management of Discomfort (PowerPoint)
Non-pharmacologic measures are often simple, safe, and inexpensive
Provide sense of control over childbirth and measures best for woman
Methods require practice for best results
Try variety of methods and seek alternatives, including pharmacologic methods, if measure used is not effective
Relaxing and breathing techniques
o Relaxation
o Breathing techniques
o Imagery and visualization
o Movement and positioning
o Music
o Water therapy (hydrotherapy)
o Touch and massage
o Continuous labor support
Types of Pharmacologic Pain Management (PowerPoint)
Analgesic Compound
Opioid anagesics
o Morphine sulfate
o Demerol
o Reversal agent (Narcan)
Narcotic angonist-anatagonist compound
o Stadol
o Nubain
Both medications cause drowsiness!
Epidural Anesthesia Block (PowerPoint)
o Most common method currently used in the United States
o Controversial
o Most effective and flexible method of pain management
o Vaginal births
Administration
o Given in the active phase of the first stage of labor; cervical dilation 4-5 cm
o Fetal head engaged at zero station
o Reassuring FHR pattern
o Make sure to assess FHR before giving anything
Advantages
o Fully awake during labor and birth
o Minimal blood loss
o Promotes good relaxation
o Start IV Fluids
o Airway reflexes remain intact
o Insert Foley Catheter
o Gastric emptying not delayed

23

Technique for Epidural Block: Threading the Catheter

Pudendal Anesthesia (PowerPoint)
Administered during the second stage of labor
Provides pain relief within 2-10 minutes and last for approx. one hour
Provides anesthesia for vaginal births, forceps or vacuum extraction, perineal repair
Monitoring
Assess maternal FHR and maternal BP
Spinal Anesthesia (PowerPoint)
Advantages
o Immediate onset
o Ease of administration
o Smaller dose
o Excellent muscle relaxant
o Does not pass through placenta
Disadvantages
o Cannot sense urge to push which results in an episiotomy, forceps or vacuum extraction
o Bladder and uterine atony
o Spinal headaches
o Assess motor reflex
o SAFETY

Pudendal Block (PowerPoint)

24
Combined Spinal-Epidural Anesthesia

Administered in the subarachnoid space
Has a faster onset of pain relief than epidural anesthesia
Use in the second stage of labor
Usually used for cesarean births
Duramorph protocol
General Anesthesia (PowerPoint)
General anesthesia rarely used for vaginal birth
o May be used for cesarean birth or when needed in emergency childbirth situation
o Used in emergency situations
Patient totally unconscious
Tubed and trached
Before Receiving Medications. (PowerPoint)
The woman should understand:
o Type of medication
o Potential adverse effects
o Route
o Implications for fetus or newborn
o Expected effects
o Safety measures
Nursing Care Management (PowerPoint)
Assessment of mother
o Willingness to receive medication (Informed consent)
o VSS
o Contraindications
Assessment of fetus
o Baseline FHR
o Short and long term variability present
o Exhibits normal movements/accelerations present
o Term pregnancy
Assessment of labor
o Contraction pattern established
o Dilating cervix
o Progressive decent of fetal presenting part
Nursing Care Management (PowerPoint)
Epidural anesthesia
o Monitoring maternal and FHR
o IV access established
o Loading dose (500ml-1000ml) of LR or NS over 15-30 minutes
o Monitor VS according to agency policy
o Monitor O2 sats
o Positioning
o Insertion of foley catheter
o NPO
o Adverse reactions and complications
Spinal anesthesia
o Positioning
o Postdural spinal headache
o Epidural blood patch
General Anesthesia
o Controlling malignant hyperthermia
o Discontinuation
Signs of Approaching Labor (pg. 363)
Lightening the effects that occur when the fetus begins to settle into the pelvic inlet engagement
o With fetal decent, the uterus moves downward, and the fundus no longer presses on the diaphragm
o With increased downward pressure of the presenting part the woman may notice the following:
Leg cramps or pains due to the pressure of the nerves that pass from the obturator foramen in the pelvis
Increased pelvic pressure
25
Increased venous stasis edema in the lower extremities

Increased vaginal secretions resulting from congestion of the vaginal mucus membranes
Braxton-Hicks contractions
Backache
Bloody show pink-tinged cervical secretions
o During pregnancy, cervical secretions accumulate in the cervical canal to form the mucus plug.
o When the mucus plug is expelled, there is a small amount of blood loss from the exposed cervical capillaries
pink-tinged secretions
o A sign that labor will begin within 24-48 hours
Recent intercourse or vaginal examination that includes manipulation of the cervix may also result in
blood-tinged discharge may be confused with bloody show
Spontaneous rupture of membranes
o Occurs when the amniotic sac surrounding the fetus, amniotic fluid, and the placenta rupture or perforate
results in the expulsion of amniotic fluid from the vagina
o 90 % of women give birth within 24 hours
o women who are 34 weeks gestation or more who present with ruptured membranes without contractions are
often started on Oxytocin Pitocin IV infusion decreased the chance of chorioamnionitis
o If engagement has not occurred there is DANGER of the umbilical cord washing out with the fluid PROLAPSED
CORD
o The open pathway into the uterus increases the risk of infection
o The woman is advised to call her certified nurse-midwife or physician and proceed to the hospital or birthing
center
o In some instances, the fluid expelled may be mistaken for episodes of urinary urgency, coughing, or sneezing
The discharge should be checked to determine the source and appropriate actions
Sudden burst of energy
o Some women report a sudden burst of energy approximately 24-48 hours before labor
o Cause is unknown
o Warn prospective mothers not to overexert themselves during this energy burst to avoid being overtired when
labor begins
o Encourage small, frequent, and nutritious meals during this period
o Encourage rest
o Encourage pregnant woman to have her spouse or partner or friend do chores and activities that she feels are
essential to complete before the baby arrives
Other
o Weight loss
1-3 lb from fluid loss and electrolyte shifts produced by changes in estrogen and progesterone levels
o Diarrhea, indigestion, or N/V just before the onset of labor

Comparison of True & False Labor (pg. 364)
Comparison of True & False Labor

True Labor
False Labor
Contractions occur at regular intervals
Contractions are irregular
Interval between contractions gradually shortens
Usually no change
Contractions increase in duration and intensity
Usually no change
Discomfort begins in back and radiates around to
Discomfort is usually in the abdomen
abdomen
Intensity usually increases with walking
Walking has no effect or lessens contractions
Cervical dilation and effacement are progressive
No changes
26

Possible Causes of Labor Onset (pg. 361)
Oxytocin production
o Direct stimulation of uterine contractions
o Indirectly stimulating prostaglandin production by the amnion and decidua
Progesterone withdrawal hypothesis
o With decreased availability of progesterone, estrogen is better able to stimulate contractions
o Progesterone is used to prevent preterm labor and birth
Prostaglandin hypothesis
o Exact purpose unknown
o The effect is clinically demonstrated by the successful induction of labor after vaginal application of prostaglandin
E
Corticotropin-Releasing Hormone CRH
o CRH is known to stimulate the synthesis of prostaglandin F and prostaglandin E by the amnion cells
Estrogen stimulation
Fetal influence

Critical Factors in Labor (pg. 354)
5 Ps of labor
o Passageway
o Passenger
o Powers
o Position
o Psychologic changes

The Birth Passage Passageway (pg. 354)

27
Pelvic Type
Gynecoid
Android
Anthropoid
Platypelloid
Implications of Pelvic Type for Labor and Birth

Pertinent Characteristics
Implications for Birth
Inlet rounded with all inlet
Favorable for vaginal birth
diameters
Midpelvis diameters adequate
with parallel side walls
Outlet adequate
Inlet heart-shaped with short
Not favorable for vaginal birth
posterior sagittal diameter
Decent into pelvis is slow
Midpelvis diameter reduced
Fetal head enters pelvis in
transverse or posterior position,
Outlet capacity reduced
with arrest of labor frequent
Inlet oval in shape with long
Favorable for vaginal birth
anterioposterior diameter

Midpelvis diameters adequate
Outlet adequate
Inlet oval in shape with long
Not favorable for vaginal birth
transverse diameters
Fetal head engages in transverse
position
Midpelvis diameters reduced
Outlet capacity inadequate
Difficult descent through
midpelvis
Frequent delay of progress at
outlet of pelvis

The Fetus Passenger (pg. 355)
Fetal head
o Molding
The cranial bones overlap under pressure of the powers of labor and the demands of unyielding pelvis
The overlapping is called molding
o Sutures
Sutures of the fetal skull are membranous spaces between the cranial bones
Allow for molding of the fetal head
Help clinician to identify the position of the fetal head during vaginal examination
o Fontanelles
Intersections of the sutures
Fetal lie
o The relationship of the cephalocaudal axis spinal column of the fetus to the cephalocaudal axis of the woman
Longitudinal Lie cephalocaudal axis of the fetus is parallel to the womans spine
Transverse Lie cephalocaudal axis of the fetus is at a right angle to womans spine
Fetal Presentation
o Determined by the fetal lie and by the body part that enters the birth canal first
Vertex presentation
Most common
The fetal head is completely flexed onto the chest
The smallest diameter presents to the maternal pelvis
Occiput is the presenting part
Fetal Position
28
Fetal Attitude
o Relation of the fetal parts to one another
o The normal attitude moderate flexion of the head, flexion of the arms onto the chest, flexion of the legs onto
the abdomen
Presenting Part
o The fetal part that enters the birth canal first
Head, leg, breech, brow, chin, shoulder etc.
Relationship Between Fetus and Passage (pg. 358)
Fetal station

Engagement
o Occurs when the largest diameter of the presenting part reaches or passes through the the pelvic inlet and is at the
level of of the ischial spines
o Can be determined by vaginal examination
o Confirms the adequacy of the pelvic inlet
Does not indicate whether the midpelvis and outlet are also adequate

Physiologic Forces of Labor Powers (pg. 359)
Primary and secondary forces work together to achieve birth of the fetus, the fetal membranes, and the placenta
Primary forces
o Uterine muscular contractions cause complete dilatation and effacement of the cervix
Frequency: the time between the beginning of one contraction and the beginning of the next contraction
Duration: measured from the beginning to the completion of that same contraction
Intensity: strength during the peak of the contraction
Secondary forces
o Use of abdominal muscles to push during the second stage of labor
o Pushing adds to the primary force after FULL DILATATION

Intrapartum
Stages of Labor (pg. 364)

29
First Stage of Labor (pg. 364)

Latent Phase
o Starts with the beginning of regular contractions, which are usually mild
o Excitement is high and her partner or other support person is often as elated as she is
o As the cervix begins to dilate it also effaces
o Dilation: 1-3 cm
o Little or no fetal descent
o Spontaneous rupture of membranes: generally occurs at the height of an intense contraction with a gush of fluid
out of the vagina
o Artificial rupture of membranes: CNM or OBGYN rupture the amniotic sac with an amniohook
Procedure is called amniotomy

Active Phase
o Anxiety tends to increase as she senses intensification of contractions and pain
o Some women show decreased ability to cope and a sense of helplessness
o Dilation: 4-7 cm
o Fetal descent is progressive
Transition Phase
o Last part of the first stage of labor
o Significant anxiety
o Contractions have the following characteristics:
Frequency of about every 1 to 2 minutes
Duration of 60-90 seconds
Strong intensity
o Dilation: 8-10 cm
o Rate of fetal descent dramatically increases
o As woman approaches 10 cm she may experience the following:
Increased rectal pressure and uncontrollable desire to bear down
The amount of bloody show may increase
Membranes may rupture if it has not happened already
Fears being torn open or split apart by the force of contractions
Woman may doubt her ability to cope with labor
May be apprehensive, irritable, and withdrawn
Terrified of being alone but doesnt want to be touched
Hyperventilation as the woman has an increased respiratory rate
Generalized discomfort:
Low backache, shaking and cramping in legs, and increased sensitivity to touch
Increased need for nurse or partner support
Restlessness
Difficulty understanding directions
A sense of bewilderment, frustration, and anger towards the contractions
Requests for medications
Hiccupping or N/V
Sweat on the upper lip or brow
Anxious and wants to get this over with
Second Stage of Labor (pg. 365)
Begins with complete cervical dilation and ends with the birth of the infant
Usually completed within 3 hours
30
Descent of the fetus continues until it reaches the perineal floor

Passive Phase: Nursing Tasks
o Assessing the womans perception or urge to push
o Evaluating the maternal-fetal oxygenation status to ensure adequate uteroplacental perfusion is occurring
o Assess fetal status through recommended monitoring protocols
The Second Phase Active Phase
o When the woman is actively pushing with her contactions
o Nursing actions:
Assessing the effectiveness of maternal pushing efforts
Provide encouragement and direction to provide a more adequate pushing effort
Assess fetal response that occurs as maternal pushing is performed including continued fetal assessment
measurements
Crowning: when the fetal head is encircled by the external opening of the vagina introitus which means birth is imminent
Cardinal Movements of Labor (pg. 366)
Descent flexion internal rotation extension restitution external rotation expulsion

Third Stage of Labor (pg. 368)
After infant is born the uterus contracts, decreasing its capacity and the surface area of placental attachment
The placenta begins to detach because of the decreased surface area
Signs of placenta separation:
o A globular-shaped uterus
o Rise of the fundus in the abdomen
o Sudden gush or trickle of blood
o Further protrusion of the umbilical cord out of the vagina
When the s/s of placental separation occur the woman may bear down to aid in placenta delivery
If this fails a CNM or OBGYN can determine when the fundus is firm gentle traction may be applied to the cord while
pressure is exerted on the fundus
o Weight of placenta aids in extraction
31
A placenta is considered to be retained if 30 mins have elapsed from completion of the second stage of labor
If the placenta separates from the inside to the outer margins, it is expelled with the fetal/ shiny side presenting
o Schultz mechanism of delivery Shiny Shultz
If the placenta separates from the outer margins, inward, it rolls up and presents sideways with maternal surface expelled
first
Duncan mechanism Dirty Duncan: placenta is rough
Fourth Stage of Labor (pg. 369)
1-4 hours after birth
Blood loss from birth ranges from 250-500 mL
o Moderate drop in BP
o Increased pulse pressure
o Moderate tachycardia
Uterus remains contracted in the midline of the abdomen
No more N/V
Woman may be thirsty or hungry
Woman may experience a shaking chill
Bladder is often hypotonic due to trauma of labor or anesthetics given that decrease sensation
o Can lead to urinary retention
Dysfunctional Labor
Protraction disorder- delayed cervical dilation and slowed decent of the fetal head
o Usually develops in the latent phase, active phase or second stage of labor
o PD= cervix is not dilating the way it should so the baby is not coming down the way it should (these are things that
bother the 5 ps)
Management
o IV fluids for hypovolemia
o Reassurance
o Mild sedatives
o Induction of labor
Arrest Disorders (pg 480)
Cephalopelvic disproportion (CPD) inability of the fetal head to pass through the maternal pelvis due to size, shape and
position
The head is too big to go through the pelvis due to size, shape, and position
Characterized by the following:
o Prolonged decelerations phase (because the mother is laboring but nothing is happening)
o Secondary arrest of cervical dilation
o Arrest of the decent of the fetal head
o Failure of the decent of the fetal head
Failure to Progress
Several elements must interact successfully for labor to progress normally.
o Powers
Contractions are not strong enough and youll want to augment her)
o Passageway
Perform an episiotomy (surgical incision of the perineum and the posterior vaginal to quickly enlarge the
opening for the baby to pass through) if the babys head is down there.
Vacuum extraction
Point is to get the baby out.
o Passenger
Problems with the Powers
Tachysystolic Labor: Hypertonic Uterine Contractions (pg 466)
Uterine contractions frequent but ineffective
o Not enough cervical dilation
A tachysystolic labor patient refers to more than 5 contractions in 10minutes averaged over a 30 minute window
Common during LATENT phase of labor
Abnormal cervical dilation
Painful due to uterine muscle cell anoxia
Ineffective coping due to stress
32
Prolonged labor
Reduced utero-placental exchange non-reassuring fetal status
o Prolonged pressure on fetal head
o Baby wont get efficient amount of oxygen
Treatment
o IV fluids
o Pain management
o Bedrest and sedation: promote relaxation and reduce pain
o Cesarean birth
Hypotonic Uterine Contractions (pg 468)
Infrequent, failure to dilate cervix
Common during active phase and second stage of labor
Causes: anything that over distends the uterus
o Macrosomic fetus
o Fetal malposition
Babys head can not get out
o Time of analgesic administration
Mother can be sleeping as well as the fetus
o Use of regional anesthesia
Treatment
o Managing the underlying cause if found
If no cause found
o ROM to promote progression of labor
If you rupture her membranes it can speed up the progress
o IV fluids
o Pitocin augmentation as oppose to the induction
o Cesarean birth
Nursing Care
o Assess bladder for distention and empty frequently (a full bladder and a full rectum can delay delivery it can
obstruct labor, pregnant woman are now given stool softeners so this can be avoided)
o Catheterize as needed
o Minimize vaginal exams (ROM can cause infections)
o Assess for signs of infection
o Provide support to decrease anxiety and discomfort

33
Precipitous Labor (PowerPoint)

Labor contractions are so frequent, intense that labor progresses too quickly
Total duration of labor is 3 hours (babys born on the way to the hospital)
Complications uncommon
Only problem is when labor occurs outside the hospital
Precipitous labor contributing factors
o Multiparity
o Large pelvis
o Previous precipitous labor
o Small fetus in a favorable position
Maternal risk of precipitous labor
o Lacerations of the vagina, cervix and perineum
o Post partum hemorrhage
Fetal risk of precipitous labor
o Fetal hypoxia
o Cerebral trauma
o Pneumothorax
Problems with the Passenger
Breech presentations (pg 475)
Frank breech
Complete breech
Footling breech
Implications of breech presentation
o Likely cesarean birth
o Increased perinatal morbidity and mortality rates
o Increased risk of prolapsed cord
o Increased risk of cervical spinal cord injuries due to hyperextension of fetal head during vaginal birth
o ECV
External cephalic version ECV (pg 494)
The fetus is changed from a breech, transverse, or oblique lie to a cephalic presentation by
external manipulation of the maternal abdomen
Criteria
o A reactive non-stress test should be obtained immediately before performing the
version
A reactive NST indicates fetal well-being
o The fetus must be 36 to 37 or more weeks gestation
A version may be accompanied by complications that require immediate birth
by cesarean.
If gestation is less than 37 weeks, a preterm birth would result.
o The fetal breech is not engaged.
Once the presenting part is engaged, it is difficult, if not impossible, to do a
version
Shoulder Presentation Transverse Lie (pg 478)
Shoulder usually presenting part
Increases risk of uterine rupture and perinatal mortality for mother and child
ECV
Cesarean birth if in active labor
Risk of prolapsed cord
Associated with the following:
o Multiparity
o Preterm fetus
o Abnormal uterus
o Excessive amniotic fluid


34
Face Presentation (pg 473)

o Chin usually presenting part
o Contracted pelvis is common cause
o Cesarean birth if fetus is in distress
o Traumatic birth
Deliver via flexion
Facial edema and head molding will subside within a few days

Brow Presentation (pg 471)
Largest diameter of fetal head is presenting part
Contracted pelvis is common cause
Vaginal birth may be impossible
Cesarean birth

Compound Presentation(PowerPoint)
o Presenting part plus extremity
o Correct spontaneously
o Prolapsed cord might be a complication
o Cesarean birth

Persistent Occipito-Posterior Position (PowerPoint)
BACK LABOR! VERY PAINFUL
Position the back of the head is to the back of the mother
Can be born vaginally or with assistance
Most common fetal malposition
Causes
o Poor quality contractions
o Abnormal flexion of head
o Incomplete rotation
o Inadequate maternal pushing efforts
Usually due to regional anesthesia
o Large fetus
o Slow labor
Risk factors:
o 5 min apgar score < 7 (baby is distressed)
o Meconium-stained amniotic fluid
Respiratory distress caused by the baby pooping because of the stress of the delivery
o Traumatic birth
o Lengthy hospital stay

35
Shoulder Dystocia (PowerPoint)

Inability of the fetal shoulder to move through the maternal pelvis following the birth of the head
Some one has to put pressure on the abdomen to move the shoulder out of the pelvic bone (Mcroberts maneuver the
mothers hips are flexed towards the abdomen and pressure is applied)
Risk factors that can lead to shoulder dystocia:
o Gestational Diabetes
o Fetal macrosomia
o Obesity
o Multiparity
o Post-term pregnancy
o Previous hx
Maternal complications
o Vaginal, cervical, perineal lacerations
o Uterine rupture
o Bladder injury
o Postpartum hemorrage
o Hematoma
Potential fetal complications
o Brachial plexus injury
o Asphyxia
o Fractures
Intervention
o McRoberts Maneuver
o SUPRAPUBIC PRESSURE NOT FUNDAL PRESSURE
o FUNDAL PRESSURE SHOULD NEVER BE APPLIED
WILL FURTHER WEDGE THE ANTERIOR SHOULDER UNDER THE SYMPHYSIS PUBIS
Fetal Size: Macrosomia (pg 477)

Excessive fetal size
o More than 4500g or 9.9lbs
Determine by palpation of the fetus in utero or based on ultrasound findings
Usually results from:
o Gestational Diabetes
o Genetics
Dad can be very tall and can lead to a big baby
o Multiparity
o Post-term pregnancy

Fetal Abnormalities (PowerPoint)
o Fetal abnormalities can contribute to dystocia in problems such as:
Hydrocephalus (most common)
Baby has a big head
Neck masses
Large or swollen fetal abdomen
Breech presentations common with hydrocephalus
Can be born attached to the other twin
Preterm Labor
Begins before 37 completed weeks gestation
Accounts for 75% of neonatal deaths
o Not enough equipment to save them
36
Cost associated with prematurity in US hospitals exceeds 2 billion each year

Other complications:
o Cerebral palsy
o Neurodevelopmental delay
o Respiratory complications
Etiology and risk factors:
o Cause unknown
o Common contributing factors
o PPROM
o Multiple pregnancy
o Incompetent cervix
o Maternal disease
Assessment findings:
o Menstrual-like cramps or abdominal pain
o Diarrhea
o Pressure in pelvis or lower back
o Increased vaginal discharge
Treatment/Care:
o Evaluation of contractions
o Bedrest
o IVF and tocolytic medications (magnesium sulfate)
o Antenatal steroid
o Albuterol can be used but mag sulfate is the most commonly used
Post-term Pregnancy and Labor (pg 469)
Extends beyond 42 weeks
o Looks like an old man babys skin starts drying up and getting wrinkly
Concerns of post-term pregnancy:
o Increase in fetal mortality rate after 40 weeks
o Mortality rate doubles by 42 weeks
o Post 40 weeks and GD increases morbidity
o Post 38 weeks the placenta begins to deteriorate
o Meconium staining increases with prolonged pregnancies
o Anxiety
o If the placenta starts aging the baby doesnt get as many nutrients and for that reason the baby is going to be
distressed
Post-term pregnancy may result in an increased possibility of:
o Probable induction of labor
o Forceps or vacuum-assisted or cesarean birth
o Decreased perfusion to the placenta
o Decreased amount of amniotic fluid and possible cord compression
o Meconium aspiration
o Macrosomia
Prolapsed Umbilical Cord (pg 479)
The umbilical cord falls in front of, lies beside, or hangs below the fetal presenting
part
o Related to a long umbilical cord
o Malpresentation
o The baby can die immediately
o If someone pushes their finger in and is able to keep the baby off the cord,
the person has to keep their fingers in there until the c-section
o The cord has 2 arteries and 1 vein
Contributing factors
o Transverse lie and breech presentations
Risk factors
o Preterm labor, fetal abnormalities,
o Polyhydramnious, pROM, placenta previa, pelvic tumors, ECV

37
Prolapsed Umbilical Cord Care

EMERGENCY!!!!!
KEEP PRESSURE OFF CORD UNTIL DELIVERY!!!
Place woman in knee-chest position, trendelenburg, sims
lateral position
Manually elevate the presenting part
Assess FHR
Keep exposed cord moist with warmed NS (do not
reinsert) and assess for pulsation and color
Administer oxygen by mask
IV Fluids
Notify HCP
Ultrasound as needed
Provide emotional support
Document all care
Prepare for emergency cesarean birth
Baby will die immediately
They need to keep the baby off the cord
Cuts off circulation by pressing on the cord

Amniotic Fluid Embolism (PowerPoint)
Amniotic fluid enters the maternal circulation reaching the pulmonary capillaries
o Rare complication with high mortality, 90% die
o Happens during the following events:
Difficult labor
Induced or augmented labor
During or just after the delivery
Predisposing factors
o Mutiparity
o Advanced maternal age
o Macrosomia
o Intrauterine fetal death
o Meconium in the amniotic fluid
Can cause:
o Sudden onset of respiratory distress
o Acute hemorrhage
o Circulatory collapse
o Cor pulmonale
o Hemorrhagic shock
o Coma and maternal death
o Fetal death if birth not immediate
Signs and symptoms
o Cyanosis
o Hypotension
o Dyspnea
o Tachypnea
o Chest pain
o Confusion
o Pulmonary edema
o Postpartum hemorrhage
Diagnostic test
o ABG, CBC, DIC profile
Nursing managment
o Provide supportive care
o Fowlers position
o Administer oxygen
o Blood products as ordered

38
o
o
o
o
o
o
Strict I&Os
Monitor FHR (if not yet delivered)
Prepare for emergency birth
Prepare for grieving process
CPR as needed
Intubation with 100% oxygen if patient is unconscious

Multiple Pregnancy (pg 458)
Increasing rates due to maternal age and use of reproductive assisted technologies
AT RISK FOR PROLAPSED CORD!
Care of the woman with more than one fetus
o Frequent assessments of FHR of each fetus
o Education of mother about signs and symptoms of preterm labor
o Preparation of equipment needed to care for each fetus
o Identification of each fetus
o Record time of birth of each fetus

Cervical Ripening and Labor Inductions (PowerPoint)
Methods for ripening the cervix
o Sexual intercourse
o Prepidil
o Breast stimulation
o Cytotec
o Pharmacologic methods
o Oxytocin
o Prostaglandins
Endogenous
o Cervidil
Exogenous

The higher the total score for all the criteria, the more likely that labor will occur.
The lower the total score, the higher the failure rate.
o Low Bishop scores have been correlated with prolonged labors and a higher incidence of cesarean births
Goal of oxytocin therapy
o To produce uterine contractions with frequency of every 2-3 minutes and lasting 40 to 60 seconds
o Lactated ringers has electrolytes
Increases maternal fetal circulation blood volume
Any other fluid with oxytocin causes water intoxication
s/s of water intoxication:
N/V
Tachycardia
Hypotension
Cardiac arrhythmia
Nursing implications
o Use infusion pump
o Monitor contractions for frequency, duration and intensity
o Assess for signs of maternal hypotension (if present discontinue and contact HCP)
o Assess FHR for nonreassuring pattern
o Intrauterine Pressure Catheter IUPC
With Pitocin
Membranes must be ruptured
2 cm dilated
Baby MUST be in cephalic presentation
Complications with use of oxytocin
39
Hyperstimulation
STOP with hypertonic contractions or non-reassuring fetal status
Can cause uterine rupture
o Hyponatremia
o Confusion
o Convulsions
o CHF
o Hypotension
o Water intoxication
Management
o Assess maternal VS and FHR
o Explain the physiology and process
o Assess uterine contractions and ROM
o Ensure MD orders
o Complete obstetrical hx.
Forceps- Assisted Birth (pg 506)
Forceps are used to rotate and provide traction to the fetal head when a womans expulsive forces are not sufficient
Indications for Use
o Prolonged second stage
o Intrapartum infection
o Failure of the presenting part to rotate fully
o Maternal hx. of heart disease
or descend into the pelvis
o Acute pulmonary edema
o Non-reassuring FHR patterns
o Fatigue
o Compromised maternal sensation
Criteria for Use
o Uterine contractions, ROM, fully dilated
o The fetal head position is known
cervix
o Forceps should never be applied to an
o Maternal bladder empty
unengaged presenting part
o Adequate anesthesia
o If the head is not engaged do not use
o Determination that birth is mechanically
forceps!! The head must be engaged to use
feasible
the forceps!
o The presenting part is vertex, face with
anterior chin or after-coming head in
vaginal breech
Complications
o Can pose risk for mother and newborn
o Fractures to the newborn head, skull,
o Forcible rotation can injure the maternal
o Scalp lacerations or subdural hematoma
uterus, vagina, cervix leading to lacerations
o Women complain of baby having cerebral
and bleeding
palsy (not practiced in US anymore)

Vacuum-Assisted Birth (pg 509)
Exceptions for vacuum extraction
Use in multiporous women with small rim cervix that is easily stretched over the fetal head
Baby will have a cephalohematoma (jewish cap, and goes away gradually)
Should never be used in preterm births
Should never be used in breech or face presentations
Criteria for use is the same as forceps
o
40
Management during vacuum-assisted birth:

o Encourage the woman to continue pushing
o Ongoing FHR monitoring
o Have newborn resuscitation equipment
available
o
o
Notify HCP is complications expected

Provide education and explanation to family

Cesarean Birth
Elective cesarean birth
o Accounts for 20% of all US and Canadian
o Fear of labor pain
births
o Planned due date
o Maternal request
o Electric fetal monitoring
o Increased malpractice suits
Emergency cesarean birth
o Failure to progress
o Placenta previa
o Non-reassuring FHR tracings
o Fetal malpositions
o Breech presentations

A. The classical incision is used in emergency situations or if the fetus is large.
a. No VBAC
B. The low cervical vertical approach is rarely used.
C. The low transverse approach is most commonly used. The scar has a decrease risk for rupture in subsequent pregnancies

Postpartum (PowerPoint)
Postpartum
The postpartum or the puerperium period is the period of time following the delivery of the child during which the
body tissues, especially the reproductive system reverts back to the pre-pregnant state, both anatomically and
physiologically.
Period when the body starts returning to the pre-pregnant state.
o Mom is bleeding
o Losing weight
o Immediately after she looks swollen
o All of this must be reverted for her to return to her prepregnant state
Puerperium
The puerperium or the postpartum period lasts for 6 weeks.
It is divided into three phases:
o Immediate Postpartum: the 24-hour period immediately following delivery.
Period in which you really need to monitor mom;
if her tummy gets soft massage it. If her uterus is to the left side or the right side empty the
bladder. **will be on final exam**
o Early Postpartum or puerperium: up to 7 days.
41
Remote postpartum or puerperium: up to 6 weeks.

Postpartum Physical Adaptations
Reproductive system
Involution of the uterus-rapid reduction in size of the uterus to a nonpregnant state following birth.
Following delivery of the placenta the uterus contracts into a hard mass; the size of a grapefruit
Uterus
o At delivery fundus is at the umbilicus*
o 1-2 hours: midway between umbilicus and symphysis pubis
o 12 hours: 1 cm above or at umbilicus
o After that the height of the uterine fundus decreases (involutes) by
approximately 1 cm per day.
o Uterus is going back down into the pelvis and it usually involutes by 1 cm
per day. Each day it should be going down by one finger.
o Involution is the uterus going back down into the pelvis into its prepregnant state.
o Should remain firm at all times
o Boggy-soft palpate or massage it so it can become firm; if boogy/soft she is at risk for PPH (post partum
hemorrhage)
o Blood and clots formation
o Failure of uterus to contract
Something could be left behind in the uterus to
prevent it from contracting
o If off to the side; suspect full bladder
o Subinvolution is the failure of the uterus to return to a nonpregnant state
Common causes- retained placental fragments and
infection
o After 10 days you should not be able to feel the uterus
anymore, it should be down in the pelvis already
o Just like a full bladder and full rectum obstruct delivery, this
obstructs the ability of the uterus to contract to keep firm.
Lochia
o Uterine debris after birth
o Mom is getting rid of all of the things that are in the uterus
o Three lochia stages:
Rubra- 1-3 days red, bloody, fleshy, musty, stale non-offensive
odor; clots
Serosa- 4-10 days pinkish, watery, odorless
Alba- 11-21 days; yellow to white, possible stale odor
o The minute the baby comes out, mom starts bleeding.
o After two weeks, if a lady comes to see you and she says that
she was lifting her son and she is bleeding is red this is ABNORMAL
because her discharge should be yellow to
white.
o If Lochia is FOUL SMELLING infection or retention of placenta
o Bleeding is measured by how saturated the moms pads are.
Small = less than 4 in
Mod = less than 6 in
Heavy = saturated entire pad in one hour
Cervical changes
o Cervical changes: soft, irregular, edematous
o Bruised-looking with multiple small lacerations
o Closes to 2 -3 cm after few days
o Admits fingertip after one week
st
o Permanent change to os after 1 delivery to slit-like
o Important to check the cervix
42
Once the lady delivers the cervix is slit-like as opposed to the circle that it was before (whether she aborted
the baby or had a regular delivery)
o If you have a c-section the cervix stays the same because nothing would have gone through the cervix.
Vaginal changes
o Edematous
o Multiple small lacerations
o Perineal pain can last for up to 2 weeks
o Painful intercourse due to lowered estrogen which leads to decreased vaginal lubrication and
vasoconstricition for 610 weeks
Good reason why she should wait 6-10 wks to have sex again
o Perineal muscle tightening, also called Kegel exercises
o Vagina is going to have bruises, abrasions d/t trauma
o Make sure that there is no fistulas or openings
Perineal changes
o Edematous and bruising
o If episiotomy present; sore tender, pain subsides in 5-6 days
o Observe for REEDA:
Redness
Edema
Ecchymosis (bruising)
Discharge/Drainage
Approximation/Alignment
o REEDA can be used to assess episiotomy and c-sections (to make sure the wound is aligned, if it is healing,
or if there is any redness, etc.)
o Healing can take up to 2-3 weeks; complete up to 4-6 months
o Perineal discomfort
Recurrence of ovulation & menstruation
o Nonlactating- 6-8 wks
For the mother who is not breast feeding her menstrual period usually comes back in 6-8 wks
o Lactating- delayed, but not reliable form of birth control
o Exclusive breastfeeding leads wider spacing of pregnancy
Because you are not ovulating when you are breastfeeding, you usually dont get pregnant J.
Abdominal
o Loose, flabby
o Striae or stretch marks
o Some people have better skin than others
o Diastisis recti separation of rectus abd muscle, may improve depending on the womans physical
condition, gravidity, exercise
o Separation of the rectus abdominis muscle may occur
Cardiovascular
o Cardiac output returns to pre-pregnant levels within 1 hour
o Maternal hypovolemia occurs immediately following birth
o Cardiac output declines by 30% in the first two weeks and reaches normal by 6-12 weeks
o Diuresis in the first 2-5 days results in a 3lb weight loss
Within the first week she should be down at least 12 lb if she gained 25 lb (7 lb from the baby 3 lb
from the fluid and 3-4 lb from the placenta)
Blood values
o Immediately postpartum you will have Nonpathologic leukocytosis- immediate PP (25,000 30,000/mm)
4,000-11,000 NORMAL
o H&H maybe difficult to interpret in the first two days
Because of the fact that your blood system is trying to return to its normal ranges
o A decrease in 2% points from hematocrit level at the time of admission indicates a blood loss of 500 ml
o Platelets usually fall due to placental separation
o Activation of clotting factors predispose to thrombus formation
o Risk for thromboembolism in the first 6 weeks
o Encourage lady to keep taking her prenatal vitamins after the baby is here
Gastrointestinal
o
43
o
o
o
o
o
Hunger & thirst common

Risk for constipation due to decreased peristalsis that took place during pregnancy, narcotics, dehydration &
decreased mobility
Risk for hemorrhoids due to pressure of pushing
Mom gets hungry and thirsty since we have kept her NPO.
Increase fiber, increase fluid intake to reduce constipation and to prevent straining because of the
hemorrhoids.
Urinary
o Increase bladder capacity and decrease bladder tone leads to decrease sensation and increase risk of
urinary retention and UTI
o Puerperal diuresis causing rapid filling
o Full bladder displaces uterus, usually R side interfering with contractility, which can lead to hemorrhage
o Full bladder displaces the uterus leads to hemorrhage
o Diaphoretic sweating usually occurs at night
o Mom is peeing a lot to get rid of the excess fluid.
Endocrine

o Estrogen and progesterone drop rapidly
o Lactation- nipple stimulation leads to Pitocin release, which leads to the release of prolactin, which leads to
milk production and let-down reflex
o Colostrum- first milk, rich in protein and immunoglobulins
o If the breast is not simulated by the baby, milk production will stop
o Important that the baby gets all of the colostrum
Afterpains
o Intermittent uterine contractions
o Contractions of the uterus to bring the uterus back to the pre-pregnant state
o Common in multiparas than primiparas
o May cause the mother severe discomfort for 2-3 days after birth
o Breastfeeding also increases the frequency and severity of afterpains
o More uncomfortable in multiparas because their uterus is larger and its gonna take more contracting to get
it back to their normal pre-pregnant state
Psychologic Adaptations
Taking-in
o First PP day or 2, mother preoccupied with own needs
Ex: Im really hungry, This has been a horrible experience
o Tells her story
o Passive, independent
o Touches and explores infant
She should touch and explore the baby a little
Taking-hold
nd
rd
o 2 or 3 PP day ready to resume control
o Obsessed with body functions
o Anticipatory guidance most effective
o Rapid mood swings
o Mothering functioning established; sees infant as unique person
Starts to see the baby as someone that needs her mothering and attention
o By this stage she should be paying more attention to the baby
Postpartum blues- TEARS!!!!
o Postpartum depression is a nonpsychotic depressive episode that begins in the postpartum period
o Manifested by tearfulness, anorexia, difficulty sleeping and a feeling of letdown
o Occurs while still in hospital
o Usually resolves within 10-14 days
o If mom worsens and blues do not go away; referral may be urgent (possible post-partum psychosis)
o Postpartum depression prevalence rates are estimated to be 10-15%.
o Etiologies: hormonal changes, genetic predisposition, and sleep loss
o Ensure that mom has some type of support/help
Maternal role attainment
o Takes about 310 months
44
This is the mother getting used to becoming a mother

Anticipatory stage during pregnancy; looks to role model (she finds people that she wants to emulate).
This is the social and psychological adaptation to the maternal role. This includes learning expectations
and can involve fantasizing about the role.
Formal stagebirth of child; influenced by others; tries to please everybody (This is how my mom did it). In
this stage, behaviors are guided by others in the mother's social system or network, and relying on the
advice of others in making decisions.
Informalmother begins making own decisions. The mother develops her own methods of mothering
which are not conveyed by a social system. She finds what works for her and the child.
Personal stage (LETTING GO)final stage; comfortable with her concept of maternal role (she is doing it
her way). In this stage, the mother finds harmony, confidence, and competence in the maternal role. In
some cases, she may find herself ready for or looking forward to another child.
o Teach the mother safety; make sure that when she has adjusted to her personal way she is not putting the baby at
risk. (ex: ensure that the baby doesnt suffocate)
Challenges
o Finding time for self
o Feelings of incompetence
o Fatigue from sleep deprivation
o Loss of freedom and added responsibility
o Challenge caring for active baby
o

Development of Family Attachment
Initial attachment behavior
o Mother explores infant with fingertips, then palms, and then enfolding newborn with whole hands and arms
o Holds infant in en face position, face-to-face position about 20cm, same plane
o Mother uses soft, high-pitched voice
o Bonding starts with breast feeding
o Eye contact with the baby helps to create the bond
o You should be looking at the baby, NOT TEXTING!
o Even if you are bottle feeding, you should keep eye contact with the baby.
Engrossment
o This is the fathers absorption, preoccupation, and interest in infant; stimulated by active participation in the
birth
o Dads gonna examine the baby from head to toe
Hes gonna have my eyes, my nose, etc.
o Share roles (one changes the diapers and the other feeds the baby)
o Attachment is something that happens by spending time with the baby
Siblings and Other
o Family-centered care and rooming-in permits siblings and grandparents to participate in the attachment process
Cultural influences
o Remember that mothers or family expectations may be different from what the nurse expect
o Foods, hygiene practices and family support may vary
o In some cultures the grandmother moves-in and helps to take care of the baby
o If the mother is 20 then the grandmother may be 40. Grandmothers are getting younger and some may not be
able to stay at home all day to take care of a baby.
o Therefore arrangements and cultural patterns are changing
Collaborative Care
Couplet care: nurses care for mother and baby as a unit
Allows mother and significant others time to interact with the infant
LDRP model (Labor, Delivery, Recovery, Post-partum)
o After delivery infants room-in with mothers
o In some hospitals woman remains in the same room throughout all four phases
Assessments during the fourth stage of labor
o Vital signs: every 15 minutes
o Temperature: at least once in first hour
o Generalized shaking and chattering of the teeth
o Uterus: every 15 minutes for fundal height and tone
45
o
o
o
o
o
o
o
o
o
Assess fundus: tone; palpation

One gloved hand above symphysis pubis: prevents any downward displacement; prolapse or inversion
Feel for uterine fundus
Assess position of fundus in relation to umbilicus; measure in fingerbreadths
Gently massage boggy fundus until uterus returns to firm; greatest risk of hemorrhage within first hour
following birth
Lochia: assess every 15 minutes for color, amount, and any clots
Expected finding: moderate lochia rubra with no clots
Excessive lochia: uterine atony; retention of placental fragments; lacerations of the perineum, vagina, or
cervix
Uterine atony

Clots present; fundus found higher than expected
Massage carefully to expel any blood clots
Perineum: every 15 minutes; identify edema or signs of hematoma
Apply ice to the affected area
Immediately after delivery, ICE is put to the perineum. She could get heat after but ICE is first.

Postpartum Nursing Assessment
Physical assessment:
o M-mental status
o A- auscultation
o B- breast
o U- uterus
o B- bladder
o B- bowel
o L- lochia
o E- episiotomy, epidural site
o H- hemorrhoids, homans sign
Recognize alterations and significance
Vital signs: Pulse, blood pressure: first 24 hours postpartum
Breast checking to see if they are engorged or if she is lactating
Uterus checking to see if it is involuting
Bladder make sure that she is voiding and that it is not displacing the uterus
Bowel ensure that she has a bowel action before she leaves the hospital
Lochia assess lochia
Homans sign no longer done because you may dislodge a clot
Vital signs
o Temperature elevations due to normal process should last up to 24 hours
Temperature that goes up immediately after delivery is not a problem
If still high after 24 hours, something is happening
o If elevated consider the time since birth to determine dehydration/infection
o If elevation is associated with symptoms assess hx.
o Blood pressure should remain stable
o Pulse rate slows; no cause for alarm
Auscultation of lungs
o Lung sounds should be clear
o Women who were treated for preeclampsia are at higher risk for pulmonary edema
Breasts
o Assess: symmetry, consistency, lumps
o Engorgement: breasts, nipples, or both hard and distended with congestion and accumulation of milk
o Assess nipples for intactness; note signs of redness, bruising, or cracking
o Periphery of the nipple: bruising
o Cracking: develops following redness
o Suction pressure on nipple
o Incorrectly positioned infants mouth
o Woman not breastfeeding; assess nipples for any discharge, lumps, or hardness
46
If she is not going to breastfeed, do not touch the nipple. Keep a supporting bra on. If you stimulate the nipple,
milk is going to come.
Inspect abdominal incisions, C-section or bilateral tubal ligation for REEDA:
o Redness
o Edema
o Ecchymosis
o Discharge
o Approximation of skin edges
Uterus
o Fundal height and tone; position of fundus in relation to the umbilicus
If palpable above level of umbilicus to the right: result of a full bladder
Encourage woman to void before assessment
Poorly contracted uterus: boggy or very soft in the abdomen
Bladder
o Assess amount, frequency, and any difficulties initiating voiding
Pressure on bladder: perineal trauma, edema
Urinary frequency: diuresis
Palpate bladder: assess for adequate emptying
Bowels
o Auscultate abdomen for bowel sounds
o Audible in all four abdominal quadrants
o Inquire about bowel movement
o Client concern: discomfort or pain
Lochia
o Assess: color, amount, and any clots
o Assess and document: clots, size, and consistency
o Differentiate between true clots and tissue
o Fourth stage of labor: lochia rubra, moderate and without clots
o Color of lochia: rubra to serosa four or five days postpartum
Perineum
o Episiotomy, laceration, or an intact
o Evaluate: redness, edema, ecchymosis,
perineum
discharge
o Midline: client to lie on either side for
o Check: sutures intact
assessment
o No episiotomy or laceration: assess for
o Lift the clients upper buttock
edema and bruising
o Allow for adequate light: visualization
o Cool compresses or ice packs
Calves
o Homans sign- assess clients lower legs: redness, swelling, or warmth are indication of early thrombophlebitis
Psychological and emotional state
o Monitor mother and infant: evidence of attachment behaviors
o Assess mothers emotional state: level of maternal fatigue
o Evaluate womans teaching needs
Postpartum Nursing Education
Caring for the breasts in the nursing mother
o Engorgement: vascular congestion and milk stasis
o Infant not fully emptying mothers breasts
o Encourage feeding every 2 or 3 hours
We usually say on demand because we dont know how much the baby is getting
o Application of warm compresses
o Express small amount of breast milk: to soften breasts, to latch successfully
Nipple tenderness: progress to redness, bruising, or cracking
o Common cause: improper positioning and latch
o Pain or bruising: upper portion of nipple infant pinching nipple with gums
Lift infants head up: baby faces nipple directly
o Candida albicans causes nipple pain: bright red and shiny, sore nipples
Remedies
o
47
Application of small amount of expressed colostrum or breast milk, tea bags, warm water compresses, lanolin
cream, and air drying nipples following feedings
o Warm water compresses
o Caring for the breasts in the non-nursing mother:
o Engorgement; assist with vasoconstriction: suggest wearing a well-fitting bra
Postpartum Nursing Management
Monitoring the fundus
o Intravenous administration: 10 to 20 units of oxytocin added to 1,000 mL of fluid (to help with the contractions of
the uterus)
o Allow woman up to use the bathroom (IF necessary, straight cath)
o Woman cannot void: bladder distended; catheterize
o Stress incontinence postpartum: Kegel exercises
Monitoring lochia
o Excessive lochia: evaluate uterus and bladder
o Assess bladder for distention: primary cause of uterine atony
o Assess odor: foul-smelling indicates endometritis
Caring for the episiotomy
o Perineal care with warm water
o Apply ice to decrease swelling
o Sitz bath
Sitz bath
o Heat application methods: use of sitz bath or tub bath
Increases circulation: aids in comfort, healing, and cleanliness
Educating the client and family
Information to care for themselves and new baby
New mother: support to get enough rest
Information available: books, internet, videos,
Education focuses: needs identified by the client and
hospital classes
family
Hormonal changes: affect womans attention span
Inform woman: available community resources;
and thinking
provide supplementary data in written format
o Teach about WICK
Fatigue and discomfort: compromise learning
abilities
Postpartal Nursing Responsibilities
Assisting lesbian parents: acknowledge partner as support for the mother
o Recognize family unit
o Facilitate inclusion of partners; encourage participation
Relinquishing A Baby
This is if she wants to give up the baby
Encourage mother to express feelings
There are many reasons a mother might choose this
Seeing newborn may assist mother in grieving
option
process
Nursing staff need to honor request
Bleeding Complications
Leading cause of postpartum morbidity and mortality
All maternal death occurs within 24 hours of giving birth
Most frequently from excessive bleeding
Postpartum hemorrhage
o Blood loss > 500ml during or after the third stage of labor
o Can be classified as:
Early within the first 24 hours of birth
Late 24 hours or more after birth
Early postpartum hemorrhage
o Causes:
Uterine atony
Lacerations of the gential tract
Ex: Fistulas (hole)

Hematomas
Uterine inversion
Uterine atony-lack of normal uterine muscle tone
Causes:
o
48
Uterine overdistension
Anything that causes the uterus to stretch too much could be the problem
o Preexisting uterine anomaly
o Poor uterine contractility secondary to high multiparity
o Rapid or prolonged labor
o Pitocin-induced or augmented labor
o Use of muscle-relaxing medications
Hemorrhage and uterine atony
o Assessment:
Excessive vaginal bleeding is the
Headache
earliest sign
If the patient appears that they
Nausea
are going into shock check her
Lightheadedness
bleeding or if person feels weak.
Dizziness
Bleeding Complications Nursing actions:
Assess vital signs frequently
Differentiate whether simple clots
Identify the cause
or placental tissue
Estimate blood loss
Palpate uterus
Pad count and any soaked linen
Lab studies: H/H, clotting profile
Change clients position
o Ongoing assessment and observation for signs of shock:
Hypotension
Extreme thirst
Tachycardia/thready pulse
Apathy, lethargy and confusion
Decrease pulse pressure
Assess her first before you give her
Cold, pale clammy skin
IV fluids because maybe shes not
Cyanosis
bleeding a lot
Oliguria (small amount of urine)
.
o Planning/intervention
Decrease blood loss
Bimanual compression (MD or
Prompt identification of cause
CNM)
Massage fundus
Pharmacologic agents: Pitocin,
Insertion of foley catheter as
Methergine
needed
Large -bore needle
o Surgical intervention
Utero-ovarian, uterine, and hypogastric vessel ligation tubes tied
Angiographic embolization
Hysterectomy removal of uterus
Late postpartum hemorrhage
o Often develops 7-14 days following birth and can occur as late as 1 month after birth
o Associated with infection/retained placental fragments subinvoluted
o Signs and symptoms:
Gush of foul-smelling uterine
Low grade fever
bleeding
Lochia rubra
Other s/s:
Diagnostic test: ultrasound
Uterine tenderness
o Planning/intervention
Physiologic needs
Laboratory studies
Psychological needs
Pharmacologic agents
Surgical: curettage; hysterectomy
If she has to have a d&c or
Broad-spectrum antibiotics
a hysterectomy you have
to offer her support
Antibiotics for the
Focus: safety and well-being
infection
Postpartum Infections (PowerPoint)
Puerperal infections
Temperature of 100.4 (38.0 degrees C) or higher on any two of the first 10 days following birth
In the first 24 hours if the temperature is up, just hydrate the patient.
o
49
Endometritis is an ascending infection where the normally sterile uterine lining becomes contaminated with organisms
from the lower reproductive tract
Endometrium is the lining of the uterus.
o Primary cause of postpartum infection
Risk factors:
o The mucus plug prevents things from
Cesarean birth
entering the uterus.
Multiple vaginal exams
o Once the membranes rupture the lady is at
Placement of intrauterine
risk for infection.
catheters, fetal scalp electrodes, or
o Anything going inside is putting her at risk
fetal pulse oximetry
for infection.
Manual removal of the placenta
PROM
Most common 24-48 hours after
Long labor
birth
Assessment and signs and symptoms:
o Fever
o Just not feeling well
o Chills
o Lower abdominal pain
o Anorexia
o Malodorous lochia
o Malaise- fatigue weakness
o Prolonged or painful afterpains
o Tachycardia
Planning/interventions:
o CBC with diff
o Semiflowlers position
o Blood cultures and cultures of the lochia,
o Perinatal hygiene
endometrium and cervix
o Hydration, nutrition
Cultures are done before
o Comfort measures
antibiotics!
o Monitor elimination
o IV antibiotics (usually Gentamycin &
Clindamycin)
Wound Infections
Lacerations or episiotomy and Cesarean wounds
Perineal infections
Relatively rare
Related to infected lochia, fecal contamination, poor hygiene
Instrument assisted births (forceps/vacuums)
Abdominal wound
o Prolonged hospital stay
o Staphylococcus
o Wound dehiscence
o Common wounds:
Episiotomy, c-section, small tears, bruises
o Teach proper perineal care: wipe front to back
o Dont wear pads for too long
o Dehiscence: opening of the wound
o Evisceration: stuff comes out of the wound
o Do not present until the 4 -5 day
o Warmth
postoperatively
o Tenderness
o Erythema
o Purulent drainage (or sanguinous,
o Edema
serosanguinous)
o Induration
Planning /interventions:
o Vital signs
o Pharmacologic treatment: antibiotics
o CBC with diff
o Sitz bath q 4-6 hours
o Wound cultures
o For the first 24 hours put ice on the
o Wound care
perineum!!!
Urinary Tract Infections
Most common medical complications during pregnancy and the postpartum period
Risk factors:
50
o Trauma to the bladder from passage of the fetus from the uterus to the perineum
o Hypotonictity of the lower urinary tract leading to urinary stasis (d/t relaxation of bladder)
o Catheterizations and vaginal exams
o Instrument-assisted births
o Primary early sign is a lingering low grade
o Dysuria
fever
o Hematuria
o Urinary frequency
o Suprapubic or lower abdominal pain
o Urgency
o Dark urine with foul odor
Planning/intervention:
o Teaching on self-care practices
Antibiotics are not good for
o CBC and urine culture
viruses.
o Pharmacologic treatment: antibiotics (IV
If a chest infection is suspected,
then PO)
antibiotics may be given. Even if
you have a virus.
Mastitis:
Infection of the breast connective tissue
Primarily occurs in women who are lactating
Causative organism: staph areus, E-coli, Strep.
Mode of transmission:
o Bacteria invades the breast tissue through traumatized tissue, fissured or cracked nipples, milk statis, manipulation
o Sources of organism- infants nasopharynx, mothers hands
Prevention strategies:
o Handwashing
o Good latch on; changing positions to
o Breastfeed frequently
prevent sore and cracked nipples
o Avoid constant pressure on the breast
o Apply warmth if breast distended prior to
feeding
Usually does not develop until the 4 week postpartum
Usually unilateral
Onset sudden and may mimic influenza
Short hx. of fever, chills, localized warmth, swelling and tenderness
Inspection: engorged, painful, hard, reddened area
Planning /intervention:
o Bedrest
o Frequent breast feeding
o Increased fluid intake
o Hot/cold compress
o Supportive bra
o Analgesic

Thromboemolic Complications:
A thrombus is the formation of a blood clot or clots inside a blood vessel and is caused by inflammation (thrombophleblitis)
or partial obstruction of the vessel.
Types:
o Superficial venous thrombosis
o Deep venous thrombosis
o Pulmonary embolism
Risk factors:
o Delayed ambulation
o Preexisting cardiopulmonary disease or
o Hx. of venous thrombosis
diabetes
o Obesity
o Route of birth (increased risk with cesarean
o Maternal age > 35 years
births)
o Surgery (trauma to vessels)
Superficial venous thrombosis
o Involves the saphenous vein
o Localized redness and warmth
o Lower extremity unilateral pain and
o Absent or low-grade fever
tenderness
o Slight elevation of pulse
Treatment:
o Application of heat
o Elevation of affected limb

51
o Bed rest
o Elastic stockings
o Analgesia
DVT clinical manifestations:
Unilateral leg pain swelling and warmth
Calf tenderness on ambulation
Planning /interventions:
o Anticoagulant therapy- IV heparin
o Analgesic
o Lab studies
o Antibiotics
o Strict bedrest
o Supportive elastic stockings
o Elevation of leg
o PO wafarin (Coumadin)
Normal Newborn Care (PowerPoint)
Transition to Extrauterine Life
Respiratory
Cardiovascular
Thermoregulation
Fetal Lung Development
Surfactant developed between 28-32 weeks. Prevents alveoli from collapsing. Promotes lung compliance.
Baby has a lot of excessive fluid in the lungs; so vaginal delivery helps remove excessive fluid less resp. infections than Csection.
Phospholipids - Lecithin and Sphingomeyelin are critical for alveolar activity.
o LS Ratio 2:1
o Infants born before the LS ratio is 2:1 will have varying degrees of respiratory distress.
o This is why the baby should stay in utero until at least term.
Respiratory Adaptations
During birth, fetal chest is compressed and squeezes fluid
The thorax recoils and air is sucked into the lung fields
Clamping of the umbilical cord
o When they clamp the umbilical cord, its cuts off the oxygenated blood coming from the placenta to the baby and
that is when the babies system must take over with neonatal circulation.
When the baby comes out, the cold air touches the babys face and the baby gasps for air. That gasp of air brings air into
the lungs and causes the lungs to expand and respiration starts.
Neonatal circulation begins after clamping of the cord.
Transition to Extrauterine Life
Fetal circulation differs from neonatal circulation in three areas:
1. The process of gas exchange
2. The pressures within the systemic and pulmonary circulations
3. The existence of anatomic structures (shunts) that assist in the delivery of oxygen-rich blood to vital organ systems.
Fetal circulation
When the baby is in utero, circulation occurs through the umbilical cord.
Once the baby is out these things need to shut, close, and dry up so that the baby can
have normal circulation.
Process of Gas Exchange
In fetal circulation, gas exchange occurs in the placenta
The lungs are nonfunctional with very little blood flow
The placenta provides oxygen and nutrients for the fetus, and removes carbon dioxide
and other waste products
The mother and fetus blood vessels intertwine but do not join (no mixture of blood)
The exchange of oxygen, nutrients, and waste materials between the mother and fetus
occurs by diffusion.
The umbilical cord connects the fetus to the placenta, and contains two small arteries
and one large vein, providing for the transport of blood to and from the fetus and
placenta
Oxygenated blood from the placenta flows by way of the umbilical vein to the inferior vena cava
Deoxygenated blood flows back to the placenta by way of the two umbilical arteries (arteries always carry blood "away"
from heart).
Mechanism of Respirations
52
Mechanical-fetal chest is compressed during the birth process removing lung fluid.
Chemical- transitory asphyxia is a chemical stimulator that contributes to the onset of breathing
Thermal- decrease in ambient temperature (causes the baby to gasp for air)
Sensory- tactile, auditory, verbal
o Tactile stimulus helps the baby to cry and breathe better. This helps to expand the lungs.
Characteristics of Normal Newborn Respirations
30-60 breaths a minute
Initial breathing is largely diaphragmatic, shallow, irregular in depth and rhythm.
Periodic breathing- pauses lasting 5-15 seconds. No color or heart rate changes
Apnea- cessation of breathing lasting more than 20 seconds.
o Cyanosis and acrocyanosis are normal for several hours after birth.
o The newborn is an obligatory nose breather
o Baby cannot mouth breathe, which is why we NEED to clean the nose.
Cardiovascular Adaptations
The onset of respirations triggers increased blood flow to the lungs after birth, which is when the lungs expand and the
normal circulation starts.
This greater blood volume contributes to the conversion from fetal circulation to neonatal circulation
Areas of Change in Cardiopulmonary Adaptation
Increase aortic pressure and decreased venous pressure
Increased systemic pressure and decreased pulmonary artery pressure
Closure of the foramen ovale (if it remains open, blood is going to pass from right atrium to the left atrium)
Closure of the ductus arteriousus (becomes patent ductus arteriousus if it remains open)
Closure of the ductus venosus (becomes a ligament)
Cardiac Function
Heart rate: resting heart rate 110-160. May decreased to 80 in full-term newborns. May be up to 180 or above when baby is
crying
Blood pressure- highest immediately after birth, lowest at around three hours of age. SBP 60-80; DBP 40-50 in full-term
newborns
90% of heart murmurs are transient and not associated with anomalies
o Should not be concerned so early about this because some foramen ovalies take longer to close fully.
HR starts high, then goes down to normal.
BP starts low, then goes up to normal.
First Moments After Birth
Begin assessment as soon as the baby emerges:
Check for meconium
o If baby has meconium staining = respiratory distress in utero
Breathing or crying
Displaying muscle tone
Gestational age (38-42 weeks)
Check apgar score
Vernix = cheesy stuff that covers the skin and protects the babies skin so they dont come out wrinkly.
Past 40 weeks the baby loses vernix and they come out looking old and wrinkly
For Vaginal and cesarean birth:
o Warmth
o Clear airway!!!
o Dry baby
o Bonding (if no issues are present the baby can bond with the mother)

Apgar Scoring
Documents the infants response to birth at 1min and 5min after birth
A: Appearance (color)
P: Pulse (heart rate)
G: Grimace (reflex irritability)
A: Activity (muscle tone)
R: Respiration (respiratory
effort)
53
A score of 8 to 10 reflects normal adaptation.

A score of 4-7- moderate difficulty adjusting to
extrauterine life. Need for stimulation.
A score of 0 to 3 difficulty adjusting to extrauterine
life and requires immediate intervention- resuscitation
EX: If a baby has a pink body and blue extremities, HR
of 140, crying vigorously, has some flexion of the limbs
and a weak cry = 7 score
For a 4-7 score baby, stimulate the baby; sometimes
rubbing the baby or drying the baby will make the baby
start crying and that will add a 1 to the score and make
the baby an 8.
A score of 0 = resuscitation

Immediate Newborn Care
The nurse should:
o Assess risk
o Assess family preferences
o Family desires
Ex: Some people want the baby to be exclusively breastfed.
Planning/intervention for infants:
o Breathing but not pink- give free-flow oxygen
o Respiratory distress/limp- more thorough assessment and possible ventilation
o Apneic- stimulation; bag and mask ventilation; baby is going to need resuscitation
Identification
o Identification bands:
o Placed on infant wrist and ankle
o Identical identification bands on mother, father, and or other family member
o Banding should occur before separation of mother and infant!!!
Vital Statistics
o Weight
o Length
We need to know if the baby is growing
o Head circumference
We need to know if the head is getting bigger (hydrocephalus)
We need to have a baseline
o Chest circumference
o Usually do foot print, palm print, and DNA
Gestational Age Assessment
Newborn classification by gestation age:
o Large for gestational age (LGA): above 90th percentile
This baby is bigger than 90% of babies in the same age group
o Appropriate for gestational age (APA) 50 percentile (baby is average)
50% of the babies will be smaller, and 50% will be larger
o Small for gestational age (SGA): below 10th percentile
90% of babies are bigger than this baby
Estimation of Gestational Age
External Physical Characteristics
o Sole creases
o Breast tissue
o Ear Cartilage
Check for ear recoil because it should recoil easily
o Lanugo
Hair that usually falls off after a while
o Testicular descent
We feel the testicles to see if the testes have descended.
If the testicles stay in the warm abdomen, it is going to kill the childs ability to have kids.
54
Scrotal rugae/labial development

If premature = scrotum appears smooth it lacks rugae
Neuromuscular Development
o Posture
o Square window sign
If the wrists can bend
o Arm recoil
When you pull the arms down they should flex back and not remain extended
o Popliteal angle
Can the baby bend the leg straight up or does the baby have a bend in the popliteal area
o Scarf sign
How far the hand can go around the neck
o Head lag
Heel to ear
Growth Curve Charts
They need to include the parents statures because this can affect the babies stature.
o If the baby has a small mother the baby might have small genes.
o It doesnt necessarily mean that something is wrong with the baby.
Physical Assessment
General Appearance- Head is usually disproportionately large for the body.
Basic Measurements:
o Weight: Average 2500-4000g (7lb 8oz)
o Length: 45-55 cm (18-22 in)
o Head: 32-37 cm (12.5-14.5 in)
o Chest: 30-33cm (12.5 in)
o Abdomen: 30-33cm
o Head and chest are usually around the same size J
Temperature
o Temperature stabilizes within 8-12 hours
o Monitor temperature
o Mode- axillary skin mode, skin probe, rectal, tympanic.
o Axillary temperature range 36.5 37.2C (97.7-98.6 F).
o Hypothermia can put the baby in respiratory distress
We shake to keep the baby warm.

Skin
o Characteristics; varies with genetic background. Bright red, puffy, smooth
Acrocyanosis Bluish discoloration of the hands and feet. Body is pink but arms are blue. Poor
peripheral circulation. Common after birth.
Mottling Lacy pattern of dilated blood vessels under the skin.
Jaundice Yellow discoloration of the skin. Evaluated by blanching the tip of the nose, forehead, chest.
When you blanch, the blood moves from under the area and the area should appear white. If area is
yellow = jaundice.
2 types:
Physiological (occurs about 2-3 days after birth; usually put baby in light and give extra fluid)
Pathological jaundice occurs within 24 hours of birth (causes: abo incompatibility; usually
requires transfusion)
The baby has excessive RBCs that he got from the mother. The liver has to mature to get rid of
the excess RBCs which is eliminated through the bile. The liver is not mature enough and the
baby is not breaking down the RBCs fast enough the bilirubin is going to accumulate.
(physiological jaundice)
Erythema Toxicum Perifollicular eruption of lesions. Called newborn rash. No treatment
Milia Exposed sebaceous glands. (looks like fine acne on the nose)
Vernix Caseosa white, cheesy, odorless. Lubricates the newborn skin.
o
55
Skin: Birthmarks
o Telangiectatic Nevi: Stork bites, pale pink or red spots found on eyelids, and neck. Fades in 2 years.
o Mongolian Spots: Macular areas of bluish/black pigmentation. Found in Asian, African and dark-skinned races.
Fades 1-2 years.
o Nevus Flemus: Port-wine stain, capillary angioma. Commonly appear on face. Does not fade.
o Nevus Vasculosis: Strawberry mark, capillary hemangioma. Commonly found on the head. About 90% resolves in
10 years.
Head
o General Appearance: Large with pliable skull bones.
Plagiocephaly: Asymmetry of head
Molding: Overriding skull bones
Sutures: Palpable and separated
Microcephaly = very small head
Hydrocephaly = very big head
Head can come out long because of the molding during labor
o Craniostenosis: Premature closure of cranial sutures
If they close early that is a problem because they wont be able to mold properly
o Fontanels
Anterior: diamond shaped, 4-5 cm, closes 18 months
Bulging fontanel = increased intracranial pressure
Depressed/sunken = dehydration
Posterior: triangular shaped, 0.5-1cm, closes 8-12 weeks.
Posterior fontanel closes first!
o Caput Succedaneum
When the baby is coming thru the birth canal the baby gets pressure on the
head.
Sustained pressure of the presenting part against the cervix.
Increased tissue fluid, edematous swelling, and occasionally bleeding under
the periosteum.
Crosses a suture line
Disappears in 12 hours to a few days

o Cephalhematoma
Collection of blood resulting from ruptured blood vessels between the
surface of the cranial bone and periosteum.
Unilateral or bilateral
Do not cross suture lines
Advise mothers to not mold the babys head because it can cause
complications
Disappears 2-3 weeks
Face, Eyes, Ears, Nose, Throat
o Face: Well designed to help the infant suckle. Sucking pads on cheeks. Recessed chin, flattened nose. Assess facial
symmetry.
o Eyes: Color established by 3 months. Check eyes for size, equality of pupil, reaction to light, blink reflex, edema,
and inflammation.
o Check the eyes to make sure that they are functioning well and that there is no swelling or infection.
(Erythromycin eye ointment is given to prevent bacterial infections of the eye in newborn babies)
Subconjunctival hemorrhages d/t trauma of baby exiting thru the birth canal
56
Transient strabismus -Squinting

Red retinal reflex Absence associated with cataracts.
Peripheral Vision. Can fixate on near objects.
Blinking reflexes should be present in the baby and that continues with us through life. Coughing and
sneezing also.
Nose: Small, narrow, nose-breathers. Capacity to smell.
Mouth: Pink lips, scant saliva, taste buds are developed. Epsteins pearls (white or yellow cysts typically seen at the
roof of the mouth), Thrush, Tongue-tied (when frenulum is at the tip of the tongue).
Ears: Soft, pliable, recoil readily when folded and released. Inspect for shape size, position, firmness. Top of ear
(pinna) parallel to the outer cantus of the eye.
Low-set chromosomal, renal abnormalities
Ears lower than the eyes = down syndrome
Preauricular tags
Neck: Short, creased with skin folds. Check muscle tone.

o
o
o
Chest
o
o
o
Cylindrical, symmetric, ribs flexible.

o Heart rate 120-160 bpm. Auscultate rate,
Xiphoid cartilage frequently seen
rhythm, intensity.
Engorged breasts-influenced by maternal
o Obtain apical pulse for a full minute.
hormones. Do not squeeze it out!!! Persist
o Assess for murmurs.
up to 2 weeks. Supernumerary nipples
o Peripheral pulses- brachial, femoral
o Respirations 30-60 bpm, diaphragmatic
o Blood pressure
Abdomen
o Usually cylindrical, protruded slightly, move with respirations.
o Auscultate bowel sounds in four quadrants
o Palpate- softness, masses.
Umbilical Cord
o White and gelatinous (whartons jelly)
o Two arteries and one vein (AVA); if one vessel, associated with congenital anomalies
o Check for bleeding, foul-smelling.
o Drying begins 1-2 hours after birth; cord separation time 7-14 days.
o Remove cord clamp within 24 hours.
Genitalia
o Female
Examine labia majora and minora, clitoris.
Look for any Vaginal tags
Look for any vaginal discharge
Pseudomensturation- withdrawal of maternal hormones.
The baby might have a pinkish bloodish discharge called Pseudomensturation.
Smegma- whitish cheeselike substance that can be
seen between the labias
o Male
Penis ensure correct position of urinary orifice
Hypospadias
Phimosis
A condition in which tight foreskin
can't be pulled back over the head
of the penis.
Scrotum-size, symmetry, testes
Cryptorchidism- A testicle that hasn't moved into the bag of skin below the penis before birth.
Hydrocele - water in the scrotal sac
Extremities
o Arms and Hand fingers should be counted. Nail extends beyond the finger tips. ROM
Polydactyl = extra digits
Syndactyl = fusion (webbing) of fingers or toes
57
Inspect hands for normal palmar creases - SIMIAN LINE: single palmar crease frequently present in
children with Downs Syndrome.
Brachial Palsy: partial or complete paralysis of the arm.
Erb-Duchenne Paralysis (Erbs Palsy): unable to move arm.
Legs and Feet: equal length with symmetrical skin folds; toes counted; ROM; evaluate for hip dislocation or
instability.
Ortholanis Maneuver: downward pressure on the hip and inward rotation; performed by a trained
clinician (If there is a click the hip may be displaced)
Talipes Deformity: clubfoot.
Back
o Spine straight and Flat; lumbar and sacral curves does not develop until infant begins to sit-up
o (hairy nevus): found at the base of the spine is associated with spinal bifida
o Pilonidal Dimple: can mean that the baby has spinal bifida.
Neurologic Status
o State of alertness, resting posture, cry, quality of muscle tone, and motor activity
o Position: partially flexed extremities with legs abducted on abdomen
o Movement: purposeless, uncoordinated
o Muscle tone
o Tremors and jitteriness
o Jitteriness: hypoglycemia
o Seizures = think low blood sugar
Reflexes
o These are the dates that the reflexes should
o Trunk Incurvation (Galant)
go away:
o Helicopter reflex
o Tonic Neck Reflex (fencer position): 4-6
o Stepping: 6-8 weeks. (When the soles of
months; brain damage
their feet touch a flat surface they will
o Palmar Grasp: 3- 6 months.
attempt to walk by placing one foot in front
o Planter Grasp: 10 months
of the other)
o Moro: 4-6 months. (baby gets startled)
o In addition, newborns can blink, yawn,
o Rooting: 3-4 months.
cough, sneeze, and draw away from pain.
o Sucking: 3-4 months
We keep all of these reflexes
o Babinski: 12 mths.
forever.
If babinski doesnt go away = think
meningitis or brain trauma
Care of the Newborn
First bath within 2-4 hours
o You should not bathe the baby until you have gotten two normal temp. readings
At least 2 normal temperatures
Bathing the baby can drop the body temperature
Reassess vital signs especially temperature post bath
Vitamin K injection (Aquamephyon): Vastas lateralis muscle
o Vitamin K is given to help with the clotting
Erythromycin: Prophylactic eye treatment; lower conjunctival sac; delayed up to one hour
Neonatal Sensory Abilities
Vision
Hearing
Smell
Touch
Taste
Thermoregulation (Important to remember)
32-34 degrees Celsius!!! 89.6-93.2 F
Factors that affect thermal stability:
o Decreased subcutaneous fat
o Blood vessels are closer to the skin
o Surfactant
Flexed posture decreases the surface area exposed

58
Heat Loss *KNOW THIS!*

Heat loss in the newborn occurs in fours ways:
Convection- Loss of heat from warm body surface to cooler air currents air-conditioned room
Radiation- Transfer of heat from heated body to cooler surfaces walls; or when you make a chair warm from sitting on it
Evaporation- Water is converted to vapor-amniotic fluid; bath; if the baby is not properly dried the excessive fluid on the
skin can cause vapors to form and cause evaporation
Conduction- Heat loss to a cooler surface; chilled hands; cold scales
o Ex: The nurse uses a cold stethoscope to assess a babys apical pulse
Know how to link questions to heat loss!!!
Heat Production
Nonshivering thermogenesis- NST
Unique to the newborn
Skin receptors
NST uses stores of BAT to provide heat
Brown adipose tissue-BAT; also called brown fat
Cold stress
Heat stress
Shivering generates heat and helps to warm us up
Babies are unable to shiver which is why we have to keep them warm
Glucose Metabolism
Hypoglycemia: BS stable at 60-70mg/dl; does not accept < 40mg/dl
o New born at risk: SGS, LGA
Risk factors:
o Jitterness
o Apnea
o Hyothermia
o Respiratory distress
o Lethargy
o Poor suck
o Hypotonia
o Vomiting
o High-pitched
o Cyanosis
o Weak cry
o Seizures
Interventions:
o Oral feedings
o Intravenous therapy
If they are not eating well, give them IV dextrose
Prevention:
o Minimized stress
o Maintain normal body temperature
o Feeding as soon as stable
Hematopoietic System
Timing of cord clamping
o Depends on the institution
Blood components
WBCs
Platelets
Blood sampling
o Usually gets sent out to be tested
Milking of the cord can supposedly cause polycythemia
Hepatic System
Bilirubin metabolism: liver plays a major role
Bilirubin: a yellow pigment formed from hemoglobin as a by product of RBC breakdown
Unconjugated (Indirect bilirubin): bilirubin bound to circulating albumin in the blood stream that has not yet been
metabolized in the liver
Conjugated (Direct bilirubin): The bilirubin that is excreted into the bile by the liver and stored in the gallbladder or
transferred to the duodenum
Jaundice
Progress from head to toe
May be more evident in dark-skinned babies
59
Physiologic jaundice: level of 5-7mg/dl in the first few days after birth; normal event
Occurs in 45%-60% of termed newborns
Treatment:
o Hydration
o Phototherapy
Gastrointestinal System
Oral feeding: critical in the development of immature gastrointestinal function
Human milk: preferred
Formula: should eat as soon as possible or within 6-8 hours of birth
Stomach capacity: 6ml/kg
o Baby should be fed based on body size.
Meconium: newborn first stool; greenish-black, tarry; passed 24-48 hours of life
o Failure to pass meconium may indicate intestinal obstruction and places the newborn at risk for
hyperbilirubinemia too much bilirubin in the blood
Immunologic System
Immature immunologic responses make the newborn susceptible to infection
Lack of exposure to common organisms result in delayed or decreased immunity
Premature infants are at greater risk
Term newborns have temporary passive immunity from the mother
The baby inherits temporary immunity from breast feeding
After 6 weeks babies begin to get immunizations
Infection prevention:
o Hand-washing
Urinary
95% of all newborns void with 24 hours
o Baby should void within the first 24 hours.
o If they have not passed urine we need to check it out
All newborns should have void by 48 hours
If newborn does not void within 48 hours, the nurse should assess adequacy of fluid intake, bladder distention, restlessness,
pain; notify HCP
Pain in Neonates
Assessment
o Behavioral responses
o Changes in heart rate
o Common signs: cry
o Respiratory rate and oxygen saturation
o Physiologic/autonomic responses
Heel sticks: laboratory studies to get the blood to send out to the lab to be tested
Circumcision
o In 1999 the American Academy of Pediatrics published a statement recommending against circumcision.
o http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b103/3/686
o The policy suggests that an analgesia or subcutaneous ring block be used during the procedure to decrease pain.
Management
o Nonpharmacologic
Swaddling- wrapped
Non-nutritive sucking
o Pharmacologic
Local and topical anesthesia
Oral analgesia
Care of the Newborn During Hospital Stay
Cultural aspect
Clothing
Signs of illness
Infant security
Wrapping
Car seat
Temperature
Holding
Pet safety
Use of bulb syringe
Comforting
Newborn Metabolic
screening (PKU)
Voiding and stooling
Parental stress
Auditory screening
Diapering
Sleep positions and SIDS
Post discharge follow-ups
Cord care
Immunizations

60
Lactation
Let-Down Reflex
o Birth result in a drop in estrogen and
o Prolactin level rises in response to the
progesterone.
infants sucking.
o Increase secretion of prolactin.
o Newborn sucking stimulates release of
o Prolactin promotes milk production.
oxytocin.
Colostrum
o Colostrum is a yellowish or creamy
o High in IgA-passive immunity
appearing fluid.
o Begins early in pregnancy
o It is thicker than milk.
o Replaced by transitional milk 2-4 days after
o Contains more protein, fat-soluble vitamins
birth.
and minerals
Facilitating Successful Breast Feeding
o Provide privacy
o Frequency -8 to 12 feedings in 24 hours.
o Comfortable position
o Length of feeding Average 30 minutes (15
o Support breast C-hold or scissor hold.
minutes per breast)
o Position baby
o Monitor progress
Disadvantages
o Inconvenience
o Exclusion of father
o CONTRAINDICATION:
Medical conditions Breast cancer, tb, hiv
o Common problems:
Sore or cracked nipples
Engorgement
Inadequate milk (If she does not have enough milk drink fluids and decrease distraction; her thoughts
have to be on the breasts and not texting)
Formula Feeding
Advantages:
o Both parents can share in this naturing and caring experience.
o Commercially prepared formula meets the need of the infant.
Disadvantages:
o Contains less Taurine
o May not have all the nutrients found in the breast milk
o Increased risk for allergy to cows milk.
Formula Products
o Cows Milk Based Similac, Enfamil, Gerber, Good Start.
o Soy Based Isomil, Prosobee, Gerber Soy.
o Specialized Formulas Nutramigen, Pregestimil, Alimentum
Potential Contraindications To Formula Feeding
o Improperly prepared formula can be detrimental to infants kidneys.
o Allergic reaction to cow-based milk.
o Iron deficiency.

The High-Risk Newborn (PowerPoint)
Associated Factors
Low socioeconomic groups
Environmental dangers- drugs, toxins, chemicals
Maternal Hx.
Weight
o LBW Low birth weight < 2500g
o VLBW- Very low birth weight-1500g or less
Complications: Preterm Newborn
Preterm- born before 38 weeks independent of birth weight
Very preterm- born before 30 weeks
Modern equipment has increased the survival rate for newborns 23-25 weeks gestation
Often may have vision, hearing, chronic lung disorder and cognitive impairments
61
Newborn characteristics:
o Skin
ruddy, thin, visible blood vessels,
fine lanugo, vernix is scant,
o Heels and palms
shiny, few creases
o Head
large, cranial sutures prominent
and movable, eyelids may be fused
shut, edematous
o Fontanels- large
o Chest- small with no breast tissue
o Abdomen- pot belly
o Females
genitalia large with wide labia and
large clitoris
o
o
o
o
o
o
o
Males
scrotal sac loose and possibly
empty
Cry- weak and whimpering
Respirations- rapid, irregular, shallow,
diaphragmatic with periods of apnea
Respiratory distress- sternal retractions,
inspiratory lag, flared nostrils, grunting
Posture- limp, weak muscles
Behavior-averting gaze, tremors, flaccid
Reflexes- poor suck and gag reflex
Physiological indicators- poor tolerance to
stress
tachycardia, periods of apnea,
color changes

Birth asphyxia may develop from inadequate oxygen transfer during labor and birth
o Interventions:
Positive pressure ventilations for HR< 100
CPR for HR< 60
Rescue breathing- central cyanosis, gasping respirations
Declining condition may need manual resuscitation bag or endotracheal tube
Respiratory Distress and Respiratory distress syndrome (RDS)
Related to deficiency of surfactant secondary to lung immaturity
o Interventions:
Supportive
Protect from infection
Oxygenation
Surfactant via ETT
Ventilatory therapy
Mechanical ventilation ( high
Blood gas monitoring
frequency)
Correct acid-base balance
Analgesic/sedatives Temperature regulation
morphine/fentanyl
Nutrition
Retinopathy of Prematurity (ROP)
o Susceptible to retinal changes because of ocular underdevelopment
o Results from high oxygen concentration
o Negative effects
Structural changes to retinal tissue
Tangling of retinal vessels
Retinal detachment
Blindness
o Diagnosis- Ophthalmic examination
o Management- cryosurgery, laser surgery
Bronchopulmonary Dysplasia (BPD)- is a chronic lung disease that results from immaturity and the use of long-term
mechanical ventilation after the development of RDS
BPD predisposes the infant to:
o Respiratory infections
o Reactive airway disease (RAD)
Feeding problems
o Prone to aspiration
o Lacking bile salts, pancreatic enzymes for
o Oral feeding delayed until 32-34 weeks
digestive enteral feedings
gestation
o Nutritional needs are increased
o Gastrointestinal immaturity can lead to
o Fluids needs are greater
gastroesophageal reflux
o Early feeding prevents:
o Stomach emptying is delayed; gut motility
Hypoglycemia
deminished
Hyperbilirubinemia
Hyperkalemia
62
Oral feedings
o Preferred
o Breast milk more desirable
o Specialized formula-oral caloric intake of 110-130kcal/kg/day of 24cal/oz rather than 20cal/oz
o Premie nipple only 15-20 min.
o Provide adequate fluids based on weight and gestational age; monitor serum electrolytes; weigh daily; maintain
correct amount of IV fluids; evaluate hydration status
Gavage feedings
o Indicated for:
Cardiovascular compromised
Cannot ingest sufficient feedings
Gestational or neurological immaturity

Anemia of prematurity results from the physiologic immaturity of the hematologic system, leading to diminished
erythropoiesis
Frequent laboratory studies can exacerbate this problem

Cold stress
Impaired thermoregulation resulting from immaturity
Brown fat develops late in gestation
Lack of insulating subcutaneous fat
Lack of flexion
Heat is loss to the environment through conduction, radiation, evaporation and convection.
Basically the person is not being able to thermo regulate.
Interventions:
o Administer warm humidified oxygen
o Use probe to monitor babys temperature
o Keep infant in double walled incubator
o If they are losing heat, avoid placing them
o Avoid placing baby on cold services
on cold surfaces.
o Place cap on head
Necrotizing Entercolitis NEC
Acute inflammatory bowel disorder associated with ischemia leading to bowel necrosis and perforation
o Causes:
Diminished gastric enzymes
Weak esophphogeal sphincter
Decreased cut motility
tone
Delayed gastric emptying
o Signs and symptoms:
Behavior changes
Diminished or absent bowel
Lethargy
sounds
Poor feeding tolerance
Abdominal distention
Temperature instability
Bloody stools
Increasing gastric residuals in tubefed newborns
o Interventions:
Stop all oral and enteral feeds
Possible ostomy
Notify neonatologist immediately
Broad spectrum antibiotics
Portable CT of abdomen
Possible blood transfusion
Start IV fluids/TPN and lipids
Assess and monitor closely can be
Surgical resection of affected
life threatening
bowel
Persistent Patent Ductus Arteriosus
Fetal circulatory structure
If it remains open we need to check the baby out.
Usually closes at birth with first cry
On Assessment:
o Bounding pulse
o Increase pulse pressure
o Auscultation of continuous murmur
o Diagnosed by echocardiogram
Treatment:
o Indomethacin (medication) or surgical ligation done to correct the problem
Intracranial Hemorrhage
o Bleeding within brain is most common
o Usually develops in preterms who weighs < 1500g and are younger than 34 weeks or both
o Can result in neurodevelopment disability or death
o Risk factors:
Birth trauma
Oscillatory ventilation
Birth asphyxia
Extracorporeal membrane
RDS
oxygenation (ECMO)
Post-term Newborn Complications
Postterm newborns characteristics:
o Typically looks lean, angular long, little subcutaneous fat
o Planter and palmar surfaces are deeply wrinkled
o Nails- long
o Skin- scaly and dry
Meconium Aspiration syndrome MAS
Meconium in the amniotic fluid indicates asphyxia insult to the fetus during labor
Usually a sign of breech presentation or fetal distress
Can be aspirated in utero or with the newborns first breath
Can result in pneumonia
Intrapartal intervention:
o Amnioinfusion
o May need deep endotracheal suctioning; 30
o Suction nasal first the oral and pharyngeal
seconds max for suctioning
as soon as the head emerges; before the
o Avoid all stimulation
first breath
Signs and symptoms:
o Tachypnea
o Management
o Retractions
o Prophylactic antibiotics
o Nasal flaring
o Chest physiotherapy
Polycythemia
Results from dehydration and hemoconcentration
Assessment:
o Moro reflex (may be first to detect CVA
o Suck
o Symmetry of movement
o Cry
Nursing responsibilities
o Maintaing airway
o Hydration
Hyperbilirubinemia
Jaundice (Icterus Neonatorium) is the most common physical finding in the newborn
refers to elevated serum blood levels
Clinical manifestation:
o After birth the infant must conjugate bilirubin
o Rate of conjugation depends on the rate of hemolysis, bilirubin load, maturity of liver, presence of albumin binding
sites
Predisposing factors:
o Prenatal
o DM
o Torch
o Rh and ABO incompatibilities
Neonatal:
o Prematurity
o Polycythemia
o Bowel obstruction
Pathologic jaundice:
o Criteria for diagnosis
o Bilirubin > 4mg/dl in cord blood
64
Total serum bilirubin increasing by more than 5mg/dl over 24 hours or 0.5mg/dl or more over 4-8 hours
In preterm newborn-over 10mg/dl at any time
In term newborn- levels > 15mg/dl that persist over 10 days
Visible jaundice that continues for more than 21 days in a preterm or more than 10 days in a term infant; unless
breastfeeding
Hyperbilirubinemia
o Can cause kernicterus
o Mental retardation
o Permanent brain damage
o Seizures
o Motor abnormalities
o Death
o Deafness
Kernicterus
o Deposits of unconjugated bilirubin in the brain especially the basal ganglia and subsequent symptoms of
neurological damage
o Associated with high levels of bilirubin. 25mg/dl is considered upper limits
o Billirubin level is so high that it stains the brain and causes neuro damage
o Assessment:
Prematurity, family history, ethnic
Differentiate between physiologic
background, birth trauma, illness
and pathologic
Correlate onset of jaundice with
Feeding behavior and alertness
gestational age
Dietary problems and lethargy
o Interventions:
Laboratory monitoring
Phototherapy
Fluids
Exchange transfusion
Monitoring intake and output
Parental education
o
o
o
o

Fetal Alcohol Syndrome
Results from maternal use of alcohol during pregnancy.
Characteristics of craniofacial deformities:
o Flat thin upper lip
o Small eyes with short slits for openings
o Flattened midface; short nose
o and low nasal bridge
o Microcephaly
Challenges (early childhood):
o Speech problems
o Inappropriate social interactions
o Developmental delay
o Aggressive behavior
o Later childhood
o Cognitive deficits and learning disabilities
Requires:
o Patience, nurturing, special education
Intervention:
o Physical and psychosocial needs
o Mother may need referral to for alcohol addiction
o Social services consult

65
Transient Tachypnea of the Newborn TTN

The newborn is unable to clear the airway of lung fluid, mucus, and
other debris, or an excess of fluid in the lungs due to aspiration of
amniotic or tracheal fluid
More prevalent in cesarean-birth newborns who have not had the
thoracic squeeze that occurs during vaginal birth and removes some
of the lung fluid
Caused by delayed clearance of fetal lung fluid in both term and
preterm infants
o usually results from c-section lack of squeeze through
birth canal through labor
o
Risk Factors
Maternal diabetes
Asthma
Male sex of the fetus
Macrosomia
Cesarean section delivery,
Especially elective without spontaneous labor

s/s of TTN
o Tachypnea within 6 hours of age
o Grunting
o Nasal flaring
o Retractions
o Transient oxygen need
o These clinical signs usually improve within 12 to 24 hours
Labs:
o Mild respiratory acidosis within 6 hours after birth
o Chest X-ray:
Increased interstitial markings (wet lung)
Increased fluid in interlobar fissures
Occasionally requires intervention:
o Oxygen
o nCPAP
o Mechanical ventilation
o Diuretics not effective
o Oral feedings are contraindicated because of rapid respiratory rates and the subsequent risk of aspiration
o IV fluids of D10W at 6080 ml/kg/day is recommended for a maintenance fluid during the NPO period
o The duration of the clinical course of transient tachypnea is approximately 72 hours
66
Medications
67

68
69

Obstetric Nursing Study Guide

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Obstetric Nursing Study Guide

Uploaded by

Copyright:

Available Formats

Maternal-Child

Exam Final Review

o Vascular congestion of the nasal mucosa

OB Final Exam Review

OB Final Exam Review

Womans perception of the

Complications at any stage of

What coping skills helped?

History of emotional or mental health

Obstetric History Tool

Standing for long periods of time

Carpal Tunnel Syndrome

Avoid gas forming foods

Danger Signs During Pregnancy (pg. 211)

Danger Signs in Pregnancy

Other Possible Causes

Fetal distress, Fetal Demise, Maternal

Slowed movements, anterior placenta

Pelvic or Abdominal Pain

Miscarriage, ectopic pregnancy, abruption

Cyst, uterine growth, ligament pain

Persistent Back Pain

Miscarriage, preterm labor

Kidney/bladder infection, cyst, normal

Regular Contractions prior to 37

Severe Headaches, Blurry Vision

Gestational Hypertension, Ecclampsia

Swelling of the Hands/Face

Miscarriage, placental abruption, placenta

Hormonal bleeding, Implantation bleeding

Assessment of Fetal Development (pg. 209)

Amniocentesis (pg 287)

OB Final Exam Review

o Determine FHR with Doppler if pregnancy is 10-12 weeks or more

OB Final Exam Review

Gestational Diabetes (pg 294)

Laboratory blood test

Deep Tendon Reflexes

OB Final Exam Review

And low birth weight infants (less than 2500g)

STDS (pg 343)

Infant -HIV testing and administration of antiviral drugs

Fetal Monitoring (pg.384)

OB Final Exam Study Guide

Managing Decelerations (pg. 391)

Combined Spinal-Epidural Anesthesia

Increased venous stasis edema in the lower extremities

Comparison of True & False Labor

OB Final Exam Study Guide

Implications of Pelvic Type for Labor and Birth

OB Final Exam Study Guide

First Stage of Labor (pg. 364)

OB Final Exam Study Guide

Descent of the fetus continues until it reaches the perineal floor

OB Final Exam Study Guide

Precipitous Labor (PowerPoint)

Face Presentation (pg 473)

Shoulder Dystocia (PowerPoint)

Fetal Size: Macrosomia (pg 477)

Cost associated with prematurity in US hospitals exceeds 2 billion each year

OB Final Exam Study Guide

Prolapsed Umbilical Cord Care

OB Final Exam Study Guide

OB Final Exam Study Guide

Heat Loss KNOW THIS!