Maternity Nursing Flashcards
amniotic fluid
Pale, straw-colored fluid in which the fetus floats. It serves as a cushion against injury from sudden blows or movements and helps maintain a constant body temperature for the fetus. The fetus modifies the amniotic fluid through the processes of swallowing, urinating, and movement through the respiratory tract.
ballottement
Rebounding of the fetus against the examiner’s finger on palpation. When the examiner taps the cervix, the fetus floats upward in the amniotic fluid. The examiner feels a rebound when the fetus falls back.
Chadwick’s sign
Violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about 4 weeks of pregnancy; caused by increased vascularity. This is considered a probable sign of pregnancy.
delivery
Actual event of birth; the expulsion or extraction of the neonate.
embryo
Stage of fetal development that lasts from day 15 until approx 8 weeks after conception or until the embryo measures 3 cm from crown to rump.
fertilization
Uniting of the sperm and ovum, which occurs within 12 hours of ovulation and within 2-3 days of insemination, the average duration of viability for the ovum and sperm.
Goodell’s sign
Softening of the cervix that occurs at the beginning of the second month of gestation. This is considered a probable sign of pregnancy.
gravida
A pregnant woman; called gravida I (primigravida) during the first pregnancy, gravida II during the second pregnancy, and so on.
Hegar’s sign
Compressibility and softening of the lower uterine segment that occurs at about week 6 of gestation. This is considered a probable sign of pregancy.
implantation
Embedding of the fertilized ovum in the uterine mucosa 6-10 days after conception.
Infant
A human born alive; also a human from 28 days of age until the first birthday.
Labor
Coordinated sequence of rhythmic involuntary uterine contraction resulting in effacement and dilation of the cervix, followed by expulsion of the products of conception.
lecithin-to-sphingomyelin (L/S) ratio
Ratio of two components of amniotic fluid, used for predicting fetal lung maturity; normal L/S ratio in amniotic fluid is 2:1 or greater when the fetal lungs are mature.
lochia
Discharge from the uterus that consists of blood from the vessels of the placental site and debris from the decidua; lasts for 2-6 weeks after delivery.
Nagele’s rule
Determines the estimates date of birth based on the premise that the woman has a 28-day menstrual cycle. Substract 3 months and add 7 days to the first day of the last menstrual period; then add 1 year. Alternatively, add 7 days to the last menstrual period and count forward 9 months.
newborn; neonate
A human from the time of birth to the 28th days of life.
Parity
Number of pregnancies that have reached viability regardless of whether the fetus was born alive or stillborn.
Placenta
Organ that provides for the exchange of nutrients and waste products between the fetus and the mother and produces hormones to maintain pregnancy. The placenta develops starting at implantation and ends by the 3rd months of gestation (week 12). Is also called afterbirth.
Quickening
Maternal perception of fetal movement for the first time, occurring usually in the 16th-20th week of pregnancy.
Surfactant
Phospholipid that is necessary to keep the fetal lung alveoli from collapsing; amount is usually sufficient after 32 weeks’ gestation.
Uterus
Organ located behind the symphysis pubis, between the bladder and the rectum.
The 4 parts of the Uterus
- Fundus (upper part)
- Corpus (body)
- Isthmus (lower segment)
- Cervix
Vagina
Tubular structure located behind the bladder and in front of the rectum; it extends from the cervix to the vaginal opening in the perineum. It functions as the outflow tract for menstrual fluid and for vaginal and cervical secretions, as the birth canal, and as the organ for coitus (sexual intercourse).
True pelvis
Lies below the pelvic brim.
Consists of the pelvic inlet, midpelvis, and pelvic outlet.
False pelvis
Is the shallow portion above the pelvic brim.
Supports the abdominal viscera.
Types of pelvis
- Gynecoid
- Anthropoid
- Android
- Platypelloid
Gynecoid (pelvis)
Normal female pelvis;
Transversely rounded or blunt;
Most favourable for successful labor and birth.
Android (pelvis)
Heart-shaped or angulated;
Resembles a male pelvis;
Not favourable for labor & birth;
Narrow pelvic planes can cause slow descent and midpelvic arrest.
Platypelloid (pelvis)
Flat with an oval inlet;
Wide transverse diameter, but short anteroposterior diameter, making labor and birth difficult.
Anthropoid (pelvis)
Oval shape;
Adequate outlet, with a narrow pubic arch.
Each reproductive cell carries ____.
23 chromosomes.
Sperm carry an X or Y chromosome - XY=Male; XX=Female.
Amnion
Encloses the amniotic cavity.
The inner membrane that forms about the 2nd week of embryonic development.
Forms a fluid-filled sac that surrounds the embryo and later the fetus.
Chorion
The outer membrane enclosing the amniotic cavity.
Becomes vascularized and forms the fetal part of the placenta.
Amniotic fluid consists of _______ by the end of pregnancy.
800-1200 mL
Fetal Heart Rate (FHR)
Depends on gestational age.
FHR is 160-170bpm in the 1st trimester, but slows with fetal growth to 110-160bpm near or at term.
FHR is about twice the maternal heart rate.
Infertility
Is the involuntary inability to conceive when desired.
Male Factors for Infertility
Abnormalities of the sperm;
Abnormal erections or ejaculations;
Abnormalities of the seminal fluid.
Female Factors for Infertility
Disorders of ovulation;
Abnormalities of the fallopian tubes or cervix.
Infertility options
Medication; Surgical procedures; Therapeutic insemination; Vitro fertilization; Surrogate mothers; Embryo hosts; Adoption
Gravidity
Refers to the number of pregnancies.
A nulligravida
is a woman who has never been pregnant.
A primigravida
is a woman who is pregnant for the 1st time.
A multigravida
is a woman in at least her second pregnancy.
Parity
the number of births (not the number of fetuses, ex: twins) carried past 20 week’s gestation, whether or not the fetus was born alive.
A nullipara
is a woman who has not had a birth at more than 20 weeks of gestation.
A primipara
is a woman who has has one birth that occurred after the 20th week of gestation.
A multipara
is a woman who has had two or more pregnancies to the stage of fetal viability.
Presumptive Signs (Pregnancy Signs)
- Amenorrhea
- N&V
- Increased size & increased feeling of fullness in breasts
- Pronounced nipples
- Urinary frequency
- Quickening
- Fatigue
- Discoloration of the vaginal mucosa
Probable Signs (Pregnancy Signs)
- Uterine enlargement
- Hegar’s sign
- Goodell’s sign
- Chadwick’s sign
- Ballottement
- Braxton Hicks Contractions
- Positive pregnancy test for determination of presence of human chorionic gonadotropin
Braxton Hicks contractions
Irregular painless contractions that may occur intermittently throughout pregnancy.
Positive signs (Diagnostic) (Pregnancy Signs)
- FHR detected by electronic device (doppler transducer) at 10-12 weeks and by nonelectronic device (fetoscope) at 20 weeks of gestation.
- Active fetal movements palpable by examiner.
- Outline of fetus via radiography or ultrasonography.
Fundal height is measured to…
evaluate the gestational age of the fetus.
Physiological Maternal Changes - Cardiovascular System
- Blood volume, Plasma, RBCs volume Increases (by 40-50%).
- Anemia occurs as plasma increase exceeds the increase in production of RBCs.
- Iron requirements are increased.
- Heart size increases and moved slightly up and to the left, as the diaphragm displaces due to enlargement of the uterus.
- Retention of sodium and water may occur.
Physiological Maternal Changes - Respiratory System
- O2 consumption increases (15-20%)
- Diaphragm is elevated because of the enlarged uterus.
- SOB may be experienced.
Physiological Maternal Changes - Gastrointestinal System
- N&V may occur due to secretion of human chorionic gonadotropin (subside in 3rd trimester).
- Poor appetite due to decreased gastric motility.
- Alterations in taste and smell.
- Constipation due to pressure of uterus causing decreased gastrointestinal motility.
- Flatulence and heartburn
- Hemorrhoids due to increased venous pressure.
- Gum tissue may swollen and bleed due to increased levels of estrogen.
- Ptyalism (excessive secretion of saliva) due to increase estrogen.
Physiological Maternal Changes - Renal System
- Frequent urination due to bladder sensitivity and pressure from uterus onto the bladder.
- Decreased bladder tone
- Renal threshold for glucose may be reduced.
Physiological Maternal Changes - Endocrine System
- Basal metabolic rate and function increases.
- Anterior lobe of the pituitary gland enlarges.
- Thyroid enlarges slightly and thyroid activity increases.
- Parathyroid increases in size.
- Aldosterone levels gradually increase.
- Body weight increases.
- Water retention is increased.
Physiological Maternal Changes - Reproductive System
- Uterus: enlarges, size and number of blood vessels and lymphatics increase, irregular contractions.
- Cervix: becomes shorter, more elastic, larger in diameter; endocervical glans secrete a thick mucous when dilation begins; increased vascularization and increase estrogen cause softening and chadwick’s sign (4 weeks gestation)
- Ovaries: secrete progesterone for first 6-7 weeks; maturation o new follicles is blocked; cease ovum prodcution.
- Vagina: hypertrophy and thickening of muscle; increase in secreting.
- Breasts: size increase; tender; nipples more pronounced; areola darker in color; superficial veins become prominent; colostrum may leak.
Physiological Maternal Changes - Skin
Increased pigmentation; Dark streak down midline abdomen; Chloasma (blotchy brown hyperpigmentation over face); Reddish purple stretch marks (striae); Hair growth increase.
Psychological Maternal Changes
- Ambivalence (dependence-independence conflict; role changes)
- Acceptance
- Emotional lability (frequent mood changes)
- Body image changes
- Relationship with the fetus (daydreaming of motherhood; accept the fact of pregnancy; accept growing fetus as distinct from herself)
Discomforts of Pregnancy
- N&V (1st trimester, subside by 3rd month)
- Syncope (1st trimester; supine hypotension in 2nd or 3rd trimester)
- Urinary urgency and frequency
- Breast tenderness
- Increased vaginal discharges
- Nasal stuffiness
- Fatigue
- Heartburn
- Ankle edema
- Varicose veins
- Headaches
- Hemorrhoids
- Constipation
- Backache
- Leg cramps
- SOB
What causes N&V in pregnancy and interventions?
Caused by elevated levels of human chorionic gonadotropin and changes in carbohydrate metabolism.
Intervention: eat dry crackers before arising; don’t brush teeth right away, eat small frequent low fat meals during the day; drink liquid between meals rather than at meals; avoid fried or spicy foods.
What cause syncope in pregnancy and interventions?
Triggered hormonally or caused by the increased blood volume, anemia, fatigue, sudden position changes, or lying supine.
Interventions: Sitting with feet elevated; Risk for falls, teach to change positions slowly.
Supine hypotension occurs as a result of…
pressure of the uterus on the inferior vena cava.
Antepartum Diagnostic Testing
- Blood type and Rh factor
- Rubella titer
- Hemoglobin and hematocrit levels
- Papanicolaou’s smear (screen for cervical neoplasia)
- STIs
- Sickle cell screening
- TB skin test
- Hepatitis B surface antigens
- Urinalysis and urine culture
- Ultrasonography
- Biophysical profile
- Doppler blood flow analysis
- Percutaneous umbilical blood sampling
- a-Fetoprotein screening
- Chorionic villus sampling
- Amniocentesis
- Kick counts
- Fern test
- Nitrazine test
- Fibronectin test
- Nonstress test
- Contraction stress test
ABO typing is performed to determine the…
woman’s blood type in the ABO antigen system.
Rh typing is done to determine the…
woman’s blood type in the rhesus antigen system.
Rh positive indicates the…
presence of the antigen.
Rh negative indicates the…
absence of the antigen.
If the client is Rh negative and has a negative antibody screen, she will need…
repeat antibody screens and should receive Rh (D) immune globulin (RhoGAM) at 28 weeks’ gestation.
Value for a negative titer is
less than 1:8
A negative titer indicating susceptibility to the rubella virus, she should receive…
the appropriate immunization postpartum.
What should the client do when getting the immunization for rubella virus?
- Using effective birth control
- Not become pregnant for 1-3 months after
- Avoid contact with immunocompromised people
- If vaccine is administer at same time as Rh0 (D) immune globin then it might not be effective.
Rubella vaccine is not given during pregnancy because…
The live attenuated virus may cross the placenta and present a risk to the developing fetus. It is administered subq postpartum before discharge.
TB skin test is performed..
after delivery. If needed chest radiography it would have to wait till after 20 weeks gestation. Treatment with medication may be needed after delivery.
Hepatitis B vaccine is…
not contraindicated during pregnancy.
Glycosuria (from urinalysis) is a common result of…
decreased renal threshold that occurs during pregnancy, but if it persist it may indicate diabetes.
WBCs in the urine may indicate…
infection.
Ketonuria in urine may result from…
insufficient food intake or vomiting.
Levels of 2+ to 4+ protein in the urine may indicate…
infection or preeclampsia.
Ultrasonography is used to
outline and identifies fetal and maternal structures; assists in confirming gestational age and estimate delivery date; evaluating amniotic fluid volume.
Can be done abdominally (need to drink water to fill bladder) or transvaginal.
Biophysical profile is a…
noninvasive assessment of the fetus (breathing movements, movements, tone, amniotic fluid index, HR patterns) via a nonstress test.
A normal fetal biophysical activities indicate that…
the CNS is functional and that the fetus is not hypoxemic.
Percutaneous umbilicus blood sampling is performed if…
fetal blood sampling is necessary; insertion of needle into the fetal umbilical vessel under ultrasound guidance.
FHR monitoring for 1 hour after; follow up ultrasound to check for bleeding or hematoma formation 1 hour after.
a-Fetoprotein screening assesses the…
quantity of fetal serum proteins.
Can detect spinal bifida and down syndrome.
Abnormal fetus serum protein levels are associated with
open neural tube and abdominal wall defects.
Chorionic villus sampling is done for the detection of…
genetic abnormalities.
HCP aspirates small sample of the chorionic villus tissue at 10-13 weeks.
Rh-negative women may be given Rh0(D) immune globulin when completing chorionic villus sampling because…
chorionic villus sampling increases the risk of Rh sensitization.
Amniocentesis
aspiration of amniotic fluid at 15-20 weeks to determine genetic disorders, metabolic defects and fetal lung maturity.
Amniocentesis risks
- Maternal hemorrhage
- Infection
- Rh isoimmunization
- Abruptio placentae
- Amniotic fluid emboli
- Premature rupture of the membranes
When doing kick counts instruct the client to notify the HCP when…
there are fewer than 10 kicks in two consecutive 2-hour periods or as instructed by their HCP.
Fern test is a…
microscopic slide test to determine the presence of amniotic fluid leakage. A fernlike pattern produced by the effects of salts of the a. fluid indicate the presence of a. fluid.
Nitrazine test is used to..
detect the presence of amniotic fluid in vaginal secretions.
Vaginal secretion have a pH of
4.5-5.5 and do not affect the nitrazine strip or swab.
Amnotic fluid has a pH of
7.0-7.5 and turns the nitrazine strip or swab blue.
Fribronectin test
sampling of cervical and vaginal secretions for fetal fibronectin.
Fetal fibronectin
A protein present in fetal tissues normally found in cervical and vaginal secretions until 16-20 weeks and again at or near term.
Fibronectin positive test results indicates…
the onset of labor in 1-3 weeks.
Nonstress Test is performed to…
assess placental function and oxygenation; fetal wellbeing; FHR.
Done for at least 20 mins.
Reactive Nonstress Test (Normal, Negative) (Results)
“Reactive” indicates a healthy fetus.
Require 2 or more FHR accelerations of at least 15 beats/min, lasting at least 15 sec in a 20 min observation.
Nonreactive Nonstress Test (Abnormal) (Results)
No accelerations or accelerations of less than 15 beats/min or lasting less than 15 sec in duration during a 40 min observation.
Unsatisfactory Nonstress Test Results
The result cannot be interpreted because of the poor quality of the FHR tracing.
Contraction Stress Test assesses…
placental oxygenation and function; fetal ability to tolerate labor and wellbeing; assess the adequacy of placental perfusion under stimulated labor conditions.
Contraction Stress test is performed when..
the nonstress test in abnormal.
Contraction Stress Test process
- External fetal monitor
- 20-30 min baseline strip recorded
- Uterus stimulated to contract by administration of a dilute dose of oxytocin (Pitocin) or nipple stimulation until 3 palpable contraction with a duration of 40 second or more in a 10 min period has been achieved
- Frequent BP when increase oxytocin
Negative Contraction Stress Test (Normal) (Results)
A negative result is represented by no late decelerations of the FHR.
Positive Contraction Stress Test (Abnormal) (Results)
A positive result is represented by late decelerations of FHR, with 50 % or more of the contractions in the absence of hyperstimulation of the uterus.
Unsatisfactory Contraction Stress Test (Results)
means that adequate uterine contractions cannot be achieved, or the FHR tracing is of insufficient quality for adequate interpretation.
Nutritional Guideline during Pregnancy
Average expected weight gain is 25-35 lb for woman with a normal prepregnancy weight.
An increase of about 300 cal/day is needed.
Calories needs are greater in the last two trimesters than in the 1st.
An increase of about 500 cal/day is needed during lactation.
A diet high in folic acid and folic acid supplements is recommended.
8-10 glasses of fluid daily.
Pica
refers to eating nonfood substances (dirt, clay, starch, freezer frost).
Iron deficiency anemia may occur as a result of pica.
Labor
Coordinated sequence of involuntary intermittent uterine contractions.
Delivery
Actual event of birth
4 major factors (4 Ps's) interact during normal childbirth.
- Power
- Passageway
- Passenger
- Psyche
They are interrelated and depend on each other for a safe delivery.
Power (4 P’s)
Uterine Contractions.
- Forces acting to expel fetus.
- Effacement
- Dilation
- Pushing efforts of mother during the 2nd stage
Effacement
shortening and thinning of the cervix during the 1st stage of labor.
Dilation
Enlargement of cervical os and cervical canal during the 1st stage of labor.
Passageway (4 P’s)
The mother’s rigid bony pelvis and the soft tissues of the cervix, pelvic floor, vagina, and introitus (external opening to the vagina).
Passenger (4 P’s)
The fetus, membranes, and placenta.
Psyche (4 P’s)
A women’s emotional structure that can determine her entire response to labor and influence physiological and psychological functioning; the mother may experience anxiety or fear.
Attitude (L&D)
The relationship of the fetal body parts to one another.
Normal intrauterine attitude is…
flexion (fetal back is rounded, head is forward on the chest, arms/legs are folded in against body).
Lie (L&D)
Relationship of the spine of the fetus to the spine of the mother.
Longitudinal or vertical (Lie)
a. Fetal spine is parallel to the mother’s spine.
b. Fetus is in cephalic or breech presentation.
Transverse or horizontal (Lie)
a. Fetal spine is at a right angle, or perpendicular, to the mother’s spine.
b. Presenting part is the shoulder.
c. Delivery by cesarean section is necessary.
Presentation (L&D)
Port of the fetus that enters the pelvic inlet first.
- Cephalic: Head first
- Breech: Buttocks first
- Shoulder
Presenting part
The specific fetal structure lying nearest to the cervix.
Position
Relationship of assigned area of the presenting part or landmark to the maternal pelvis.
Station
Measurement of the progress of descent in cm above or below the midplane from the presenting part to the ischial spine.
Station 0
At ischial spine
Minus station
Above ischial spine
Plus station
Below ischial spine
Engagemtn
When the widest diameter of the presenting part has passed the inlet; corresponds to a 0 station.
Lightening or dropping
Also known as engagement and occurs when the fetus descends into the pelvis about 2 weeks before delivery
Mechanisms of Labor
- Engagement (fetus nestles into pelvis)
- Descent (fetal head undergoes journey through the pelvis; process from the time of engagement until birth; measurement called station)
- Flexion (fetal head forward toward chest)
- Internal Rotation
- Extension (beings after head crowns; is completed when head passes under the symphysis pubis and occiput)
- Restitution (realignment of fetal head with body after head emerges)
- External Rotation (shoulder externally rotate after head emerges)
- Expulsion (birth of the entire body)
True Labor
Contractions may manifest as back pain in some women; contractions often resemble menstrual cramps during early labor.
False Labor
Also known as prodromal labor, contractions are felts in the abdomen and groin and may be more annoying than painful.
Leopold’s Maneuvers - Description
Methods of palpation to determine presentation and position of the fetus and aid in location of fetal heart sounds.
Variability in Fetal Heart Rate
Absent Variability: Undetected variability
Minimal Variability: Greater than undetected but not more than 5 beats/min.
Moderate Variability: FHR fluctuations are 6-25 beats/min.
Marked Variability: FHR fluctuations are greater than 25 beats/min.
Fetal Bradycardia
Less than 110 beats/min for 10 minutes or longer.
Fetal Tachycardia
More than 160 beats/min for 10 mins or longer.
What to do if fetal bradycardia or tachycardia occurs
- Change the position of the mother
- Administer O2
- Assess mother’s vital signs
- Notify HCP as soon as possible
Decreased variability can result from..
fetal hypoxemia, acidosis, or certain medications. Can also occur when fetus is in a sleep state - doesn’t last longer than 30 minutes.
Accelerations
Brief, temporary increases in FHR of at least 15 beats/min more than baseline and lasting at least 15 seconds.
Early decelerations
Are decreases in FHR below baseline; the rate at the lowest point usually remains greater than 100 beats/min. Occur during contraction as the fetal head is pressed against pelvis or soft tissues.
Not associated with fetal compromise and require no interventions.
Late decelerations
Are nonreassuring patterns that reflect impaired placental exchange or uteroplacental insufficiency. Being well after the contraction beings and returns to baseline.
Interventions for late decelerations:
Immediately improve placental blood flow and fetal oxygenation.
Variable decelerations
Caused by conditions that restrict flow through the umbilical cord.
These are significant when FHR repeatedly declines to less than 70 beats/min and persists at that level for at least 60 sec before returning to baseline.
Interventions for variable decelerations
Change the position of the mother.
Administer O2.
Discontinue oxytocin (Pitocin) if infusing,
Assess mother’s vital signs.
Notify HCP
Assist when amnioinfusion (intrauterine instillation of warmed saline to decrease compression on the umbilical cord) if prescribed.
Hypertonic uterine activity
Assessment includes: frequency, duration, intensity of contractions, and uterine resting tone. Perform by palpation or with an internal uterine pressure catheter.
The uterus should relax between contractions for…
60 seconds or longer.
Uterine contraction intensity is…
about 50-75 mmHg during labor and may reach 110 mmHg with pushing during second stage.
Average resting tone is…
5-15 mmHg
Hypertonic uterine activity
when the uterine resting tone between contractions is high, reducing uterine blood flow and decreasing fetal O2 supply.
Nonreassuring Fetal Heart Rate Patterns
- Bradycardia
- Tachycardia
- Late decelerations
- Prolonged decelerations
- Hypertonic uterine activity
- Decreased or absent variability
- Variability decelerations falling to less than 70 beats/min for longer than 60 sec
Actions to Take for a Nonreassuring Fetal Heart Rate Pattern
- Identify the cause
- Discontinue oxytocin (Pitocin) infusion
- Change the mother’s position
- Administer O2 by face mask at 8-10 L/min and infused IV fluids are prescribed
- Prepare to initiate continue electronic fetal monitoring with internal devices if not contraindicated
- Prepare for cesarean delivery if necessary
- Document the event, actions taken and mother’s response
Four Stages of Labor
Stage 1: Latent phase; Active phase; Transition phase
Stage 2
Stage 3
Stage 4
Stage 1: Latent Phase
Cervical dilation 1-4 cm;
Uterine contractions q15-30 min, 15-30 secs duration, mild intensity.
Interventions: Assist with comfort measures, changes of position, ambulation; keep parents informed of progress; offer fluids and ice chips; encourage voiding q1-2 hours.
Stage 1: Active Phase
Cervical dilation 4-7 cm;
Uterine contractions q3-5 min, 30-60 secs duration, moderate intensity.
Interventions: Effective breathing patterns; quiet environment; keep informed of progress; promote comfort (pillow support, back rubs, position changes); offer fluids/ice chips; encourage voiding q1-2 hours.
Stage 1: Transition Phase
Cervical dilation 8-10 cm;
Uterine contractions q2-3 min, 45-90 secs duration, strong intensity.
Interventions: encourage rest between contractions; wake mother beginning of contraction to begin breathing patterns; provide privacy; offer fluids/ice chips; encourage void q1-2 hr.
Interventions throughout stage 1
- Monitor maternal vital signs
- Monitor FHR via ultrasound Doppler, fetoscope, or electronic fetal monitor.
- Assess FHR before, during and after a contraction, noting normal FHR is 110-160 beats/min.
- Monitor uterine contractions
- assess status of cervical dilation and effacement
- assess fetal station presentation and position
- assist with pelvic examination and prepare for a fern test.
Stage 2
Cervical dilation is complete;
Progress of labor is measured by descent of fetal head through the birth canal (fetal station);
Contraction q2-3 min, last 60-75 sec, strong intensity;
Increase in bloody show occurs;
Mother feels urge to bear down; assist with pushing efforts.
Interventions: assessments q5 min; vital signs, FHR; assist with pushing effort; Monitor for signs of approaching birth (head, perineal bulging); prepare for birth.
Stage 3
Contraction occur until placenta is expelled; Placental separation and expulsion 5-30 mins after birth of infant; Schultze mechanism; Duncan mechanism.
Interventions: vitals, uterine status, provide info about expulsion of placenta; examine placenta; assess shivering and provide warmth; promote parental neonatal attachment.
Stage 4
Period 1-4 hours after delivery.
Assessment:
- Blood pressure returned to prelabor level.
- Pulse slightly lower than during labor.
- Fundus remains contracted, in the midline, 1 or 2 fingerbreadths below the umbilicus.
Interventions: maternal assessment q15 min for 1 hr, q30 min for 1 hr, and hourly for 2 hours; provide warm blankets; ice packs to the perineum; massage the uterus if needed; provide breast-feeding supports.
Local anesthesia
Used to block pain during episiotomy;
Administered just before birth;
Has no effect on the fetus.
Lumbar epidural block
Injection site is in epidural space at L3 to L4;
Administered after labor is establishes or before a C-section;
May prolong Stage 2 and cause hypotension;
Administer fluids as prescribed for hypotension
Intrathecal opioid analgesics
Medication injected into the subarachnoid space and has a rapid onset of action;
May be used in combination with a lumbar epidural block.
Subarachnoid (spinal) block
Injection in the spinal subarachnoid space at L3 to L5; administered just before birth; may cause hypotension, headache; Must lie flat for 8-12 hours after.
General anesthesia
May be used for some surgical interventions; mother is not awake. Presents a maternal danger of respiratory depression, vomiting, and aspiration.
Bishop score
Used to determine maternal readiness for labor and evaluates cervical status and fetal position;
Is indicated before the induction of labor;
Five factors are assigned a score of 0-3, and total score is added; A score of 6 or more indicates a readiness for labor induction.
Induction
Is a deliberate initiation of uterine contractions that stimulates labor;
Elective induction may be accomplished by oxytocin infusion;
Obtain a baseline of FHR and contractions;
Increase dose as prescribed only after assessing contractions, FHR and BP and pulse of mother.
Do not increase when desired contraction pattern is obtained (q2-3 min and lasting 60 sec).
Amniotomy
Artificial rupture of the membranes is performed by the HCP to stimulate labor; Performed in fetus is at 0 or a plus station; Increases the risk of prolapsed cord and infection; Monitor FHR.
External version
The manipulation of the fetus from an abnormal position into a normal presentation; Is indicated for abnormal presentation after 34th week;
Monitor vital sings;
Prepare nonstress test;
Premature rupture of the membranes refers to…
spontaneous rupture of the amniotic membranes before the onset of labor.
When the rupture of membranes is before term and delivery will be delayed, _____ becomes a risk.
infection
Premature Rupture of the Membranes - Assessment
- presence of fluid pooling in vaginal vault; nitrazine test is positive.
- amount, color, consistency, and odor of fluid needs to be assessed.
- Vital signs, elevated temp may indicate infection.
- fetal monitoring, tachycardia may indicate infection.
Premature Rupture of the Membranes - Interventions
- assist with test to assess gestational age.
- avoid vaginal examinations due to risk of infection.
- monitor maternal and fetal status for infection.
- administer antibiotics as prescribed.
Prolapse Umbilical Cord - Description
The umbilical cords is displaced between the presenting part and the amnion or protruding through the cervix, causing compression of the cord and compromising fetal circulation.
Prolapse Umbilical Cord - Assessment
- Pt has feeling that something is coming through the vagina.
- Umbilical cord is visible or palpable.
- FHR is irregular and slow
- FHR shows variable decelerations or bradycardia after rupture of membranes.
- If fetal hypoxia is severe, violent fetal activity may occur and then cease.
Steps to Take if Umbilical Cord Prolapse is Suspected
- Elevate the fetal presenting part that is lying on the cord by applying finger pressure with a gloved hand.
- Place the pt into extreme Trendelenburg’s or modified Sims’ position or a knee-chest position.
- Administer O2 (8-10L/min) by face mask.
- Monitor FHR and assess for fetal hypoxia.
- Prepare to start IV fluids or increase rates.
- Prepare for immediate birth.
- Document event, actions taken and pt’s response.
Placenta Previa
Is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os.
Total Placenta Previa
The internal cervical os is covered entirely by the placenta when the cervix is dilated fully.
Partial Placenta Previa
The lower border of the placenta is within 3 cm of the internal cervical os, but does not fully cover it.
Marginal Placenta Previa
The placenta is implanted in the lower uterus, but its lower border is more than 3 cm from the internal cervical os.
Placenta Previa - Assessment Findings
- Sudden onset of painless, bright red vaginal bleeding occurs in the last half of pregnancy.
- Uterus is soft, relaxed, and nontender.
- Fundal height may be more than expected for gestational age.
Placenta Previa - Interventions
- Monitor mom’s vital, FHR, and fetal activity.
- Prepare for ultrasound to confirm diagnosis.
- Vaginal exam or other actions that would stimulate uterine activity are avoided.
- Maintain bed rest in a side-lying position.
- Monitor amount of bleeding (treat signs of shock).
- Administer IV fluids, blood products, or medications as prescribed.
- if bleeding heavy, a cesarean delivery may be performed.
_____ are contraindicated if the client is suspected of having or has a known placenta previa.
Vaginal exams
Abruptio Placentae
Premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered.
Abruptio Placentae - Assessment
- Dark red vaginal bleeding. If the bleeding is high in the uterus or is minimal, there can be an absence of visible blood.
- Uterine pain or tenderness or both.
- Uterine rigidity
- Severe abdominal pain
- Signs of fetal distress
- Signs of maternal shock if bleeding is excessive.
Abruptio Placentae - Interventions
- Vital and FHR
- Assess for vaginal bleeding, abdominal pain and increase in fundal height.
- Bed rest; O2; IV fluids/Blood products as prescribed
- Place pt in Trendelenburg’s position to dercrease pressure of fetus on the placenta, or in lateral position in HOB flat if hypovolemic shock occurs.
- monitor/report uterine activity
- Prepare for delivery
- Monitor for signs of disseminated intravascular coagulation in the postpartum period.
Differences between Placenta Previa and Abruptio Placentae
In placenta previa, there is painless, bright red vaginal bleeding, and the uterus is soft, relaxed, and nontender. In abruptio placentae, there is dark red vaginal bleeding, uterine pain or tenderness or both, and uterine rigidity.
Supine Hypotension (Vena Cava Syndrome)
Occurs when the venous return to the heart is impaired by the weight or the uterus on the vena cava.
The syndrome results in partial occlusion of the vena cava and aorta and in reduced cardiac return, cardiac output, and BP.
Supine Hypotension (Vena Cava Syndrome) - Assessment Findings
- Pallor
- Faintness, dizziness, breathlessness
- Tachycardia, Hypotension
- Sweating, cool and damp skin
- Fetal distress
Supine Hypotension (Vena Cava Syndrome) - Interventions
- Position pt on side to shift the weight of the fetus off the vena cava until signs and symptoms subside and vital signs stabilize.
- Monitor vitals and FHR
To prevent supine hypotension:
- avoid the supine position
2. position client by placing a pillow/wedge under the pt’s hip to displace the gravid uterus off the vena cava.
Placental Abnormalities (3)
- Placenta accreta: an abnormally adherent placenta.
- Placenta increta: occurs when the placenta penetrates the uterine muscle itself.
- Placenta percreta: occurs when the placenta goes all the way through the uterus.
Placental Abnormalities - Assessment
May cause hemorrhage immediately after birth because the placenta does not separate cleanly.
Placental Abnormalities - Intervention
- Monitor for hemorrhage and shock
2. Prepare client for a hysterectomy if a large portion of the placenta is abnormally adherent.
Preterm Labor
Occurs after the 20th week but before the 37th week of gestation.
Preterm Labor Risk Factors
Hx of medical conditions; present/past obstetric problems; infection; substance use; multifetal pregnancy; anemia; decrease O2 supply to uterus; age younger than 18 or 1st pregnancy and age older than 40 years.
Preterm Labor - Assessment
- Uterine contractions (painful or painless)
- Abdominal cramping
- Lower back pain
- Pelvic pressure or heaviness
- Changes in character and amount of discharge
- Rupture of amniotic membranes
Preterm Labor - Interventions
- Focus on stopping labor (infection?; restrict activity; ensure hydration).
- Bed rest and lateral position
- monitor fetal status
- administer fluids and medication as prescribed
Precipitous Labor and Delivery
Labor lasting less than 3 hours
Precipitous Labor and Delivery - Interventions
- Have precipitous delivery tray available (hemostats, scissors, cord clamp).
- Stay with client at all times.
- Provide emotional support and keep pt calm.
- Encourage client to pant between contractions.
- Prepare for rupturing membranes when the head crowns, if they are not already ruptured.
- Do not try to keep the fetus from being delivered.
Dystocia
Is difficult labor that is prolonged or more painful. Occurs because of problems caused by uterine contractions, the fetus, or the bones and tissues of the maternal pelvis. May have hypotonic or hypertonic contractions. Can cause maternal dehydration, infection, fetal injury, or death.
Hypotonic Contractions
Short, irregular, and weak; amniotomy and oxytocin (Pitocin) infusion may be treatment measures.
Hypertonic Contractions
Painful, occur frequently, and are uncoordinated; treatment depends on the cause and includes pain relief measures and rest.
Dystocia - Assessment
- Excessive abdominal pain
- Abnormal contraction pattern
- Fetal distress
- Maternal of fetal tachycardia
- Lack of progress in labor
Dystocia - Interventions
- Assess FHR; monitor for fetal distress.
- Monitor uterine contractions
- Monitor for maternal temp and HR.
- Assist with pelvic exam, measurements, ultrasounds, etc.
- Administer IV fluid and antibiotics as prescribed
- Monitor I&O
- Maintain hydration
- Breathing techniques and relaxation exercises.
- Monitor color of amniotic fluid
- Assess for prolapse of cord after membranes rupture.
Amniotic Fluid Embolism
Is the escape of amniotic fluid into the maternal circulation. The debris-containing amniotic fluid deposits in the pulmonary arterioles and is usually fatal to the mother.
Amniotic Fluid Embolism - Assessment Findings
- Abrupt onset of respiratory distress and chest pain.
- Cyanosis
- Fetal bradycardia and distress if delivery has not occurred at the time of the embolism.
Amniotic Fluid Embolism - Intervention
- Institute emergency measures to maintain life.
- Administer O2 (8-10L/min face mask or resuscitation bad delivering 100% O2).
- Prepare for intubation and mechanical ventilation.
- Position pt on side.
- IV fluids, blood product, medication to correct coagulation failure.
- Monitor fetal status
- Prepare for emergency delivery when the pt is stabilized.
- Provide emotional support to pt, partner, family.
Fetal Distress - Assessment Findings
- FHR less than 110bpm or greater than 160bpm.
- Meconium-stained amniotic fluid.
- Fetal hyperactivity.
- Progressive decrease in baseline variability.
- Severe variable decelerations.
- Late decelerations
Fetal Distress - Interventions
- Place pt in a lateral position.
- Administer O2 (8-10L/min via face mask).
- Discontinue oxytocin if infusing.
- Monitor maternal and fetal status.
Intrauterine Fetal Demise - Assessment
- Loss of fetal movement
- Absence of fetal heart tones
- Disseminated intravascular coagulation (monitor for coagulation abnormalities because DIC is a complication r/t to intrauterine fetal demise).
- Low hct and hgb, platelets; prolonged bleeding and clotting time.
- Bleeding from puncture sites (could indicate DIC).
Intrauterine Fetal Demise
or still born. Medical term for a baby that dies in the womb after the 20th week of pregnancy.
Intrauterine Fetal Demise - Interventions
- Encourage pt and family to verbalize feelings; provide support.
- Incorporate religious and cultural health care beliefs and practices in the plan of care.
- Allow client choices r/t to labor and delivery.
- Administer IV fluids, medications, blood products as prescribed in DIC occurs.
Rupture of the Uterus
Complete or incomplete separation of the uterine tissue as a result of a tear in the wall of the uterus from the stress of labor.
Complete Rupture of the Uterus
Direct communication between the uterine and peritoneal cavities.
Incomplete Rupture of the Uterus
Rupture into the peritoneum covering the uterus, but not into the peritoneal cavity.
Rupture of the Uterus - Risk Factors
Labor after previous cesarean section, overdistended uterus (multiple fetuses or hydramnios) after cesarean section, abdominal trauma.
Hydramnios
is a condition that occurs when too much amniotic fluid builds up during pregnancy.
Rupture of the Uterus - Assessment Findings
- Abdominal pain or tenderness
- Chest pain
- Contractions may stop or fail to progress
- Rigid abdomen
- Absent of FHR
- Signs of maternal shock
- Fetal palpated outside the uterus (complete rupture)
Rupture of the Uterus - Interventions
- Monitor and treat signs of shock (O2, IV fluids, blood products).
- Prepare for cesarean delivery
- Provide support
Uterine Inversion
Uterus completely or partly turns inside out;
Can occur during delivery or after delivery of the placenta.
Uterine Inversion - Risk Factors
Fundal implantation of the placenta, manual extraction of the placenta, short umbilical cord, uterine atony, leiomyomas, abnormally adherent placental tissue.
Uterine Inversion - Assessment Findings
- Depression in the fundal area of the uterus is noted.
- Interior of the uterus may be seen through the cervix or protruding through the vagina.
- Severe pain
- Hemorrhage is evident
- Signs of shock
Uterine Inversion - Interventions
- Monitor for hemorrhage and signs of shock (treat if needed).
- Prepare for a return of the uterus to the correct position via the vagina; if unsuccessful, laparotomy with replacement to the correct position is done.
Postpartum
Period when the reproductive tract returns to the normal, nonpregnant state.
Starts immediately after delivery and completed by week 6 following delivery.
Involution
The rapid decrease in the size of the uterus as it returns to the nonpregnant state. Mom’s who breastfeed may experience a more rapid involution because of the release of oxytocin during breastfeeding.
The weight of the uterus decreases from approximately __ to ___ in __ weeks
2lbs; 2oz; 6 weeks
Fundal height decreases about ___/day (postpartum)
1 cm/day
By __ days postpartum, the uterus cannot be palpated abdominally.
10 days
A flaccid fundus indicates _____ and it should be ____.
uterine atony; massaged until firm (tender fundus indicates an infection).
Lochia
Discharge from the uterus that consists of blood from the vessels of the placental site and debris from the decidua.
Ruba
Bright red discharge that occurs from delivery day to day 3.
Serosa
Brownish pink discharge that occurs from days 4 to 10.
Alba
White discharge that occurs from days 11-14.
Cervix - Postpartum
Cervical involution occurs, and the muscle beings to regenerate after 1 week.
Vagina - Postpartum
Vaginal distention decreases, although muscle tone is never restored completely to the pregravid state.
Menstrual flow resumes ____ in non-breast-feeing mothers and ____ in breast-feeding mothers.
1-2 months; 3-6 months
Breast continue to secrete colostrum for _____ after delivery.
the first 48-72 hours
A decrease in ___ and ___ levels after delivery stimulates increased ____ levels, which promote breast milk production.
estrogen; progesterone; prolactin
Breasts become distended with milk on the __ day.
third
Engorgement occurs on approx day __ in both breast-feeing and non-breast-feeing mothers.
4
Breast-feeding relieves engorgement.
Breast Care for Non-Breast-Feeding Mothers
Avoid nipple stimulation;
Apply a breast binder, wear a snug-fitting bra, apply ice packs, or take a mild analgesic for engorgement;
Engorgement usually resolves within 24-36 hours after it begins.
Postpartum Interventions
- Vital signs
- Pain level
- Assess height, consistency, location of fundus
- Monitor color, amount, odor of lochia
- Assess breast for engorgement
- Monitor perineum for swelling or discoloration
- Monitor for perineal lacerations or episiotomy for healing
- Assess incision or dressing from c-section
- monitor bowel status
- I&O
- Void frequently
- Encourage ambulation
- Assess bonding with newborn and emotional state
- Administer Rh D immune globulin as prescribe within 72 hours postpartum to Rh negative pt who has given birth to Rh positive newborn.
If the mother is breast-feeding, calories needs increase by _____, and the client may require to increase fluid and vitamins and minerals.
200-500 cal/day
Bowel movements soften by the __ day postpartum.
3-4th day
Cystitis
An infection of the bladder;
Can occur in the postpartum period and the postpartum woman should be encouraged to consume adequate fluids and void frequently to avoid bladder distention.
Hematoma
Is a localized collection of blood in the tissues and can occur internally, involving the vaginal sulcus or other organs; vulvar hematomas are the most common. Can be life-threatening.
Hematoma - Assessment Findings
- Abnormal, sever pain
- Pressure in the perineal area
- Sensitive, bulging mass in the perineal are with discolored skin.
- Inability to void
- Decrease hbg and hct
- Signs of shock if significant blood loss occured.
Hematoma - Internvetions
- Vitals
- Monitor pain or perineal pressure
- Place ice at the hematoma site
- Administer analgesics a.p.
- I&O
- encourage fluids and voiding
- Prepare for urinary catheter if unable to void
Hemorrhage
Bleeding of 500 mL or more after delivery;
Primary cause of maternal mortality.
Hemorrhage - Intervention
- Massage fundus for uterine atony.
- Monitor vitals and for shock.
- notify HCP is signs of shock or if hemorrhage.
- Assess and estimate blood loss by pad count (1 gram= 1mL of blood).
- assess LOC
- monitor Hgb and Hct
Early Hemorrhage
Hemorrhage occurs during the 1st 24 hours after delivery.
Late Hemorrhage
Occurs after the 1st 24 hours following delivery.
Infection - Postpartum
Any infection of the reproductive organs that occurs within 28 days of delivery or abortion.
Infection - Postpartum ( Assessment Findings)
- Fever
- Chills
- Anorexia
- Pelvic discomfort or pain
- Vaginal discharge that is malodorous; normal vaginal discharge has a fleshy odor or an odor similar to a menstrual period.
- Elevated WBCs
A temp of 100.4 F is ____ during the 1st 24 hours; A temp of 100.4 or greater after 24 hours indicates __.
normal; infection
Mastitis
Inflammation of the breast as a result of infection.
Primarily in BF mothers 2-3 weeks after delivery.
Mastitis - Assessment Findings
- Localized heat and swelling.
- Pain; tender axillary lymph nodes.
- Elevated temp
- Complaints of flulike symptoms
Mastitis - Interventions
Good hand washing; promote comfort; apply heart/cold to the site; encourage manual expression of breast milk or use a pump q2hours; support breast with supportive bra, avoid underwire; analgesics; antibiotics.
Pulmonary Embolism
Passage of a thrombus, often originating in a uterine or other pelvic vein, into the lungs, where it disrupts the circulation of the blood.
Pulmonary Embolism - Assess Findings
- Sudden dyspnea and chest pain.
- Tachypnea and tachycardia.
- Cough and lunch crackles.
- Hemoptysis.
- Feeling of impending doom.
Pulmonary Embolism - Interventions
- Administer O2
- Increased HOB
- Vital signs
- Monitor for respiratory distress and for signs of increasing hypoxemia.
- IV fluids; anticoagulants.
Subinvolution
Incomplete involution or failure of the uterus to return to its normal size and condition.
Subinvolution - Assessment Findings
- Uterine pain on palpation.
- Uterus larger than expected.
- More than normal vaginal bleeding.
Subinvolution - Interventions
- Vitals
- Assess uterus and fundus
- Monitor uterine pain and vaginal bleeding
- Elevate legs to promote venous return
- Monitor hgb and hct.
- Prepare to administer methylergonovines maleate (Methergine), which provides sustained contraction of the uterus, as prescribed.
Thrombophlebitis
A clot forms in a vessel wall as a result of inflammation of the vessel wall; partial obstruction of the vessel can occur.
Types of Thrombophlebitis
- Superficial thrombophlebitis
- Femoral thrombophlebitis
- Pelvic thrombophlebitis
Superficial Thrombophlebitis- Assessment Findings
Palpable thrombus that feels bumpy and hard;
Tenderness and pain in affected lower extremity;
Warm and pinkish red color over the thrombus area.
Femoral Thrombophlebitis - Assessment Findings
Malaise; Chills and fever; Diminished peripheral pulses; Shiny white skin over affected area; Pain, stiffness, and swelling of affected leg.
Pelvic Thrombophlebitis- Assessment Findings
Severe chills; Dramatic body temp changes; Pulmonary embolism may be the first sign.
Thrombophlebitis - Interventions
Specific therapy depends on the location;
Assess lower extremities for edema, tenderness and increase skin temp; maintain bed rest, elevate affected leg; never massage the leg; Heparin may be ordered.
Client Education for Thrombophlebitis
Never massage the leg; avoid crossing the legs; avoid prolonged sitting; avoid constrictive clothing; avoid pressure behind the knees; anticoagulant medication; stockings.
Perinatal Loss
Is associated with miscarriage, neonatal death, stillbirth, and therapeutic abortion.
Chorioamnionitis
Bacterial infection of the amniotic cavity; can result from premature or prolonged rupture of the membranes, vaginitis, amniocentesis, or intrauterine procedures. May cause postpartum endometritis and neonatal sepsis.
Uterine tenderness; increase temp; tachycardia; foul odor to amniotic fluid; leukocytosis.
Disseminated Intravascular Coagulation (DIC)
Clotting cascade is activated, resulting in the formation of clots in the microcirculation. Dead fetus syndrome is considered a risk factor.
The 3 classic signs of preeclampsia are:
hypertension, generalized edema, and proteinuria.
