Perry S RN, MSN

Maternal/Child

Learning Outcomes
1.
2.

3.

Describe the beginning of labor and

variables that affect labor and birth.
List the stages and mechanisms of
labor and important nursing
interventions for each stage.
Identify nursing diagnoses and nursing
interventions to assist the client in
labor.

Learning Outcomes
4.

5.

Describe the role of the LPN/LVN in

preparing the mother for birth and in
providing infant care.
Identify causes of high-risk labor and
appropriate nursing interventions for them.

Care of the Patient in Labor

Components of Labor
Signs of impending labor

Lighteningdescent of the fetus into the

pelvis
Braxton Hicks contractionsirregular
painless contractions
Cervical changeseffacement and dilatation
Bloody showpassage of the mucous
plug
Ruptured membranes
Sudden burst of energy

Birthing Suite

Figure 53.18 Birthing suite.

The 5 Ps of Labor

Passage
Maternal pelvis

Passenger
Lie, Size, Presentation, Attitude

Power
Position

Maternal

Psyche

Passage
Size and shape of maternal pelvis
See page 1459 in Ramont, figure 53-1
Cephalopelvic disproportion fetal head
larger than maternal pelvis
Station is the relationship between the
maternal ischial spines and fetus
See page 1460 in Ramont figure 53-2
Station 0 is when the fetal head reaches
the ischial spines, fully engaged

Passenger
Size: Fetal head largest part, molding,
anterior and occipital fontanels used to
determine the position of the fetus See in
Ramont page 1460 figure 53-3
Fetal attitude: Degree of flexion of the fetal
head and limbs to the trunk
Fetal Lie: the relationship of the long axis
of the fetus to long axis of mother.
Fetal presentation: Fetus body part that is
closest to cervix

Passenger
Vertex area between anterior and
posterior or the occiput presents first
Brow forehead or brow presents
Face
Complete breech: Buttocks presents
first, hips and knees flexed on abdomen
Frank Breech: Buttocks presents first
but the knees are extended with feet
close to head

10

Passenger
Fetal position is the relationship of the
presenting part to the four quadrants of
the maternal pelvis.
See Ramont page 1462 figure 53-7
See Ramont page 1462, table 53-2

11

Primary Powers

Involuntary muscle contractions of the

myometrium
Contractions due to shortening of muscle
fibers
Frequency: is the beginning of one
contraction to the onset of the next
contraction
Duration: beginning of contraction to the
end of the contraction
Intensity is the strength of the contraction
at its highest point

12

Secondary Power
Pushing of the fetus through the birth
canal
Fergusons reflex is the desire to push,
abdominal contraction initiated by
stretching of pelvic soft tissues.

13

Position
Position of mother during labor
Back = frequent contraction of low
intensity
Side = less frequent contraction but of
higher intensity

14

Psyche
Mothers emotional state
Fear and anxiety cause release of
epinephrine and norepinephrine which
causes blood vessels to constrict which
decreases the effectiveness of
contractions and makes labor more
painful

15

Station of the Fetal Head

Figure 53.2 Measuring the station of the fetal head while it is descending. In
this view, the station is -2/-3.

Normal Fetal Attitude

Figure 53.5 A. Fetal attitude. The relationship of body parts of this fetus is
normal. The head is flexed forward, with the chin almost resting on the chest.
The arms and legs are flexed.

Breech Fetal Position

Figure 53.5 (continued) B. Frank breech presentation.

Stages of Labor

First Stage of Labor

Latent Phase
Active Phase
Transition Phase

Second Stage of Labor

Third Stage of Labor
Fourth Stage of Labor

Figure 53.9 Contraction patterns in first, second, and third stages of

labor. Primigravidas may be 100% effaced before labor begins.

Effacement and Dilation

Beginning of Labor

Figure 53.11 Effacement and dilatation of the cervix in the primigravida. A. Beginning of
labor. There is no cervical effacement or dilatation. The fetal head is cushioned by
amniotic fluid.

Beginning Cervical Effacement

and Dilatation

Figure 53.11 (continued) Effacement and dilatation of the cervix in the primigravida.
B. Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid
collects below the fetal head.

Mid-Cervical Effacement and

Early Dilatation

Figure 53.11 (continued) Effacement and dilatation of the cervix in the primigravida.
C. Cervix about one-half effaced and slightly dilated. The increasing amount of amniotic
fluid exerts hydrostatic pressure..

Complete Effacement and

Dilatation

Figure 53.11 (continued) Effacement and dilatation of the cervix in the primigravida.
D. Complete effacement and dilatation.

Figure 53.13 The two most common types of episiotomy are

midline and mediolateral.

Mechanism of Labor
Engagement
Descent
Flexion
Internal rotation
Extension
Restitution/External rotation
Expulsion (lateral flexion)

Assessments

Ask about
contractions
Ask if membranes
ruptured
V.S.
Labs, urine dipstick
for glucose and
protein
FHR

Monitor contractions
Vaginal exams
Nitrazine test
Signs of PIH

animation labor and birth

Non Pharmacologic Comfort

Measures
Emotional Support
Informational Support
Physical Comfort Behaviors

First Stage
Second Stage

Advocacy Support

Drugs Used in Labor

Management

Pudendal Block

Narcotic/Analgesics
Sedatives
Anesthetics
Local

Pudendal
Spinal/Epidural

. Pudendal block by transvaginal approach

Figure 53.17 (continued) A. Schematic diagram showing pain path and sites of
interruption. A. Paracervical block (sensory pathways and site of interruption in
relation to fetus). B. Pudendal block by transvaginal approach. C. The lumbar
epidural block. The epidural space is located between the dura and the vertebra.

Medical Interventions
for Labor Complications

Induction
Prostaglandins
Artificial Rupture of Membranes (AROM)
Pitocin (Oxytocin)

Forceps/Vacuum
Dilation and Curettage
Cesarean Section

Emergent

Artificial Rupture of Membranes

(AROM)

Preterm Labor
20-37 weeks contractions with cervical
changes
Tocolytic for preterm see page 1474 in
Ramont table 53-6

36

Induction of Labor
Prostaglandins (PGE 1) Softens cervix
Artificial rupture of membranes (ARM)
Pitocin (oxytocin)

38

Precipitous Birth
Last < 3hours
Increased risk of ruptured uterus,
cervical and vaginal lacerations,
hemorrhage, fetal distress, and fetal
cerebral trauma
Ramont page 1477 box 53-3

40

Cord Prolapse

Figure 53.21 Cord prolapse through the introitus. The prolapse of an

umbilical cord creates an emergency situation requiring birth by cesarean
section.

Cesarean Delivery
When labor does not progress normally
(dystocia), the nurse must be prepared
to assist with a cesarean birth.
Surgical birth is performed for a variety
of reasons, including:

Placenta previa, abruptio placentae, CPD,

fetal distress, breech presentation,

pregnancy-induced hypertension, multiple
pregnancy, and previous cesarean birth.

POST PARTUM PERIOD

Postpartum Period

Past placenta delivery to 6 weeks after

delivery

44

Learning Outcomes
1.

2.
3.

Describe the physical changes that

occur after a woman has delivered a
baby and placenta.
Identify psychological changes in the
postpartum woman.
Describe important aspects of support
for the postpartum woman.

Learning Outcomes
4.

5.
6.

Explain nursing interventions to use

when providing nursing care for a
postpartum woman.
Discuss methods of providing pain
relief for the postpartum woman.
Identify crucial areas of client teaching
for the postpartum woman.

Learning Outcomes
Describe important factors in self-care for
women after discharge.
8. Discuss client teaching about postpartum
emergencies.
9. Identify adaptations in postpartum care for
women after cesarean section.
7.

Learning Outcomes
10.

11.

Discuss important nursing

considerations regarding the new
family.
Discuss nursing care and teaching
related to breastfeeding.

Physiologic/Anatomic Changes of the

Postpartum Client

Breasts
Breast feeding vs. Non breast feeding

Cardiovascular system
Normal blood loss effect

Abdomen
Gastrointestinal System
Urinary System

Natural diuresis

Physiologic/Anatomic Changes of the

Postpartum Client

Uterus
Involution

Lochia
Types/Amount

Cervix
Vagina
Perineum

Intact
Lacerated/Episiotomy

Involution

Figure 54.1 Involution of the uterus. A. Immediately after delivery of the placenta, the
top of the fundus is in the midline and about halfway between the symphysis pubis and
the umbilicus. B. About 6 to 12 hours after birth, the fundus is at the level of the
umbilicus. The height of the fundus then decreases about one fingerbreadth (about 1 cm)
each day.

Medications for the Post Partum Client

Analgesics
Narcotics
Salicylates
Anti inflammatory agents
Prostaglandins

Postpartum Nursing Responsibilities

B reasts
U terus
B owel
B ladder
L ochia
E pisiotomy/Incision

Psychological Changes
Taking in stage: 1-2 days past
delivery; recalls birth experience, relies
on others for care
Taking hold stage: 3rd day, control of
herself and infant
Letting go stage: letting go of the
perfect pregnancy, perfect transition and
perfect baby. Desire to social interaction
Attachment: Bond to infant
Negative feelings: negative, baby blues,
post-partum depression

55

Care of the Postpartum

Woman
Vital signs should be assessed every 15
minutes in the first hour after birth.
When vital signs are stable, the time
interval can be lengthened.
Pain with dorsiflexion (Homans sign) is
an indication of an inflamed vessel in the
leg.

Fundal Massage
Fundal massage is done to prevent or
correct uterine atony and remove clots
from the uterus in order to evaluate
uterine bleeding and prevent
hemorrhage.
A fundus requiring massage will be soft
and can be felt above the umbilicus.

Fundal Massage

Figure 54.15 Nurse positioning hands to remove clots from uterus. Note that
lower hand supports the uterus.

Hemorrhage
Life-threatening hemorrhaging can occur
in the postpartum woman hours or even
days after delivery.
A low blood pressure may indicate
hemorrhage.
Tachycardia associated with
hypotension may indicate hemorrhage.

Care After Cesarean

Delivery
It is very important that adequate pain
relief be provided following a cesarean
section.
If the woman is receiving medication via
a PCA pump, she should be instructed
to push the button when she needs the
medication, and to notify the nurse if
pain relief is not adequate.

Care After Cesarean

Delivery
An indwelling urinary catheter may be in
place. Measure intake and output,
checking for signs of blood.
Instruct the woman to keep the incision
clean until healing is complete.
Once the dressing is removed, the
woman may shower without any special
precautions.

Care After Cesarean Delivery

Instruct her to allow the incision to dry
completely after washing and to apply a
small dressing if desired.
If Steri-Strips have been applied to the
incision, they will not be harmed by the
shower and will come off in about 1 week.
Teach the woman who has had a cesarean
section that it is important not to overdo
activity for 4 to 6 weeks.

Listening Skills

Listening is one of the most important

skills a postpartum nurse needs to learn.
It can make the difference between a
positive and a negative postpartum
experience.

Client Teaching
Mother and baby care and education
should begin as soon as the mother and
baby are stable.
A womans choice regarding care of
herself and her infant must be
recognized as a very important element
in her care.

Client Teaching
Instruct the client about expected
progression of lochiafrom red to dark
brown, to pale yellow or white.
Instruct the client to report any
deviations from this pattern.
Instruct the client regarding ways to
prevent perineal infection, such as
frequent pad changes, avoiding
tampons, and using a peri bottle after
voiding.

Client Teaching
Instruct the client about expected
progression of lochiafrom red to dark
brown, to pale yellow or white.
Instruct the client to report any
deviations from this pattern.
Instruct the client regarding ways to
prevent perineal infection, such as
frequent pad changes, avoiding
tampons, and using a peri bottle after
voiding.

Client Teaching
The teenage mother may require a
different approach to teaching. Handson education with client return
demonstration is often most effective.
The postpartum woman should be
instructed not to have intercourse until
she has seen her obstetrician or midwife
for a follow-up visit and has been told
that she may resume intercourse.

Client Teaching
Instruct all postpartum women, whether
lactating or not, that absence of a
menstrual period does not mean they
are infertile.
Encourage the woman to simplify
routines for this period of time and not to
make any major changes.

Client Teaching

Instruct the woman in the signs of

postpartum emergencies in her infant
and herself and tell her to call the
pediatrician or obstetrician if any occur.

THE NEONATE

Learning Outcomes
Identify physiologic adaptations of the
neonate.
2. Describe the use and method of
obtaining an Apgar score.
3. List aspects of delivery room care and
nursing interventions for the neonate.
4. Explain nursery care of the neonate.
1.

Learning Outcomes
List differences that identify the
gestational age of the neonate.
6. Describe the physical characteristics of
the neonate.
7. Explain proper hygiene methods in
caring for a newborn.
8. Compare and contrast two methods of
providing neonatal nutrition.
5.

Learning Outcomes
9.
10.

Identify common procedures in care of the

newborn.
Provide discharge teaching to parents of a
newborn.

Neonatal Period
The neonate is the infant from delivery
through the first month of life.
Initial care revolves around meeting the
basic biologic needs and helping the
newborn adjust to life outside the womb.
Most infants are born without
complications, and require routine care.

Foundations of Neonate
Care
An understanding of the physiologic
adaptation to life outside the uterus
guides the nurses actions when setting
priorities in the care of the newborn.
They involve:

Airway.
Breathing.

Circulation.
Thermoregulation.

Figure 51.4 Fetal circulation. Blood leaves the placenta and enters the fetus through the umbilical vein. After circulating
through the fetus, the blood returns to the placenta through the umbilical arteries. The ductus venosus, the foramen
ovale, and the ductus arteriosus allow the blood to bypass the fetal liver and lungs.

Initial Newborn Assessment

Apgar Scoring
A ppearance (Color)
P ulse (Heart rate)
G rimace (Reflex)
A ctivity (Muscle tone)
R espiratory Effort

APGAR score

Newborn Assessment

Characteristics of the
Newborn Skin
Acrocyanosis
Ecchymosis
Petechiae
Lanuago
See Ramont page 1540 figure 56-11
Mongolian spots
Milia

82

Characteristics of the Newborn

Head

Molding
Caput succedaneum edema of scalp crossing
suture lines
Cephalhematoma accumulation of blood
between the periosterum and skull bones, does
not cross suture lines.
See Ramont page 1542 figure 56-12
Strabismus lack of eye coordination see page
1542 figure 56-13
Epsteins earls= small cyst on the palate
83

Reflexes

Rooting reflex ;
Sucking reflex
Palmar grasp reflex:
Plantar reflex: last 8 months, foot touched
and toes curl under
Babinski reflex: big toe dorsiflexs and other
toes flare
Stepping reflex
Tonic neck reflex
Moro or startle reflex

85

Hygiene Care
Bathing: once temperature stable, no
bath tub until cord falls off
Change diaper every 2 hours or more
frequently if needed
Perineal care with each diaper change
Eye care eye ointment to prevent
ophthalmia neonatorum
Umbilical cord care: with each diaper
change

86

Newborn Assessment Taking Measurements

Figure 56.21 Neonatal measurements are taken immediately after birth. For
height, it is often helpful to have two staff members work together to ensure the
accuracy of the measurement from crown to heel.

Newborn Assessment Taking Measurements

Head circumference
is a measurement of
a childs head
around its largest
area.
measures the
distance from above
the eyebrows and
pinas and around the
occiput.

Components of Newborn Assessment

Body size and

shape
Skin Characteristics
Reflexes
Nutritional needs
Temperature
Elimination
Rest/Activity
Bonding

Nursery Care
Safety in the newborn nursery involves
protecting the newborn from injury and
abduction.
Routine care of the neonate involves
sponge baths, feeding, cord care,
circumcision care, and diapering in a
warm, calm environment.
The neonate should only be transported
in a bassinet, not held in the arms.

Umbilical Cord Alarm

Figure 56.5 B. Umbilical alarm attached to newborn infant.

Common Neonate
Medications
1.0% tetracycline or 0.5% erythromycin
ophthalmic ointment (to prevent eye
inflammation and infection)
Vit. K. AquaMEPHYTON IM (to prevent
hemorrhagic disorders)
Hepatitis B immunization may be
administered in the newborn nursery
with parental consent.

Promotion of Optimum Health for the

Newborn

Nutrition
Breast
Formula

Sleep/Rest/Exercise
Safety/Bonding
Family Structure/Support
Impact on Family

Healthy vs. Abnormality

Breastfeeding
When

Why
How

How
often
How
much

Neonate Nutrition
A full-term infant needs 50 to 55 kcal/lb
(110 to 120 kcal/kg) that equals 20 oz
(600 mL) of breast milk or formula per
day.
At birth, the newborns stomach will hold
20 mL, or slightly less than an ounce.

Neonatal Nutrition
The infant will need to be fed every 2 to
4 hours to meet nutritional needs.
The American Academy of Pediatrics
recommends breast milk for the first
year of life.
It is important for parents to receive
information regarding the benefits of
both breastfeeding and bottle-feeding.

Sleep
The neonate generally sleeps for
approximately 20 to 22 hours a day.
The newborn likes the security and
warmth offered by swaddling.
The infant should be placed on his or
her back for sleeping.
All objects including stuffed animals,
pillows and blankets should be removed
from the crib to prevent suffocation.

Neonatal Screening Tests

Accomplished through heel sticks for

blood draw to test for:
Hypoglycemia
Phenylketonuria

Bilirubin

Heel Stick

Figure 56.19 A. Potential puncture sites for heel sticks. Avoid shaded areas to
prevent injury to arteries and nerves in the foot.

Newborn Jaundice

Physiologic
Occurs after the first 24 hours
Increased RBC during development

Improve O2 transport
Immature liver development

Inability to handle the breakdown process

Bilirubin held in the blood stream

Newborn Jaundice

Pathologic
Occurs prior to the first 24 hrs
ABO/Rh incompatibility
Treatment
Exchange transfusion
Phototherapy
F/U bilirubin

Phototherapy

Phototherapy
How does it work?
Bilirubin in the baby's body is changed
into another form that can be more
easily excreted in the stool and urine.
When do they have to use photo therapy?
When serum bilirubin is greater than 8
mg/dl at 24 hours of life

Discharge Teaching
Any time care is provided in the
presence of the mother, and/or
significant others, teaching should be
provided regarding the care that is
given, the reasons for the care, and
whether the parents should do the same
care at home.
The LPN/LVN assists the RN by
teaching parents about routine newborn
care.

Discharge Teaching

Topics that require client teaching prior to discharge

include the following:
Nutrition
Elimination
Diapering
Hygiene
Placing infant on back to sleep

Discharge Teaching

Topics that require client teaching prior to

discharge include the following:
Perineal care
Circumcision care

Umbilical cord care

Safety

Newborn Assessment