Labor & Delivery

Birthing Options
Home Delivery
Pros:
● Greater control over the birthing
experience
● Familiar setting
● High chance of vaginal birth
● Fewer medical interventions will be used
● More support and individualized care
● More unlimited skin-to-skin time with
baby
● Reduced cost
● Religious and cultural beliefs are often
easier to follow in the home setting.
Birthing Center
Pros:
● A good option for women who want an
unmedicated, low intervention birth.
● The rooms are built to feel like home, not
a hospital.
● Water births are encouraged/allowed
● The center will deal with the clean up
● Often, they offer more personalized care
options, like being one-on-one with a
midwife.
Cons:
● It is less safe for both the mother and
baby, especially if there are underlying
conditions or risk factors (placenta previa,
pre-eclampsia, GDM, etc)
● Insurance will often not cover the costs of
a home birth.
● It is still possible that the mother/baby
will need transfer to the hospital in an
emergency
● It’s mess! Have plastic sheets, towels,
plastic wading pool, etc.
Cons:
● Women are generally sent home about 6
hours after birth.
● There are no medications available
● No food/meals are offered during the stay
● They generally do not have lactation
consultants on staff.
● Insurance will often not cover the costs
● If an emergency happens, mother and
baby may need to be transported to the
hospital.
Hospital
Pros:
● If an emergency happens, there is
equipment on site to treat mother and/or
baby quickly.
● The mother and baby’s health is CLOSELY
attended to by a team of medical
professionals
● Meals, medications, sanitary napkins,
toiletries, etc are all provided.
● There are specialists to help with skills
like breastfeeding.
Delivery Methods
Cons:
● It’s hard to rest as people are often in and
out of the room constantly.
● Sterile environment
● It is more difficult to follow a natural birth
plan
● Many holistic birthing options, like water
birth, are not an option.
● It is important to have an advocate
● It teaching hospitals, there can be several
students observing your care (although
they SHOULD ask first).
● There is an increases risk of exposure to
infectious disease.
Vaginal Delivery
● The baby is born through the vaginal/birth canal.
● Most women naturally give birth around 39-41 weeks
● Recommended unless there is a medical reason for a c-section.
● Benefits:
○ Shorter hospital stays
○ Fewer infections
○ Faster maternal recovery
○ Babies have a lower risk of respiratory issues when born vaginally.

Cesarean Section
● A delivery of the baby that is completed by making a surgical incision in the
mother’s abdomen and uterus.
● While this can be scheduled in advance, this is often done in a response to
an unforeseen complication.
● Events requiring c-section:
○ Multiples
○ Macrosomia
○ Prior C-sections or other uterine conditions
○ Malposition of the fetus–breech (bottom first) or transverse (sideways position)
○ Placenta previa
○ Fibroid or other large obstruction
● Ultimately, this is a major surgery, requiring longer recovery times. Therefore,
it should only be done for medical reasons.
Cesarean Section cont.
Low Transverse (horizontal) Incision: Vertical (classical) Incision:

● This incision cuts across the lower, thinner
part of the uterus. These muscles don’t
contract as strongly as the upper uterus
(fundus) during labor.
● Unlikely to rupture during a subsequent
labor and delivery.
● This is usual practice for ob/gyns since the
1970’s.
● Rupture risk of 0.5-0.9% per every birth.
● This incision cuts up and down through
the muscles of the uterus that contract
very strongly during labor.
● Therefore, it is more likely to rupture
during a subsequent labor, The risk is
higher if the incision is higher up on the
uterus.
● Rarely used now, unless the uterus has
dense scar tissue or adhesions. Also used
in morbid obesity.
● Rupture risk of 4-9%.

Vaginal Delivery after C-Section

● VBAC-Vaginal Birth After C-section
● Historically, when a woman had a c-section, she wasn’t able to try for a
vaginal birth in the future. Now, however, it is estimated that about 75% of
women who try VBAC have a successful vaginal delivery.
● It isn’t for everyone, as some conditions remove the possibility of a
successful VBAC (ex. Placenta previa).
● Not all hospitals offer the option, as smaller systems tend to lack the staff
and resources to perform an emergency c-section if the VBAC attempt fails.
● The most serious risk is for uterine rupture. While this is a rare outcome, it is
known to lead to serious harm to both the mother and baby.
Vacuum Delivery
● A procedure used to assist with a vaginal childbirth.
● The provider uses this by applying the vacuum (a soft cup with a handle and
vacuum pump) to the baby’s head.
● Using gentle traction, this will help guide the baby out of the birth canal.

Forceps Delivery
● A forceps delivery is considered a type of operative vaginal delivery.
● The provider applies the forceps (which look like a large salad tongs) to the
baby’s head. This helps to gently guide the head through the canal.
● It is very important that the head is grasped gently. Injuries include bruising,
facial palsies and even brain damage/cerebral palsy)
 Signs and Symptoms of Labor
True vs False Contractions
True Labor
● Contractions are regular, with the interval
getting shorter and shorter with time.
● Regardless of whether the mother moves
or rests, the contractions will continue.
● The intensity of contractions will get
increasingly strong.
● For many women, they tend to start in the
lower back on move towards the front of
the abdomen.
The 5-1-1 Rule
False Labor
● Irregular contractions that DO NOT get
closer together.
● Contractions stop with walking, resting or
changing position.
● They are generally weak and irregular
● The pain is generally felt primarily in the
front.
Amniotic Sac Rupture
● This can occur while a woman is actively in labor, or before a woman starts
laboring (contracting). Typically, if the rupture happens first, contractions
soon follow.
● Rarely is there a gush of fluid. Typically, about 90% of the time, the rupture
will present as more of a steady trickle of fluids.
● PROM=Premature Rupture of Membranes
● PPROM=Preterm Premature Rupture of Membranes
● AROM=Artificial Rupture of Membranes, aka: Amniotomy

Other Signs
● Bloody show
● Mucous Plug
● Back pain–especially in the lower back
● Nausea and Vomiting

Ultimately, it is up to the provider to determine when a patient is likely in

labor. The gold standard is to perform a cervical check as contractions that
lead to cervical dilation = true labor!
How to Assess Cervical Changes
Dilation Effacement

● The cervix must grow from 0 to 10 cm ● As the cervix dilates, it also thins out.
in order for the baby to fit through the ● It is measured in percentages with the
birth canal. help of the index finger!

NCLEX Question
A primigravida patient at 38 weeks arrives at the hospital maternity triage unit
reporting a "sudden gush of clear fluid" from her vagina shortly before
arrival. The maternity triage nurse suspects the patient has experienced a
prelabor rupture of membranes (PROM). Which of the following is the most
appropriate method for the nurse to use to confirm her suspicion?

A. An internal vaginal examination

B. Ultrasound
C. Nitrazine paper test
D. A Gram stain
Answer: C
Choice C is correct. Nitrazine paper is used to measure the pH of the fluid
to determine if the amniotic membrane has ruptured. Once the fluid
comes into contact with nitrazine paper, the pH of the fluid will cause the
paper's color to change. The resulting color will correlate to a pH allowing
the nurse to decipher whether the fluid is amniotic fluid (i.e., PROM) or
vaginal fluid.

NCLEX Question
Which of the following are symptoms of true labor? Select all that apply.

A. Contractions that dissipate with walking

B. Contractions that come in regular intervals
C. Lower back pain
D. Contractions of consistent intensity
Answer: B and C
Choices B and C are correct. Contractions that come in regular intervals
are a sign of actual labor. You should educate mothers to seek care for
contractions that occur at regular intervals, become stronger, and closer
together with time. These contractions will also not go away with a change
in position or activity (Choice B). Lower back pain is a sign of actual labor.
Both lower back pain and pelvic pain indicate real labor, so mothers
should be educated to seek treatment when such symptoms present.
'False' labor, or Braxton hicks, do not present with these symptoms. They
are much weaker than contractions and typically subside with a change in
position or by going on a short walk (Choice C).

Induction of Labor
Why are some women induced?
● Post-term pregnancy (>1-2 weeks after the full term due date)
● PROM
● Growth restriction
● Macrosomia/Uncontrolled GDM
● High Blood Pressure/Preeclampsia
● Uterine infection
● Rh incompatibility
● Placental abruption
● Maternal medical conditions involving the heart, lungs, kidneys. Also severe obesity.
● HIstory of a precipitous labor
● Elective labor induction

Preterm Birth
Risk factors:
● History of premature delivery
● Pregnant with multiples
● Short time between pregnancies (less than 18 months)
● Conception through IVF
● History of problems with the uterus, cervix or placenta
● Use of cigarettes or illicit drugs
● Infection
● Physical injury or trauma to the abdomen
● Stressful life events
● Chronic conditions like diabetes or high blood pressure

OB Pharmacology
Tocolytics
Slow contractions

○ Terbutaline
○ Magnesium-sulfate

Oxytotics
Stimulate contractions

○ Oxytocin

Terbutaline
• Therapeutic class: Selective Beta 2 adrenergic agonist.

• Mechanism of action: Binds to beta 2 adrenergic receptors in the respiratory system to cause
bronchodilation by inhibiting the release of hypersensitivity reaction products from mast cells.
ALSO works on beta 2 receptors in the uterus to slow or stop contractions.

• OB Indications
• Preterm labor
• Nursing considerations:
• SE: shakiness, jitteriness, dizziness, drowsiness, sleep disturbances, weakness, headache,
nausea, vomiting tachycardia, hypertension, hyperglycemia. CNS overstimulation.
• Assess HR, BP, EKG, blood glucose
• Monitor HR of mom and baby when used in labor. Monitor fetal heart monitor strips
closely.
• Monitor EKG
Magnesium-sulfate
Therapeutic class: Electrolyte

Indication: Hypomagnesemia, torsade de point, pre-eclampsia, preterm labor,

seizures, asthma exacerbation

Nursing Considerations:

● Monitor for hypermagnesemia

○ Confusion, dizziness, weakness, decreased reflexes
● Give IV slowly

Oxytocin
Therapeutic class: Hormones

Indication: Induction of labor; PPH

Action: Stimulates uterine smooth muscle causing it to contract

Nursing Considerations:

● Monitor contractions
● Monitor fetus
● Warn mother contractions will be more painful
● Monitor BP, HR, glucose, and K
 Prostaglandins
Ripen the cervix

Prostaglandin E1 (Misoprostol)

Prostaglandin E2 (Dinoprostone)

Misoprostol
Therapeutic class: Prostaglandin E1 analogue

Indication: Stomach ulcers, induction of labor, elective pregnancy termination, D&C

Action: Inhibits acid secretion through stimulation of the prostaglandin E1 receptors in

the stomach. It also causes the cervix to soften and the uterus to contract.

Nursing considerations:

● Closely monitor uterine contraction and the FHR in response to the contractions.
● Can be given SL or Vaginally.
● Use with caution in women who have had a prior uterine surgery, as it can
increase the risk of uterine rupture.
Dinoprostone
Therapeutic class: Prostaglandin E2 Analogue

Indication: Induction of labor, elective termination of pregnancy

Action: Stimulates the muscles in the uterus to contract and also causes cervical
dilation.

Nursing considerations:

● Closely monitor uterine contractions and the FHR in response to the contractions.
● It can be given as a vaginal gel or a vaginal suppository.
● It can very slightly increase the risk for Amniotic Fluid Embolism.

NCLEX Question
A client presents to the obstetrics floor at 39 weeks gestation with irregular contractions.
After you get the client situated in a labor, delivery, and
recovery room, you notice the client's health care provider (HCP) enter the room to evaluate
the client. Following the evaluation, the HCP exits the
room, and shortly thereafter, you enter. During your discussion, the client states the HCP
"went to order oxytocin." In anticipation of that order, you
understand this client's oxytocin will be administered via which route of administration?

A. Intramuscular administration
B. Intravenous administration via mainline infusion using an infusion pump
C. Intravenous administration via piggyback using an infusion pump
D. Oral administration
Answer: C
Choice C is correct. Oxytocin should always be administered
intravenously as a piggyback infusion. Intravenous infusion is the only
acceptable method of parenteral administration of oxytocin for the
induction or stimulation of labor. Accurate control of the infusion rate is
essential and is best accomplished by an infusion pump. The current FDA
recommendation is "to piggyback the Pitocin (oxytocin) infusion on a
physiologic electrolyte solution, permitting the Pitocin (oxytocin) infusion
to be stopped abruptly without interrupting the electrolyte infusion."
 Pain Control Methods

Natural methods
● Hypnobirthing
● Hydrotherapy
● Touch therapy
● Movement
● Positioning
● Breathing
Nitrous Oxide
● First made popular in Europe and Australia, this method is becoming more
common throughout U.S. hospitals as a minimally invasive tool to manage
labor pain.
● A tasteless and odorless gas that is mixed with oxygen through a mask.
● The mother will hold the mask and decide when to take a breath–this
typically is most effective if the mother begins to inhale about 30 seconds
before the onset of a contraction.
● It helps to reduce anxiety and causes a feeling of well-being.
● It does not limit movement for the patient, slow labor or cause significant risk
for the baby.

Systemic Analgesics
● Lessens the pain without a loss of feeling or muscle movement.
● Typically, the medications used are Opioids, given through the I.V.
● Typical narcotics given in labor include:
○ Meperidine (Demerol), Butorphanol (Stadol), Morphine and Nalbuphine (Nubain)
● These typically “take the edge off”, but the bulk of the pain will remain.
● These do cross the placenta, so limited use is better, as it can lead to
respiratory depression in both the mother and baby. However, with
regulated use, APGAR scores are generally not or minimally impacted.
● Some hospital limit use an hour prior to expected delivery to lessen sedation
in the newborn. This can impact breathing and the first breastfeeding
attempts.
Local Anesthetics
● This method is often used if an incision needs to be made the vaginal
opening bigger (episiotomy) or to repair a laceration/tear that occured during
delivery.
● It will very quickly numb a specific area and negative effects to the mother or
baby are rare.
● This will do nothing to relieve the pain from contractions, so typically women
use this in addition to other forms of pain control.

Regional Anesthesia–Epidural
● Small catheters are placed into the lower spine that slowly pumps pain
medication to that area. This will stop pain signals from traveling from your
spine to the brain.
● This method removes the most pain without slowing labor much. The
mother is awake and alert and should still be able to feel
pressure/contractions to know when to push.
● They don’t always work–some women report no or partial pain relief if the
catheter wasn’t placed correctly.
● They can drop blood pressure quickly–monitor closely!
● Many women with an epidural cannot walk or move their lower
extremities–sometimes a catheter is placed in the bladder in this case.
Regional Anesthesia–Spinal Block
● Typically used for pain control during a planned C-section.
● This medication is injected directly into the fluid of the spinal cord and will
block pain for a couple of hours. It takes effect very quickly, so it also may be
given if a painful procedure is needed during a vaginal delivery (vacuum
assist).
● It will completely remove any pain from the lower body for 1-2 hours.
● It may decrease blood pressure, so monitor closely. In rare cases, this will
also lead to a drop in fetal HR.

General Anesthesia
● This is reserved for use only during emergency situations.
● It may also rarely be used if a spinal/epidural won’t work (history of spinal
injury).
● This causes complete loss of sensation and consciousness.
● It will delay how quickly the mother can bond with her new baby and often
impacts breastfeeding negatively.
● Risks of this method include:
○ Inability to place the ETT, increased risk for pneumonia/lung infections.
○ Anesthetic medication toxicity
○ Respiratory depression in the newborn
○ Fetal lethargy
○ Longer hospital stays and recovery times.
Station
● How far down in the
birth canal the baby is.
● Measured in relation to
mom’s ischial spine
○ Most narrow spot
○ At ischial spine = 0 station
 Stages of Labor

First Stage
● It begins when labor starts (contractions that begin to cause cervical
changes/dilation).
● It ends, when the cervix is fully dilated to 10cm.
● This is further divided into 2 phases: latent and active phase
● Latent phase is when the cervix dilates from 0 to 6 cm. Slower and less
predictable
● Active phase is the dilation that occurs from 6 to 10 cm. Faster, with a more
predictable rate of cervical changes.
● The lack of any cervical dilation for 4 hours or greater (despite adequate
contractions) indicates an arrest of labor.
Second Stage
● This stage begins when the cervix is fully dilated to 10 cm and ends when
the neonate is fully delivered.
● The fetus will pass through the birth canal with 7 cardinal movements
during this stage: engagement, decent, flexion, internal rotation, extension,
external rotation, and expulsion.
● This is the pushing stage, and typically lasts up to 3 hours for nulliparous
women and up to 2 hours for multiparous women. This stage can take longer
if a women gets an epidural.
● Multiple elements determine how long this stage takes, including fetal size
and position, maternal pelvis shape and pushing ability and other factors like
chronic health issues, age and prior deliveries.

Third Stage
● Starts when the fetus is fully delivered and ends when the placenta has
been delivered.
● Separation of the placenta from the uterine wall includes 3 distinct signs:
○ A gush of blood from the vagina
○ Lengthening of the umbilical cord
○ A globular shaped uterine fundus when palpated
● Spontaneous expulsion of the placenta typically takes about 5-10 minutes. If
it takes >30 minutes, the risk for PPH increases.
● The provider often assists with placental delivery by placing gentle traction
on the umbilical cords while applying fundal pressure/massage.
● In some cases, the provider may manually reach into the uterus to remove
the placenta/clots/blood.
Fourth Stage
● The first 1-2 hours after delivery.
● During this time, the provider is often repairing any lacerations or tears that
may have occurred.
● The goal of this stage is to monitor the mother closely for signs of
hemorrhage, infection and uterine atony.
● Simultaneously, nursing is also doing preliminary assessments and
treatments for the baby.

NCLEX Question
The nurse is taking care of a client in the fourth stage of labor. She notes that her
fundus is firm but she is still bleeding profusely. What should be the
nurse's first action?

A. Document the findings.

B. Massage the client's fundus.
C. Notify the physician.
D. Put the client in Trendelenburg position.
Answer: C
Choice C is correct. Profuse bleeding may indicate a laceration of the
birth canal or cervix, which needs the attention of a doctor to initiate
appropriate interventions.
Choice A is incorrect. The nurse should document the findings; however,
the nurse should notify the physician first.
Choice B is incorrect. The nurse should massage the client's fundus if it is
still soft to stimulate contraction. Massaging the funds if it is already firm
does not help in controlling the bleeding. Profuse bleeding may indicate a
laceration of the birth canal or cervix, which needs the attention of a
physician.

Labor and Delivery

Complications:
Placenta Previa
 Normal Previa

Assessment
● Major symptom is PAINLESS bright red bleeding
● The fact that it is painless is very important
● That sets it apart from an abruption
● To assess the bleeding
○ Pad count to determine the amount
○ Clots
○ Color
● Ultrasound done to confirm diagnosis
● Ultrasound will determine type of previa
Nursing Interventions
● Never ever perform a vaginal exam if you suspect a placenta previa!
● Would never want to irritate the placenta or uterus.
● Continue to monitor for blood loss.
○ Client may have to stay on the unit to be monitored
○ Preform pad counts
○ Weigh pads
■ 1 gram = 1 mL blood loss.
● Bed rest
○ This may minimize blood loss
● Monitor baby
○ If there is excessive blood loss, perfusion to the fetus can be decreased.
● Cesarean section indicated in most cases

Labor and Delivery

Complications:
Abruptio Placentae
 Anatomy

Types
● Causes massive amounts of painful bleeding.
● Two types
○ Incomplete
○ Complete
● Incomplete is only partial separation of the placenta.
○ Causes internal bleeding
○ Blood backs up behind the placenta
● Complete is when the placenta completely detaches
○ Causes massive external bleeding
○ Very painful
Assessment
● Dark red bleeding
● Intense abdominal pain
● Board like abdomen (due to internal bleeding)
● Rigid uterus
● Hypotension (Think shock due to blood loss)
● Maternal tachycardia
● Fetal bradycardia (fetal distress!!)

Interventions
● Monitor for fetal distress
○ Signs of distress? Stat c-section!
● Monitor maternal bleeding
○ Abdominal pain
○ Board like abdomen
○ Dark red vaginal bleeding
○ Change in fundal height (blood in abdomen?)
● Keep the BP up with IVF and/or blood products
● Prepare for delivery - most likely c-section.
 NCLEX Question
You are triaging a new client in the antepartum unit. They tell you that they started
bleeding this morning and were told to come in by their OB. They deny any pain or other
symptoms. Which of the following nursing interventions do you anticipate initiating? Select
all that apply.

a. Bed rest
b. Pad counts
c. Emergency vaginal delivery
d. Vaginal exam
e. Ultrasound

Answer: A, B, and E
A is correct. The nurse suspects a placenta previa based off of the clients complaint of painless bleeding. With a placenta previa, bed rest is indicated to
prevent further bleeding. This is an appropriate nursing intervention to initiate for both the safety of the mother and fetus and should be done right away.

B is correct. Pad counts are a way of monitoring the quantity of blood loss. Because the nurse suspects placenta previa and the client is reporting vaginal
bleeding, pad counts are an appropriate nursing intervention to initiate. When obtaining pad counts, they can be done in two ways. If exact quantity of
blood loss is not indicated, the nurse can just count the number of pads saturated with blood. If the health care provider orders strict monitoring, the pads
will be weighed to obtain the exact number of milliliters of blood lost. When weighing pads, 1 gram is 1 milliliter of blood lost. Pad counts at a minimum
should be initiated for any suspected placenta previa, so this is an appropriate nursing intervention.

C is incorrect. An emergency vaginal delivery is contraindicated for a client with suspected placenta previa. Because we believe that the placenta is either
partially or fully covering the cervix of this client, a cesarean section will need to be performed. This may be distressing for some mothers, so be sure to
provide education about why this is the safest option for their and their baby’s health. Vagnial deliveries with a placenta previa can cause serious harm to
the mother and fetus, and are contraindicated.

D is incorrect. Vaginal exams are contraindicated for a client with a suspected placenta previa. In this client, we suspect that the placenta is either
partially or fully covering the cervix of this client. That means that if a vaginal exam were to be performed, the hand of the examiner would touch the
placenta. We do not want to cause this irritation and exacerbate the bleeding that is already occurring. Vaginal exams are always contraindicated on
clients with either confirmed or suspected placenta previa.

E is incorrect. You suspect a placenta previa, and the diagnosis for this is will be made via ultrasound, so this is an expected intervention.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological adaptation

Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. Elsevier Health Sciences.

Subject: Maternal and Newborn Health

Lesson: Labor and Delivery
NCLEX Question
Which of the following signs and symptoms are expected for your patient
experiencing placental abruption? Select all that apply.

A. Painless bleeding
B. Dark red bleeding
C. Hypotension
D. Rigid abdomen

Prolapsed Umbilical Cord

 What is a prolapsed cord?
● Umbilical cord slips through
the cervix and into the vagina
after rupture of membranes
and before the baby
descends into the birth canal.
● During delivery, the
prolapsed cord become
compressed by the
presenting part of the fetus
● This cuts off oxygen to the
fetus

Assessment
● Cord visualized protruding through vagina
● Cervical exam
○ Something squishy?
○ Pulsing?
○ Mom feels something between legs
Nursing Interventions
● Elevate the presenting part of the fetus off of the prolapsed cord
● Keep your hand on the baby’s head lifting it up and call for help
● Positioning
○ Knees-to-chest position - open the pelvis
○ Trendelenburg - let gravity shift the baby off the cord
● Administer oxygen
● Wrap cord in sterile moist towel

● NEVER ATTEMPT TO PUSH THE CORD BACK IN!!!!

● Emergency Cesarean delivery

Shoulder Dystocia
What is it?
● This condition happens when one or both of the baby’s shoulders get stuck
behind the mother’s pubic bone or sacrum during birth.
● This can lead to severe complications, including nerve injuries to the baby.
● This is considered a medical emergency when it occurs!

Risk Factors
● The single most common cause is the use of a vacuum extractor or forceps
during vaginal delivery.
● Macrosomia (baby > 8lbs 13 ounces)
● Fetal malposition
● Maternal malposition
● Narrow/abnormal pelvic opening
● Maternal obesity/excess weight gain during pregnancy
● Maternal diabetes
● Short stature
● AMA
● Epidural use
Complications
Maternal Fetal

● Tears/lacerations ● Brachial Plexus Palsy

● Hemorrhage ● Fractures to the clavicle or humerus
● Infection ● Horner’s syndrome
● Damage to nerves (which can lead to ● Compressed umbilical cord
fecal and urinary incontinence).
● Rectovaginal fistula
● Uterine rupture
● Separation of the pubic bones

Assessment
● It is diagnosed based on three main factors being met:
○ The baby’s head was delivered, but the mother isn’t able to push the shoulders out.
○ At least one minute has passed since the baby’s head was delivered.
○ The baby is determined to need medical intervention to be delivered successfully.
● Turtle sign–this is suggestive, but not diagnostic. After the baby’s head has
been delivered, if the head emerges and then pulls back in against the
perineum .
Interventions
H-Call for help! Get the delivering provider in the room along with all necessary
equipment.

E-Evaluate for episiotomy

L-Legs

P-Pressure

E-Enter maneuvers

R-Remove posterior arm

R-Roll the patient

Nursing considerations
● Do not apply fundal pressure due to increased risk of uterine rupture!
● Instruct the patient to stop pushing until the dystocia is resolved–keep the
mother calm during this process.
● As in any emergent situation, it is ideal if there is a dedicated nurse to
document:
○ Time of diagnosis
○ Management techniques
○ Time of delivery
○ Sequelae
Chorioamnionitis
What is it?
A serious condition in pregnancy, when the membranes that surround the fetus
are infected by bacteria.

This leads to complications for both the mother and fetus.

It gets its name from the two membranes surrounding the fetus–the Chorion
(outer membrane) and the Amnion (the inner membrane).

It occurs in about 1-5% of births in the U.S. Is a major cause of preterm birth.

It is caused by bacteria, typically from the vagina or rectum that then spreads to
the uterus after the water breaks.

Symptoms and Testing:

● Fever
● Maternal and/or fetal tachycardia
● Very tender/painful uterus, especially to
touch.
● Vaginal discharge/lochia with a foul smell
and unusual color.
● WBCs–very elevated. If >15,000/mm3 or
if there is a significant left shift.
● Culture–diagnostic gold standard as it will
tell you the microbial cause.
● Gram stain
● Amniotic fluid sampling
Possible Complications:
For mother: For baby:

● Infections of the pelvic region or ● Sepsis

abdomen ● Meningitis
● Endometritis ● Pneumonia
● Blood clots
● Sepsis

Postpartum
Complications:
Postpartum
Hemorrhage
Risk factors for PPH
● Twins or triplets
● Macrosomic fetus
● Preeclampsia
● Prolonged labor
● Precipitous labor
● Use of forceps or vacuum during delivery
● Placenta previa
● Abruptio placenta
Assessment
● Boggy uterus
○ This is a uterus that is not contracting to clamp down on the blood vessels
○ The fundus will feel soft instead of hard as it should.
● Blood loss
○ Pad counts - most PPH clients are saturating pads every 15 minutes
○ Puddle of blood in the bed
○ If they try to stand up for the first time there could be a huge gush of blood
● Shock - if there is large amounts of blood loss leading to hypovolemia
○ Decreased LOC
○ Pale
○ Diaphoretic
○ Hypotensive
○ Tachycardic

Interventions
● Fundal massage
○ Massage the fundus - hard!
○ Warn the mother this will hurt, but you must do it to get the uterus to contract and stop the
bleeding.
○ Every 15 minutes at a minimum
● Estimated Blood Loss (EBL)
○ Weigh pads to estimate the loss
○ 1 g = 1 mL
○ Monitor hemoglobin and hematocrit
● Mediations
○ Oxytocin
○ Methylergonovine
○ Blood products
 NCLEX Question
The client in the delivery room has just delivered her third child. The physician ordered
methylergonovine (Methergine) for the client and it was
promptly administered. Which manifestation would indicate to the nurse that the
medication is having its intended effect?

A. The client reports a decrease in pain.

B. The nurse palpates a firm uterus on the client.
C. The client states that she wants to empty her bladder.
D. The client's blood pressure increases.

Answer: B
Choice B is correct. Methylergonovine promotes vasoconstriction and uterine
contraction. A firm and contracted uterus is a sign that the medication is having its
desired effect.
Postpartum Complications:
Breastfeeding Issues

Mastitis
Mastitis

What is it?
● An inflammation of the breast tissue. Often, there is also an infection.
● This causes severe pain, swelling, breast lumps, warmth and redness of the
breast.
● Women often have systemic, flu-like symptoms as well. This includes severe
fatigue, high fevers, chills, headaches and nausea/vomiting.
● In advanced mastitis, there is often also lymphadenopathy in the axillary
region of the affected side.
Risk Factors
● Breastfeeding, especially if:
○ There are cracked, sore nipples
○ The mother uses improper latching techniques
○ The mother wears tight-fitting bras and clothing that can restrict milk flow
● Breast implants
● Diabetes or autoimmune disease
● Eczema or similar skin conditions
● Nipple piercings
● Tobacco/Nicotine addiction
● Nicks/cuts in skin from plucking or shaving the area

Types of Mastitis
Lactation: Periductal:

● Affects breastfeeding women ● Most common in menopausal and

● Also known as puerperal mastitis
● The most common form of mastitis,
occurring multiple times in the
postpartum period for some women.
postmenopasual women, but is also
seen commonly in smokers.
● Also known as mammary duct
ectasia
● This condition occurs when milk
ducts thicken, which can lead to
inflammation and infection.
● The nipple on the affected breast
may also invert and produce milky
discharge.
How is it treated?
● Antibiotics (Dicloxacillin, Keflex)
● Warm compress/warm showers
● Frequent breastfeeding/pumping
● Gentle massage to the area
● OTC NSAIDs and Acetaminophen
● Wear a supportive bra that doesn’t compress the breast tissue.

Many women are fearful of breastfeeding while experiencing an infection and

while taking antibiotics. It is very important that they continue to to so!

Nursing Considerations/Education
● Encourage frequent feeding–avoid long period of time between feedings as
that allows milk to sit in the ducts and become trapped or infected.
● Avoid nursing pads or bras that keep the nipples moist–cotton pads and bras
are best.
● Encourage the mother to nurse on one side until that breast is empty, then
switch to the other side.
● Recommend that the mother use her finger to break the baby’s suction on
the nipple if the latch is wrong.
 Postpartum Complications:
Postpartum Depression

Overview
● Mood changes after pregnancy are very common, but aren’t often discussed.
About 60-80% of women will experience the “baby blues”, while about
10-20% of women will experience full PPD.
● There is often not any one cause, but a combination of factors that lead to
this issue, including:
○ Rapid hormonal changes after birth
○ Personal history of depression/anxiety
○ Family history
○ Poor social/economic support
○ First time mothers/young mothers
○ Breastfeeding issues
Baby Blues vs Depression
Baby Blues: Depression:

● Usually occurs within the first 3 days and
lasts for up to 2 weeks.
● Self-limiting, resolves on its own with
time
● Expressed with frequent/prolonged
crying, anxiety, irritability, poor sleep, a
sense of vulnerability and mood lability.
● There are no thoughts of suicide or death.
● More debilitating and longer lasting–lasts
longer than 2 weeks and can persist for
up to a year.
● Expressed with feeling of despondency,
tearfulness, intense feelings of
inadequacy and guilt, anxiety and fatigue.
● It is especially concerning if the mother
doesn’t feel like she can bond with the
baby.
● There are often frequent, recurring
thoughts of death and suicide.

Postpartum Psychosis
This is a very rare condition that typically occurs within the first week after
delivery.

Symptoms are severe, including:

● Feeling confused/lost
● Obsessive thoughts about the baby
● Hallucinations/delusions
● Paranoia
● Attempts to harm self or baby
When to recommend treatment
● Symptoms don’t resolve in two weeks.
● Symptoms consistently get worse.
● The mother reports that she is having a lot of difficulty:
○ Caring for the baby
○ Caring for herself and completing everyday tasks
● The mother has thoughts of harm herself or the baby.

Many women avoid treatment/help, as they ashamed of the feelings they’re

experiencing. It is very important to share that this is VERY common, it is NOT
their fault and there is help!

Treatment options:
● First, make an initial appointment with the provider:
○ Interview
○ Assessment
○ Labs
● Psychotherapy
● Antidepressants – Brexanolone (Zulresso)-The first drug approved
specifically for postpartum depression in adults.
● Anti-anxiety medications
● Mother+Baby meetup groups
● Lactation support/groups
 Postpartum Complications:
Thrombophlebitis

What is it?
● An inflammatory process that causes blood clot(s) to form and block one or
more veins (usually in the legs).
● When the affected vein is near the surface of the skin, it is a superficial
thrombophlebitis.
● When the vein is deep within a muscle, it is a deep vein thrombosis (DVT).
● A DVT is more concerning, as a clot can break off of this can cause a
pulmonary embolism (PE).
● Risk for these issues is increased for about 6-8 weeks after delivery.
Women at risk for this issue:
● Any woman in the postpartum stage
● Surgery (C-section, post-delivery D&C, Tubal ligation, etc)
● History of blood clots or a clotting disorder
● BMI >25
● PreE/Elevated blood pressure
● Smoking
● PPH
● Infection
● Immobility
● Increasing age
● Start birth control too early
● Varicose veins

Symptoms:
Superficial Thrombophlebitis: Deep Vein Thrombosis:

● Warmth, tenderness and pain in the ● Warmth, tenderness and pain

affected area.
● Redness and swelling
● You might see a red, hard cord just under
the skin’s surface. It will be tender to the
touch.
● Redness and swelling
● You will not see an obvious hard cord, as
the clot is too deep. It will present just
with significant general swelling that is
very painful to touch.

Next step: Ultrasound!

Treatment:
Prevention: Management once a clot has occurred:

● Walk/move frequently. For superficial clots:

● Move and elevate the legs if sitting for
● Warm compress, compression bandages,
longer periods of time.
elevation of the limb.
● Drink plenty of fluids.
● Some women who are determined to be For DVT:
high risk may take anticoagulants during
the postpartum period (usually for 6 ● Anticoagulants
weeks). ● IVC (Inferior vena cava) Filter
○ Low dose aspirin ● Surgical removal of the clot
○ Heparin
○ Low molecular weight heparin (Lovenox)
● SEDs
● TED hose/support stockings

NCLEX Question
A nurse is assigned to care for four clients who are each one day postpartum. Following the
nurse performing an initial assessment on each client,
which finding would prompt further evaluation by the nurse?

A. A client complaining of mild pain

A client with a pulse rate of 65 bpm
C. A client with colostrum discharge from both breasts
D. A client with red, foul-smelling lochia
Answer: D
Choice D is correct. Lochia is vaginal discharge following childbirth. At
one day postpartum, the client's discharge is expected to be dark red or
red-brown, similar to a heavy menstrual discharge, and should have a
fleshy, earthy odor. A client with foul-smelling lochia should prompt
further evaluation by the nurse, as lochia which smells foul or fishy could
indicate infection. Additionally, the nurse may need to elaborate further
on the discharge color rather than simply using the term "red," as the
anticipated discharge color at this point in the postoperative period
should likely be darker in color.

NCLEX Question
While providing education to a group of expected mothers regarding the prevention of
postpartum thrombophlebitis, you know they understand your
teaching when they make which of the following statements?
Select all that apply.

A. "After we give birth, we are at an increased risk of clots for 6 to 8 weeks."

B. "We shouldn't go on car rides longer than 4 hours for a few weeks after we give birth."
C. "After delivery, we should get up and walk as soon as we are able to prevent clots from
forming."
D. "Trying not to cross our legs will help prevent clots from forming
Answer: B
Choices A, B, C, and D are all correct.

A is correct. Mothers are at an increased risk for clots for about 6 to 8 weeks after delivery. This
is due to a natural increase in clotting factors in the body at this time. When there are increased
clotting factors, clots form more readily. Therefore mothers are at risk for developing postpartum
thrombophlebitis.

B is correct. You should advise mothers not to go on car rides longer than 4 hours for a few
weeks after they give birth. This is due to the increased amount of clotting factors present after
birth, which puts them at higher risks for clots. Sitting still in a car for longer than 4 hours could
be dangerous due to the likelihood of developing a clot.

C and D are correct. This is excellent advice to share with expecting mothers for the prevention
of thrombophlebitis