Chapter 11 - Maternal Adaptation During Pregnancy

• SIGNS OF PREGNANCY
❑ Presumptive
❑ Probable
❑ Positive
• Presumptive signs (subjective)(time of occurrence) : Changes that the client experiences
that make them think that they might be pregnant. Signs also might be a result of
physiological factors other than pregnancy (peristalsis, infections, stress).
– Signs that the mother can perceive; least reliable indictor of pregnancy
• Breast tenderness (3 to 4 weeks)
➢ Hormonal changes
• Nausea and vomiting (4 to 14 weeks)
➢ GI disorders
• Amenorrhea (4 weeks) The most obvious presumptive sign of pregnancy
➢ Stress/Exercising
• Breast enlargement (6 weeks)
➢ Hormonal changes
• Urinary frequency (6 to 12 weeks)
➢ UTI
• Uterine enlargement (7 to 12 weeks)
➢ Cancer/Cysts
• Fatigue (12 weeks)
➢ Anemia
• Hyperpigmentation of skin (16 weeks)
➢ Prolonged sun exposure
• Fetal movements (quickening) (16 to 20 weeks)- refer by the mother

• Probable (objective) signs

– Signs that can be detected on physical examination by a health care provider
• Positive pregnancy test (4 to 12 weeks)
➢ hCG (pregnancy hormone)
• hCG levels in normal pregnancy usually double every 48 to 72
hours until they peak approximately 60 to 70 days after
 fertilization; at this point, they decrease to a plateau at 100 to
130 days of pregnancy
• The hCG doubling time has been used as a marker by
clinicians to differentiate normal from abnormal gestations;
low levels are associated with an ectopic pregnancy and higher-
than-normal levels may indicate a molar pregnancy or
multiple-gestational pregnancies
• This elevation of hCG corresponds to the morning sickness
period of approximately 6 to 12 weeks during early pregnancy
• Goodell’s sign (5 weeks)
➢ Softening of the cervix; due to vasocongestion (estrogen is
responsible)
• Chadwick’s sign (6 to 8 weeks)
➢ A bluish-purple coloration of the vaginal mucosa and cervix; due to
becoming more vascular (ESTROGEN)
• Hegar’s sign (6 to 12 weeks)
➢ Softening of the lower uterine segment or isthmus (lower uterine
segment); due to increased production of progesterone
• Abdominal enlargement (14 weeks)
➢ Uterine tumors
• Braxton Hicks contractions (16 to 28 weeks)
➢ False contractions
• Ballottement (16 to 28 weeks)
➢ The examiner pushes against the woman’s cervix during a pelvic
examination and feels a rebound from the floating fetus
Positive signs: Positive signs are those that can be explained only by pregnancy.
– The positive signs of pregnancy confirm that a fetus is growing in the uterus
– Ultrasound verification of embryo or fetus (4 to 6 weeks)
– Auscultation of fetal heart tones via Doppler (10 to 12 weeks)
– Fetal movement felt by experienced clinician (20 weeks)

• A nurse is reviewing the health record of a client who is pregnant. The provider
indicated the client exhibits probable signs of pregnancy. Which of the following
findings should the nurse expect? (Select all that apply.)
A. Montgomery’s glands
B. Goodell’s sign
C. Ballottement
D. Chadwick’s sign
E. Quickening

P H Y S I O L O G I C A D A P TAT I O N S D U R I N G P R E G N A N C Y

• R E P R O D U C T I V E S Y S T E M A D A P TAT I O N S
Uterus
– Increase in size, weight, length, width, depth, volume, and overall capacity
➢ In the first few months, due to the hormone estrogen
– Pear shape to ovoid shape; positive Hegar’s sign
➢ The shape changes from pear shape to a solid globe in the first trimester, and
then expands to become a hollow vessel
➢ Changes add to urinary frequency
– As pregnancy progresses, 80% to 90% of uterine blood flow goes to the placenta,
with the remainder distributed between the endometrium and myometrium
– Enhanced uterine contractility; Braxton Hicks contractions
➢ Spontaneous, irregular, and painless contractions
➢ Begin during the first trimester; continue throughout pregnancy, becoming
especially noticeable during the last month, when they function to thin out or
efface the cervix before birth
 – Ascent into abdomen after first 3 months
➢ Goes from a pelvic organ to an abdominal organ after first trimester
➢ The uterus in the last trimester can fall back against the inferior vena cava in
the supine position, resulting in vena cava compression, which reduces venous
return and decreases cardiac output and blood pressure, with increasing
orthostatic stress (orthostatic hypotension)
▪ This acute hemodynamic change, termed supine hypotensive
syndrome, causes the woman to experience symptoms of weakness,
light-headedness, nausea, dizziness, or syncope; These changes are
reversed when the woman is in the side-lying position, which
displaces the uterus to the left and off the vena cava
– Fundal height by 20 weeks’ gestation at level of umbilicus; 20 cm; reliable
determination of gestational age until 36 weeks’ gestation
➢ The fundus reaches its highest level, at the xiphoid process, at
approximately 36 weeks
➢ Between 38 and 40 weeks, fundal height drops as the fetus begins to descend
and engage into the pelvis; because it pushes against the diaphragm, many
women experience shortness of breath
➢ By 40 weeks, the fetal head begins to descend and engage in the pelvis, which
is termed lightening
– For the woman who is pregnant for the first time, lightening usually
occurs approximately 2 weeks before the onset of labor; for the
woman who is experiencing her second or subsequent pregnancy, it
usually occurs at the onset of labor
– Although breathing becomes easier because of this descent, the
pressure on the urinary bladder now increases and the woman now
experiences urinary frequency again, as she did in the first trimester of
pregnancy
• Cervix
– Softening (Goodell’s sign) between week 6 and 8.
➢ Due to estrogen and increased vasocongestion
– Mucus plug formation
➢ Due to the influence of progesterone; blocks the cervical os and protects from
infections
– Increased vascularization (Chadwick’s sign) a cyanosis or bluish-purple discoloration
of the cervix
– Ripening about 4 weeks before birth
➢ Softening, effacement, and increased distensibility
• Vagina
– Increased vascularity with thickening
➢ Due to estrogen; prepares for distention during birth
– Lengthening of vaginal vault
– Secretions more acidic, white, and thick; leukorrhea
➢ Increased vaginal discharge
➢ Increased risk for overgrowth of Candida albicans; can be passed to neonate
during birth (oral thrush)
• Ovaries
– Enlargement until 12th to 14th week of gestation
– Cessation of ovulation
➢ Because of the elevated levels of estrogen and progesterone, which block
secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH)
from the anterior pituitary
➢ Very active in hormone production to support the pregnancy until about weeks
6 to 7, when the corpus luteum regresses and the placenta takes over the major
production of progesterone
• Breasts
– Increase in size and nodularity to prepare for lactation; increase in nipple size,
becoming more erect and pigmented (striae or stretch marks)
– Production of colostrum: antibody-rich, yellow fluid that can be expressed after the
12th week; conversion to mature milk after delivery

GI SYSTEM ADAPTATIONS
▪ Gums: hyperemic, swollen, and friable (due to increased estrogen)
▪ Ptyalism (excessive salivation; becomes more acidic)
➢ Some women get temporary relief from gum chewing or sucking on hard candies
▪ Dental problems; gingivitis (due to an increase in hormones)
➢ Previous studies linked periodontal disease with preterm birth; preeclampsia, and
low-birth-weight risk, stillbirth and early-onset neonatal sepsis
▪ Decreased peristalsis and smooth muscle relaxation (due to progesterone)
➢ Leads to bloating and constipation
▪ Constipation + increased venous pressure + pressure from uterus = hemorrhoids
▪ Slowed gastric emptying; heartburn
➢ Over-the-counter antacids will usually relieve the symptoms, but they should be taken
with the health care provider’s knowledge and only as directed
▪ Prolonged gallbladder emptying (due to the smooth muscle relaxation from
progesterone)
➢ Increased risk for gallstone formation
▪ Nausea and vomiting
➢ Linked to the high levels of hCG, high levels of circulating estrogens, prostaglandins,
reduced stomach acidity, advancing maternal age, slowed peristalsis, genetic factors,
and the lowered tone and motility of the digestive tract

CARDIOVASCULAR SYSTEM ADAPTATIONS

▪ Increase in blood volume (50% above prepregnant levels)
• Increase in cardiac output; increased venous return; increased heart rate and stroke
volume.
▪ Slight decline in blood pressure until mid-pregnancy, then returning to pre-pregnancy levels
➢ Any significant rise in blood pressure during pregnancy should be investigated to rule
out gestational hypertension
➢ Record vitals at first prenatal visit; will be considered baseline values and help
determine the development of other conditions
➢ Gestational hypertension is a clinical diagnosis defined by the new onset of
hypertension (systolic of 140 mm Hg or higher and/or diastolic of 90 mm Hg or
higher) after 20 weeks gestation
▪ Increase in number of RBCs; plasma volume > RBC leading to hemodilution (physiologic
anemia)
➢ Volume expansion occurs faster than production of RBCs
▪ Increase in iron demands, fibrin and plasma fibrinogen levels, and some clotting
factors, leading to hypercoagulable state
➢ Increased risk for blood clots

RESPIRATORY SYSTEM ADAPTATIONS

▪ Breathing more diaphragmatic than abdominal due to increase in diaphragmatic excursion,
chest circumference, and tidal volume
▪ Increase in oxygen consumption
▪ Congestion secondary to increased vascularity, estrogen induce edema
▪ During pregnancy, the amount of space available to house the lungs decreases as the uterus
puts pressure on the diaphragm and causes it to shift upward by 4 cm above its usual position
➢ Breathing becomes easier around 36 weeks gestation
▪ Anatomic and physiologic changes of pregnancy predispose the mother to increased
morbidity and mortality and increase the risks of a less than optimal outcome for the fetus
➢ Because of these various changes, pregnant women with asthma, pneumonia, or
other respiratory pathology are more susceptible to early decompensation
▪ Rising levels of sex hormones and heightened sensitivity to allergens may influence the
nasal mucosa, precipitating epistaxis (nosebleed) and rhinitis with hypersecretion of mucus.
This congestion gives rise to nasal and sinus stuffiness and changes in the tone and quality of
the woman’s voice

RENAL/URINARY SYSTEM ADAPTATIONS

▪ Dilation of renal pelvis; elongation, widening, and increase in curve of ureters
▪ Increase in length and weight of kidneys
▪ Increase in GFR; increased urine flow and volume
➢ This change has important clinical implications for medication use because renally
excreted drugs may require higher doses and more frequent administration for
therapeutic blood levels during pregnancy
▪ Increase in kidney activity with woman lying down; greater increase in later pregnancy with
woman lying on side
➢ Which may explain why the increased need to urinate when laying down or trying to
sleep
▪ The renal system must handle the effects of increased maternal intravascular and
extracellular volume and metabolic waste products as well as excretion of fetal wastes

MUSCULOSKELETAL SYSTEM ADAPTATIONS

▪ Softening and stretching of ligaments holding sacroiliac joints and pubis symphysis.
▪ Postural changes: increased swayback and upper spine extension
▪ Forward shifting of center of gravity
▪ Increase in lumbosacral curve (lordosis); compensatory curve in cervicodorsal area to
maintain the balance
▪ Relaxation and increased mobility of joints occur because of the hormone's progesterone and
relaxin, which lead to the characteristic “waddle” gait that pregnant women demonstrate
toward term.

INTEGUMENTARY SYSTEM ADAPTATIONS

Increased activity of the maternal adrenal and pituitary glands, along with a contribution for the
developing fetal endocrine glands, increasing cortisone levels, accelerated metabolism, and
enhanced production of progesterone and estrogenic hormones are responsible for most skin
changes in pregnancy
▪ Hyperpigmentation; mask of pregnancy (facial melasma)
▪ Linea nigra
➢ Extends from the umbilicus to the pubic area
▪ Striae gravidarum
➢ stretch marks, are irregular reddish streaks that appear on the abdomen,
breasts, and buttocks
▪ Varicosities
➢ Elevating both legs when sitting or lying down
➢ Avoiding prolonged standing or sitting; changing position frequently
▪ Vascular spiders
▪ Palmar erythema
➢ Well-delineated pinkish area on the palmar surface of the hands. This
integumentary change is also related to elevated estrogen levels
▪ Decline in hair growth; increase in nail growth
➢ May experience hair loss

ENDOCRINE SYSTEM ADAPTATIONS

▪ Thyroid gland: slight enlargement; increased activity; increase in BMR
▪ Pituitary gland: enlargement; decrease in TSH, GH; inhibition of FSH and LH; increase in
prolactin, MSH (Melanocyte-stimulating hormone); gradual increase in oxytocin with fetal
maturation
▪ Pancreas: insulin resistance due to hPL and other hormones in second half of
pregnancy (see Box 11.2)
• Insulin needs will increase in pre-existing diabetic condition
• hPL acts as an antagonist against maternal insulin
▪ Adrenal glands: increase in cortisol and aldosterone secretion
▪ Prostaglandin secretion
▪ Placental secretion: hCG, hPL, relaxin, progesterone, estrogen

IMMUNE SYSTEM
▪ A general enhancement of innate immunity (inflammatory response and phagocytosis) and
suppression of adaptive immunity (protective response to a specific foreign antigen) take
place during pregnancy
 ➢ These immunologic alterations help prevent the mother’s immune system from
rejecting the fetus (foreign body), increase her risk of developing certain infections
such as urinary tract infections, and influence the course of chronic disorders such as
autoimmune diseases
▪ Some chronic conditions worsen (diabetes) while others seem to stabilize (asthma) during
pregnancy, but this is individualized and not predictable. In general, immune function in
pregnant women is like immune function in nonpregnant women. Table 11.4 summarizes the
general body systems’ adaptations to pregnancy.

CHANGING NUTRITIONAL NEEDS OF PREGNANCY

NUTRITIONAL NEEDS
▪ Direct effect of nutritional intake on fetal well-being and birth outcome
➢ Inadequate nutritional intake, for example, is associated with preterm birth, low birth
weight, and congenital anomalies
➢ Excessive nutritional intake relates to fetal macrosomia (>4,000 g), leading to a
difficult birth, neonatal hypoglycemia, and continued obesity in the mother and the
potential for childhood obesity and the components of metabolic syndrome
▪ Need for vitamin and mineral supplement daily
➢ Prenatal vitamins
▪ Dietary recommendations
➢ An increase of about 300 calories per day is needed during pregnancy. Caloric
needs are greater in the last two trimesters than in the first
➢ An increase of about 500 calories per day is needed during lactation
➢ Increase in protein, iron, folate, and calories (see Table 11.5)
➢ Use of USDA’s Food Guide MyPlate (see Figure 11.5)
➢ Avoidance of some fish due to mercury content
▪ Avoid eating shark, swordfish, king mackerel, orange roughy, ahi
tuna, and tilefish because they are high in mercury levels
MATERNAL WEIGHT GAIN
▪ Healthy weight BMI: 25 to 35 lb
➢ First trimester: 3.5 to 5 lb
➢ Second and third trimesters: 1lb/wk
▪ BMI <19.8 : 28 to 40 lb
➢ First trimester: 5 lb
➢ Second and third trimesters: 1+ lb/wk
▪ BMI > 25: 15 to 25 lb
➢ First trimester: 2 lb
➢ Second and third trimesters: 2/3 lb/wk
• The general rule is that clients should gain 1 to 2 kg (2.2 to4.4 lb) during the first trimester
and after that approximately 0.5 kg (1 lb) per week for the last two trimesters.
NUTRITION PROMOTION

▪ USDA Food Guide MyPlate

▪ Client education (see Teaching Guidelines 11.1)

▪ Special considerations
➢ Cultural variations
➢ Lactose intolerance
▪ Additional or substitute sources of calcium may be necessary. These may
include peanuts, almonds, sunflower seeds, broccoli, salmon, kale, and
molasses
➢ Vegetarianism
▪ The concern with any form of vegetarianism, especially during pregnancy, is
that the diet may be inadequate in nutrients
▪ Other risks of vegetarian eating patterns during pregnancy may include low
gestational weight gain, iron-deficiency anemia, compromised protein
utilization, and decreased mineral absorption
➢ Pica
▪ Intense craving for and eating of non-food items
▪ Soil: replaces nutritive sources and causes iron-deficiency anemia
▪ Clay: produces constipation; can contain toxic substances and cause parasitic
infection
▪ Ice: can cause iron-deficiency anemia, tooth fractures, freezer burn injuries
▪ Laundry starch: replaces iron-rich foods, leads to iron deficiencies, and
replaces protein metabolism, thus depriving the fetus of amino acids needed
for proper development
➢ Food Concerns During Pregnancy
▪ The safety of artificial sweeteners consumed during pregnancy remains
controversial
▪ Another food issue concern for pregnant women is consumption of food
contaminated with the gram-positive bacillus Listeria; commonly found in
processed and prepared foods and in raw or unpasteurized milk. This can lead
to preterm births, miscarriages, stillbirths, and high neonatal mortality rates

DIETARY COMPLICATIONS DURING PREGNANCY

Nausea and constipation :

• Client Education:
For nausea, eat small amounts frequently (every 2 to 3 hr)
Also avoid consuming excessive amounts of fluid, and DO NOT take a medication to control
nausea without first checking with the provider.
For constipation, increase fluid consumption, perform physical activity, and include extra fiber in
the diet. Fruits, vegetables, and whole grains all contain fiber.
P S Y C H O S O C I A L A D A P TAT I O N S D U R I N G P R E G N A N C Y

MATERNAL EMOTIONAL RESPONSES

▪ Ambivalence
➢ The woman may feel proud and excited by the news, while at the same time fearful
and anxious of the implications
▪ Introversion
➢ The woman may withdraw and become increasingly preoccupied with herself and her
fetus
➢ As a result, she may participate less with the outside world, and she may appear
passive to her family and friends.
▪ Acceptance
➢ During the second trimester, the physical changes of the growing fetus, including an
enlarging abdomen and fetal movement, bring reality and validity to the pregnancy
▪ Mood swings
➢ Extremes in emotion can make it difficult for partners and family members to
communicate with the pregnant woman without placing blame on themselves for their
mood changes
➢ Clear explanations about how common mood swings are during pregnancy are
essential
▪ Changes in body image
➢ Some women feel as if they have never been more beautiful, whereas others spend their
pregnancy feeling overweight and uncomfortable, positives and negatives changes. Physical
changes and symptoms the woman experiences during pregnancy contribute to her body
image. Cultural beliefs may affect how the woman views body changes.
Ensurin Ensuring safe passage throughout

Seeking acceptance of infant by others

Seeking

Seeking Seeking acceptance of self in maternal role

Learning to give of oneself

•Learning to become a mother (see Box 11.4)
Learning

PREGNANCY AND SEXUALITY

▪ Numerous changes, possibly stressing sexual relationship
▪ Changes in sexual desire with each trimester
▪ Sexual health and link to self-image

PREGNANCY AND PARTNER

▪ Family-centered emphasis
▪ Partner’s reaction to pregnancy and changes
➢ Ambivalence
➢ Couvade syndrome
➢ Physically, they may gain weight around the middle and experience
nausea and other GI disturbances; sympathetic response
➢ Acceptance of roles (second trimester)
➢ Preparation for reality of new role (third trimester)

SIBLINGS ADAPTATION
The addition of an infant into the family unit affects everyone in the family, including siblings

who can experience a temporary separation from parents. Siblings become aware of changes in

the parents’ behavior because the infant requires much more of parents’ time.

Nursing assessment of sibling adaptation to the infant includes the following.

• ● Assess for positive responses from the sibling.
– Interest and concern for the infant
– Increased independence
• ● Assess for adverse responses from the sibling.
– Indications of sibling rivalry and jealousy
– Regression in toileting and sleep habits
– Aggression toward the infant
– Increased attention-seeking behaviors and whining
NURSING ACTIONS
– Take the sibling on a tour of the obstetric unit. ● Encourage the parents to do the
following.
– Let the sibling be one of the first to see the infant.
– Provide a gift from the infant to give the sibling.
– Arrange for one parent to spend time with the sibling while the other parent is caring
for the infant.
– Allow older siblings to help in providing care for the infant.
– Provide preschool-aged siblings with a doll to care for.
COMPLICATIONS
❖ NURSING ACTIONS
– Emphasize verbal and nonverbal communication skills between the client, caregivers,
and the infant.
– Provide continued assessment of the client’s parenting abilities, as well as any other
caregivers for the infant.
– Encourage continued support of grandparents and other family members.
– Provide home visits and group sessions for discussion regarding infant care and
parenting problems.
– Give the client and caregivers information about social networks that provide a
support system where they can seek assistance.
– Notify programs that provide prompt and effective community interventions to
prevent more serious problems from occurring.
Chapter 12 - Nursing Management During Pregnancy

PRECONCEPTION CARE

PRECONCEPTION SCREENING TOOL

A preconception screening tool provides a foundation for planning health promotion activities
and education.
➢ Ensure that the woman’s immunizations are up to date.

➢ Create a reproductive life plan to address and outline their reproductive needs.

➢ Take a thorough history of both partners to identify any medical or genetic conditions
that need treatment or a referral to specialists.

➢ Identify history of STIs and high-risk sexual practices so they can be modified

➢ Complete a dietary history combined with nutritional counseling

➢ Gathered information regarding exercise and lifestyle practices to encourage daily exercise
for well-being and weight maintenance.

➢ Stress the importance of taking folic acid to prevent neural tube defects.

➢ Urge the woman to achieve optimal weight before a pregnancy.

➢ Identify work environment and any needed changes to promote health.

➢ Address substance use issues, including smoking and drugs; identify victims of violence
and assist them to get help.

➢ Manage chronic conditions such as diabetes and asthma.

➢ Educate the couple about environmental hazards, including metals and herbs.

➢ Offer genetic counseling to identify carriers.

➢ Suggest the availability of support systems, if needed.

NURSING MANAGEMENT

Preconception care involves obtaining a complete health history and physical examination
of the woman and her partner. Key areas include:
➢ Immunization status of the woman.
 ➢ Underlying medical conditions, such as cardiovascular and respiratory problems or genetic
disorders.
➢ Reproductive health data, such as pelvic examinations, use of contraceptives, and STIs.
➢ Sexuality and sexual practices, such as safer-sex practices and body image issues.
➢ Nutrition history and present status.
➢ Lifestyle practices, including occupation and recreational activities.
➢ Psychosocial issues such as levels of stress and exposure to abuse and violence.
➢ Medication and drug use, including use of tobacco, alcohol, over-the-counter and
prescription medications, and illicit drugs.
➢ Support system, including family, friends, and community.

RISK FACTORS FOR ADVERSE PREGNANCY OUTCOMES

➢Isotretinoin:(e.g., Accutane-medication for acne) result in serious birth defects such as cleft
palate, congenital heart defects, hearing loss, and microcephaly.
➢Alcohol misuse: Fetal alcohol syndrome
➢Antiepileptic drugs:(e.g., valproic acid). Recommendations suggest that before conception,
women who are on a regimen of these drugs and who are contemplating pregnancy should be
prescribed lower dosages of these drugs.
➢Diabetes (preconception): Birth defects in women with type 1 and type 2 diabetes (hormone
hpv blood glucose to the baby) is substantially reduced through proper management of
diabetes.
➢Folic acid deficiency: Daily use of vitamin supplements containing folic acid (400 mcg)
reduce of neural tube defects.
➢Hepatitis B: Vaccination is recommended that prevents transmission of infection to infants.
➢HIV/AIDS: If HIV infection is identified before conception, timely antiretroviral treatment
can be administered, and women (or couples) can be given additional information that can help
prevent mother-to-child transmission.
➢Rubella Sero-Negativity: Rubella vaccination provides protective seropositivity and prevents
congenital rubella syndrome.
➢Obesity: Adverse perinatal outcomes associated with maternal obesity include neural tube
defects, preterm delivery, diabetes, cesarean section, hypertensive and thromboembolic disease.
Appropriate weight loss and nutritional intake before pregnancy reduce these risks.
➢Sexually transmitted infections (STIs): Chlamydia trachomatis and Neisseria gonorrhoeae
have been strongly associated with ectopic pregnancy, infertility, and chronic pelvic pain. STIs
during pregnancy might result in fetal death or substantial physical and developmental
disabilities, including intellectual disability and blindness. Early screening and treatment
prevent these adverse outcomes.
➢Smoking: Preterm birth, low birth weight.

FIRST PRENATAL VISIT

Once a pregnancy is suspected and/or confirmed by a home pregnancy test, the woman should
seek prenatal care to promote a healthy outcome.
Start prenatal care:
➢ Prenatal care can be delivered in one of the two methods: individually or in a group format
termed centering.
➢Establishment of trusting relationship.

➢Focus on education for overall wellness.

➢Detection and prevention of potential problems.

➢Comprehensive health history, physical examination, and laboratory tests.

▪ During the history-taking process, the nurse and client establish the foundation of a
trusting relationship and jointly develop a plan of care for the pregnancy.

▪ At the first prenatal visit, measure fasting plasma glucose, HbA1c, or random plasma
glucose of all women or all high-risk women based on her risk factors, weight status, and
family history; if glucose testing is not diagnostic of overt diabetes, the woman should be
tested for gestational diabetes from 24 to 28 weeks of gestation with a 2-hour 75-g oral
glucose tolerance test (Box 12-3). The thresholds for the diagnosis of overt diabetes
during pregnancy are: Fasting plasma glucose: 126 mg/dL, Hemoglobin A1c level: at
least 6.5%, Random plasma glucose: 200 mg/dL

▪ Counseling and education of the pregnant woman and her partner are critical.

COMPREHENSIVE HEALTH HISTORY

Reason for seeking care:

➢ Suspicion of pregnancy:
 * Date of last menstrual period.
* Signs and symptoms of pregnancy.
* Presumptive or probable signs of pregnancy that she might be experiencing.
* Urine or blood test for hCG.

▪ Past medical, surgical, and personal history .

➢This information is important because conditions that the woman experienced in the past
(e.g., urinary tract infections) may recur or be exacerbated during pregnancy.
➢Also, chronic illnesses, such as diabetes or heart disease, can increase the risk for
complications during pregnancy for the woman and her fetus.
➢Ask about any history of allergies to medications, foods, or environmental substances.
➢Ask about any mental health problems, such as depression or anxiety.
➢Ask about her occupation, possible exposure to teratogens, exercise and activity level,
recreational patterns (including the use of substances such as alcohol, tobacco, and drugs),
use of alternative and complementary therapies, sleep patterns, nutritional habits, and
general lifestyle.

▪Woman’s reproductive history: menstrual, obstetric, and gynecologic history.

MENSTRUAL HISTORY
▪ Menstrual cycle:
➢Age at menarche.
➢Days in cycle.
➢Flow characteristics.
➢Discomforts.
➢Use of contraception.

▪Date of last menstrual period (LMP).

▪ Calculation of estimated or expected date of birth (EDB) or delivery (EDD).

➢Nagele’s rule:
▪ Use first day of LNMP(last menstrual period): 11/21/07
▪ Subtract 3 months: 8/21/07
▪ Add 7 days: 8/28/07
▪ Add 1 year: 8/28/08 = EDB
➢Gestational or birth calculator or wheel (see Figure 12.3).
➢Ultrasound is the best method of dating a pregnancy.

OBSTETRIC HISTORY

▪Gravida: a pregnant woman.

➢Gravida I (primigravida): First pregnancy.
➢Gravida II (secundigravida): second pregnancy, etc.
▪ Para: a woman who has produced one or more viable offspring carrying a pregnancy 20
weeks or more.
➢Primipara: one birth after a pregnancy of at least 20 weeks (“primip”).
➢Multipara: Two or more pregnancies resulting in viable offspring (“multip”).
➢Nullipara: no viable offspring; para 0.

▪Terminology:
➢G (gravida): the current pregnancy.
➢T (term births): the number of pregnancies ending >37 weeks’ gestation, at term.
➢P (preterm births): the number of preterm pregnancies ending >20 weeks or viability but
before completion of 37 weeks.
➢A (abortions): the number of pregnancies ending before 20 weeks or viability.
➢L (living children): number of children currently living.

PHYSICAL EXAMINATION

▪Preparation.
➢Ask patient to empty bladder; collect for urine specimen (typically clean-catch).

▪ Vital signs:.
➢Blood pressure, respiratory rate, temperature, and pulse; also measure the client’s height and
weight
 ➢Bassline values to be used for future comparisons; any abnormalities should be investigated.

▪ Head-to-toe assessment:
➢Head and neck:
▪ Assess the head and neck area for any previous injuries and sequelae; assess ROM;
palpate the thyroid gland for enlargement (some enlargement is normal).
▪ Palpate for any enlarged lymph nodes or swelling.
▪ Note any edema of the nasal mucosa or hypertrophy of gingival tissue in the mouth; these
are typical responses to increased estrogen levels in pregnancy.
➢Chest:
▪ Auscultate heart sounds, noting any abnormalities; a soft systolic murmur caused by the
increase in blood volume may be noted
▪ Expect elevations in Vs if patient is in second trimester or beyond.
▪ Estrogen promotes relaxation of the ligaments and joints of the ribs.
▪ Inspect and palpate the breasts and nipples for symmetry and color.
➢Abdomen, including fundal height if appropriate:
➢At 12 weeks gestation the fundus can be palpated at the symphysis pubis.
➢At 16 weeks gestation the fundus is midway between the symphysis and the umbilicus.
(At the belly bottom level)
➢At 20 weeks the fundus can be palpated at the umbilicus and measures approximately 20
cm from the symphysis pubis. (Level umbilical)
➢By 36 weeks the fundus is just below the xiphoid process.

▪Extremities:

➢Inspect and palpate both legs for dependent edema, pulses, and varicose veins; early edema
needs to be further inspected and edema in third trimester is expected.

▪Pelvic examination:
➢Examination of external and internal genitalia.
➢Lithotomy position and draped appropriately; the external genitalia are inspected visually.
They should be free from lesions, discharge, hematomas, varicosities, and inflammation
upon inspection. A culture for STIs may be collected at this time.
➢The internal genitalia are examined via a speculum; assess cervical changes. May
perform a pap smear at this time.
➢Bimanual examination.
➢The health care provider reinserts the index finger into the vagina and the middle finger
into the rectum to assess the strength and regularity of the posterior vaginal wall.
➢Pelvic shape: gynecoid, android, anthropoid, platypelloid.
➢Taking internal pelvic measurements determines the actual diameters of the inlet and
outlet through which the fetus will pass
➢This is extremely important if the woman has never given birth vaginally.
➢ Pelvic measurements: diagonal conjugate, true (obstetric) conjugate, and ischial tuberosity.

▪ Diagonal conjugate: This measurement, usually 12.5 cm or greater, represents the

anteroposterior diameter of the pelvic inlet through which the fetal head passes first. The
diagonal conjugate is the most useful measurement for estimating pelvic size because a
misfit with the fetal head occurs if it is too small.
▪ True (obstetric) conjugate: This measurement is important because it is the smallest
front-to-back diameter through which the fetal head must pass when moving through the
pelvic inlet.
▪ Ischial tuberosity: This measurement is made outside the pelvis at the lowest aspect of the
ischial tuberosities. A diameter of 10.5 cm or more is considered adequate for passage of
the fetal head.

RECOMMENDED VACCINES DURING PREGNANCY

❖FLU Vaccine during each pregnancy to protect herself and her baby, with immunity for the
first few months of life.

❖Tdap vaccine at any time during pregnancy, but optimally between 27 and 36 weeks of each
pregnancy, to protect yourself and your baby from pertussis, also known as whooping cough.

❖NO LIVE VACCINE DUING PREGNANCY!!

VACCINES NOT RECOMMENDED DURING PREGNANCY

Some vaccines are not recommended during pregnancy, such as:

Human papillomavirus (HPV) vaccine

Measles, mumps, and rubella (MMR) vaccine

Live influenza vaccine (nasal flu vaccine)

Varicella (chicken pox) vaccine

LABORATORY TESTS

▪Urinalysis (albumin, glucose, ketones, and bacteria casts).

▪ Complete Blood Count.
▪ Blood Sugar Test.
▪ Blood typing.
▪ Rh factor: indicative for the administration of RhoGAM.
▪ Rubella titer.
▪ Hepatitis B surface antigen.
▪ HIV test.
▪ VDRL and RPR testing (Syphilis).
▪ Chlamydia & Gonorrhea- 1st & 3rd trimesters.
▪ Cervical Pap smears.
▪ Ultrasound.

FOLLOW-UP VISITS

▪Visit schedule:
➢
➢Every 4 weeks up to 28 weeks.
➢
➢Every 2 weeks from 29 to 36 weeks.
➢
➢Every week from 37 weeks to birth.

▪At each subsequent prenatal visit, the following assessments are completed:
➢Weight and BP compared to baseline values.

➢Urine testing for protein, glucose (if client has diabetes mellitus), ketones (also if
client has diabetes mellitus), and nitrites (if client has UTI).

! Diabetes, edema, infections, organ system functioning.

➢Blood work:

! If the mother is Rh negative, her antibody titer is evaluated. RhoGAM is given if

indicated. RhoGAM is used to prevent development of antibodies to Rh+ red cells
whenever fetal cells are known or suspected of entering the maternal circulation such
as after a spontaneous abortion or amniocentesis. It is also recommended for
prophylaxis at 28 weeks gestation and following birth if the infant is Rh+.

! In addition, screening for group B streptococcus, gonorrhea, and chlamydia is done.

Fetal presentation and position (via Leopold’s maneuvers) are assessed.

➢Fundal height (see Figure 12.5).

➢The fundal height is measured to help gauge the fetus' gestational age.
 • During the second and third trimesters (weeks 18-30), fundal height in centimeters
approximately equals the fetus's age in weeks, plus or minus 2 cm.

• At 16 weeks, the fundus can be found halfway between the symphysis pubis and the
umbilicus.

• At 20 to 22 weeks, the fundus is at the umbilicus.

• At 36 weeks, the fundus is at the xiphoid process.

• Measuring fundal height:

• Have client lie on her back, with knees slightly flexed, McDonald method.

• Place end of tape measure at level of symphysis pubis.

• Stretch measure tape from the top of the pubic bone to the top of uterine fundus.

• Note and record measurement.

➢Quickening/fetal movement (see Box 12.4).

➢Fetal heart rate (see Nursing Procedure 12.1).

! Should be 110 to 160 bpm; assessed via a Doppler.

▪Teaching: danger signs.

➢Evaluate pre-term labor risks.
▪At each follow-up visit answer questions, provide anticipatory guidance and education, review
nutritional guidelines, and evaluate the client for adherence to prenatal vitamin therapy.
Throughout the pregnancy, encourage the woman’s partner to participate if possible.

DANGER SIGNS DURING PREGNANCY

FIRST TRIMESTER

● Burning on urination (infection)

● Severe vomiting -from 1 to 15 weeks- (hyperemesis gravidarum) (acg hormone associated to
nausea and vomiting.)
● Diarrhea (infection)
● Fever or chills (infection)
● Abdominal cramping and/or vaginal bleeding (miscarriage, ectopic pregnancy)

SECOND AND THIRD TRIMESTER

● Gush of fluid from the vagina (rupture of amniotic fluid) prior to 37 weeks of gestation
 ● Vaginal bleeding (placental problems such as abruption or previa)
● Abdominal pain (premature labor, abruptio placentae, or ectopic pregnancy)
● Changes in fetal activity (decreased fetal movement might indicate fetal distress)
● Persistent vomiting (hyperemesis gravidarum) - dehydration
● Severe headaches (gestational hypertension) - iclancia- seizures
● Elevated temperature (infection)
● Dysuria (urinary tract infection)
● Blurred vision (gestational hypertension)
● Edema of face and hands (gestational hypertension)
● Epigastric pain (gestational hypertension)
● Concurrent occurrence of flushed dry skin, fruity breath, rapid breathing, increased thirst and
urination, and headache (hyperglycemia)
● Concurrent occurrence of clammy pale skin, weakness, tremors, irritability, and
lightheadedness (hypoglycemia)

Diabetes and hypertension most common complications in pregnant women.

Fundal height measurement. Memorize 12, 16, 20, 36

FETAL MOVEMENT DETERMINATION

▪Perception of fetal movement typically begins in the second trimester and occurs earlier in
multiparous women versus nulliparous women.

▪ The mother’s first perception of fetal movement, termed “quickening,” is commonly described
as a gentle fluttering.

▪ Maternal perception of fetal movement is an important screening method for fetal well-being,
because decreased fetal movement is associated with a range of pregnancy pathologies and
poor pregnancy outcomes.

▪ Decreased fetal movement may indicate asphyxia and FGR (Fetal Growth Restriction). If
you don’t feel the baby go to ER immediately.

▪ If compromised, the fetus decreases its oxygen requirements by decreasing activity.

▪ Reduced fetal movement is thought to represent fetal compensation in a chronic hypoxic

environment due to inadequacies in the placental supply of oxygen and nutrients.

▪ Fetal movement counting is a method used by the mother to quantify her fetus’s movement;
provide count sheets.

▪ Instruct the client about how to count fetal movements, the reasons for doing so, and the
significance of decreased fetal movements. Urge the client to perform the counts in a relaxed
environment and a comfortable position, such as semi-Fowler’s or side-lying.

▪ The most common method used is “Count to 10,” whereby a woman focuses her attention on
her fetus’s movement and records how long it takes to document 10 movements in 2 hrs. If it
takes longer than 2 hours, the woman should contact her health care provider for further
evaluation. Around 16-21 week best period to feel the baby.

TEACHING ABOUT THE DANGER SIGNS OF PREGNANCY

▪It is important to educate the client about danger signs during pregnancy that require further
evaluation. Explain that she should contact her health care provider immediately if she
experiences any of the following:
➢During the first trimester: spotting or bleeding (miscarriage), painful urination (infection),
severe persistent vomiting (hyperemesis gravidarum), fever >100 °F (37.7 °C; infection),
and lower abdominal pain with dizziness and accompanied by shoulder pain (ruptured
ectopic pregnancy).
➢During the second trimester: regular uterine contractions (preterm labor); pain in calf,
often increased with foot flexion (blood clot in deep vein); sudden gush or leakage of fluid
from vagina (premature rupture of membranes); and absence of fetal movement for more
than 12 hours (possible fetal distress or demise).
➢During the third trimester: sudden weight gain; periorbital or facial edema, severe upper
abdominal pain, or headache with visual changes (gestational hypertension and/or
 preeclampsia); and a decrease in fetal daily movement for more than 24 hours (possible
demise). Any of the previous warning signs and symptoms can also be present in this last
trimester.
➢Also teach patient how to distinguish false contractions (Braxton hicks) from true labor
contractions.

ASSESSMENT OF FETAL WELL-BEING

▪Ultrasonography (see Figure 12.6):

▪ Obstetric ultrasound is a standard component of prenatal care used to identify pregnancy
complications, to establish an accurate gestational age and estimate the delivery date in
order to improve pregnancy outcomes. Best way to find out the delivery date.
▪ Transvaginal vs Abdominal.
▪ Nursing management during the ultrasound procedure focuses on educating the woman
about the ultrasound test and reassuring her that she will not experience any sensation from
the sound waves during the test. No special client preparation is needed before performing
the ultrasound, although in early pregnancy the woman may need to have a full bladder.

▪Doppler flow studies:

▪ Comprehensive assessment of fetal well-being involves monitoring of fetal growth,
placental function, central venous pressure, and cardiac function.
▪ Doppler flow studies can be used to measure the velocity of blood flow via ultrasound.
Doppler flow studies can detect fetal compromise in high-risk pregnancies. The test is
noninvasive and has no contraindications. The color images produced help to identify
abnormalities in diastolic flow within the umbilical vessels.

▪Alpha-fetoprotein analysis:
▪ AFP (10 ng/ml-150 ng/ml) is present in amniotic fluid in low concentrations between 10 and
14 weeks of gestation and can be detected in maternal serum beginning at approximately 12
to 14 weeks of gestation. If a developmental defect is present, such as failure of the neural
tube to close, more AFP escapes into amniotic fluid from the fetus. AFP then enters the
maternal circulation by crossing the placenta, and the level in maternal serum can be
measured.
▪ The optimal time for AFP screening is 16 to 18 weeks of gestation.
▪ Elevation of maternal serum AFP levels are seen in many conditions including open
neural tube defect (spina bifida, anencephaly), underestimation of gestational age, the
presence of multiple fetuses, gastrointestinal defects, low birth weight,
oligohydramnios, maternal age, diabetes, fetal nephrosis and decreased maternal
weight.
▪ Lower-than-expected maternal serum AFP levels are seen when fetal gestational age is
overestimated or in cases of fetal death, hydatidiform mole, increased maternal weight,
maternal type 1 diabetes, and fetal trisomy 21 (Down syndrome) or trisomy 18
(Edward’s syndrome).
▪Marker screening tests:
▪ Using maternal serum is an effective, noninvasive method for identifying fetal risk for
aneuploidy (trisomies 13, 18, and 21) and neural tube defects.
▪ Abnormalities in maternal serum marker levels and fetal measurements obtained during the
first trimester screening can be markers for not only certain chromosomal disorders and
anomalies in the fetus, but also for specific pregnancy complications; pregnancy-associated
plasma protein A (PAPP-A) is a key regulator of insulin-like growth factor essential for
normal fetal development.
▪ A low maternal serum PAPP-A, at 11 to 13 weeks of gestation, is associated with stillbirth,
infant death, preterm birth, preeclampsia, and chromosomal abnormalities; increases with
gestational age.
▪ Multiple blood screening tests may be used to determine the risk of open neural tube defects
and Down syndrome: the Triple-marker screen (AFP, hCG, and unconjugated estriol) or
the Quad screen, which includes the triple screening tests with the addition of a fourth
marker, inhibin A (glycoprotein secreted by the placenta). The quad screen is used to
enhance the accuracy of screening for Down syndrome in women younger than 35 years of
age.

▪Nuchal translucency screening:

▪ Nuchal translucency screening (ultrasound) is also done in the first trimester between 11 and
14 weeks; this allows for early detection and diagnosis of some fetal chromosomal and
structural abnormalities.
▪ Ultrasound is used to identify an increase in nuchal translucency, which is due to the
subcutaneous accumulation of fluid behind the fetal neck. It is used for screening Down
syndrome.

▪Amniocentesis (see Figure 12.7):

➢A transabdominal puncture of the amniotic sac to obtain a sample of amniotic fluid for
analysis; requires informed consent.
➢Amniocentesis is performed in the second trimester, usually between 15- and 18-weeks
gestation; at this age, the amount of fluid is adequate (approximately 150 mL), and the ratio
of viable to nonviable cells is the greatest (Amniocentesis can be performed in any of the
three trimesters of pregnancy).
➢Amniocentesis is performed after an ultrasound examination identifies an adequate pocket of
amniotic fluid free of fetal parts, the umbilical cord, or the placenta.
➢A long needle is guided into the amniotic sac; when the desired amount of fluid has been
withdrawn, the needle is removed, and slight pressure is applied to the site.
➢Risks include lower abdominal discomfort and cramping that may last up to 48 hours after
the procedure, spontaneous abortion (1 in 200), maternal or fetal infection, post
 amniocentesis chorioamnionitis that has an insidious onset, fetal–maternal hemorrhage,
leakage of amniotic fluid in 2% to 3% of women after the procedure, and higher rates of
fetal loss in earlier amniocentesis procedures (<15 weeks gestation) versus later ones.
➢When preparing the woman for an amniocentesis, explain the procedure and its potential
complications, and encourage her to empty her bladder just before the procedure to avoid the
risk of bladder puncture.
➢Inform her that a 20-minute electronic fetal monitoring strip usually is obtained to evaluate
fetal well-being and obtain a baseline to compare after the procedure is completed. Obtain
and record maternal vital signs.
➢After the procedure, assist the woman to a position of comfort and administer RhoGAM
intramuscularly if the woman is Rh negative to prevent potential sensitization to fetal blood.
➢Assess maternal vital signs and fetal heart rate every 15 minutes for an hour after the
procedure. Observe the puncture site for bleeding or drainage.
➢Instruct the client to rest after returning home and remind her to report fever, leaking
amniotic fluid, vaginal bleeding, or uterine contractions or any changes in fetal activity
(increased or decreased) to the health care provider.

Technique for amniocentesis: Inserting needle.

▪Chorionic villus sampling (CVS):
➢An invasive procedure involving an 18-gauge needle stick through the abdomen or passage
of a suction catheter through the cervix under ultrasound guidance; requires informed
consent and generally performed 10 to 13 weeks after the LMP.
➢This test is used to obtain a sample of the chorionic villi from the placenta for prenatal
evaluation of chromosomal disorders such as Down syndrome or cystic fibrosis, enzyme
deficiencies, and fetal gender determination and to identify sex-linked disorders such as
hemophilia, sickle cell anemia, and Tay–Sachs disease.
➢Chorionic villi are fingerlike projections that cover the embryo and anchor it to the uterine
lining before the placenta is developed.
➢Abdominal (needle aspiration) or cervical approach placed in lithotomy position (requires a
full bladder to better visualize structures).
 ➢Potential complications of CVS include post procedure vaginal bleeding and cramping (most
common), hematomas, spontaneous abortion, limb abnormalities, rupture of membranes,
infection, chorioamnionitis, and fetal–maternal hemorrhage.
➢Explain to the woman that the procedure will last about 15 minutes. An ultrasound will be
done first to locate the embryo, and a baseline set of vital signs will be taken before starting.
➢For transcervical CVS, inform the women that a speculum will be placed into the vagina
under ultrasound guidance.
➢After either procedure, assist the woman to a position of comfort and clean any excess
lubricant or secretions from the area. Instruct her about signs to watch for and report, such as
fever, cramping, and vaginal bleeding. Urge her not to engage in any strenuous activity for
the next 48 hours. Assess the fetal heart rate for changes and administer RhoGAM to an
unsensitized Rh-negative woman after the procedure.

NON-STRESS TEST
• Provides an indirect measurement of uteroplacental function; normal fetus produces
characteristic fetal heart rate patterns in response to fetal movements. Can be done twice
weekly after 28 weeks of gestation
• Before the procedure, the client eats a meal to stimulate fetal activity, placed in the left
lateral recumbent position to avoid supine hypotension syndrome, empty bladder
• An external electronic fetal monitoring device is applied to her abdomen. The client is
handed an “event marker” with a button that she pushes every time she perceives fetal
movement. When the button is pushed, the fetal monitor strip is marked to identify that fetal
movement has occurred. The procedure usually lasts 20 to 30 minutes.
• Obtain baseline blood pressure and recheck pressure frequently
Reactive NST- normal/negative
• includes at least two fetal heart rate accelerations from the baseline of at least 15 bpm for
at least 15 seconds within the 20-minute recording period
Nonreactive NST- abnormal
• characterized by the absence of two fetal heart rate accelerations using the 15-by-15 criterion
after 40-minutes time frame
Unsatisfactory Result
• Poor quality of the FHR tracing prevents interpretation
*A nonreactive test has been correlated with a higher incidence of fetal distress during labor,
fetal mortality, and IUGR.

CONTRACTION STRESS TEST

• Used to assess placental oxygenation and function, determine fetus's ability to tolerate labor
and reveals fetal well-being. Fetus is exposed to the stressor of contractions to assess the
adequacy of placental perfusion under simulated labor conditions
• Performed if non-stress test findings are abnormal (nonreactive)
• External fetal monitor is applied to the mother, and a 20- to 30-minute baseline strip is recorded
• Uterus is stimulated to contract, either by the administration of a dilute dose of oxytocin
(Pitocin) or by having the mother use nipple stimulation until- 3 palpable contractions with a
duration of 40 seconds or more in a 10-minute period have been achieved. Contractions are
registered by the monitor strip
• Frequent maternal blood-pressure readings are performed, and the mother is monitored closely
while increasing doses of oxytocin are given

Negative Result-
• Normal
• No late or variable decelerations of the FHR
Positive Result-
• Abnormal
• Late or variable decelerations of the FHR, with 50% or more of the contractions in the absence
of hyperstimulation of the uterus
Equivocal Result-
• Contains decelerations but with fewer than 50% of the contractions, or uterine activity shows a
hyperstimulated uterus
Unsatisfactory Result-
• Adequate uterine contractions cannot be achieved or the FHR tracing is not of sufficient
quality for interpretation

NONSTRESS TEST

Nonstress test (NST) is the most widely used technique for antepartum evaluation of fetal well-
being performed during the third trimester.

INTERPRETATION OF FINDINGS

❖Reactive if the FHR accelerates at least 15/min (10/min prior to 32 weeks) for at least 15
seconds (10 seconds prior to 32 weeks) and occurs two or more times during a 20-min period.
(6.1) 15 BPM/15 sec x20 min

❖Nonreactive NST is a test that does not demonstrate at least two qualifying accelerations in a
20-min window. If this is so, a further assessment, such as a contraction stress test (CST) or
BPP, is indicated.

CONTRACTION STRESS TEST

❖Nipple-stimulated contraction test

❖Oxytocin-stimulated contraction test

INDICATIONS
! High-risk pregnancies (gestational diabetes mellitus, post-term pregnancy)
! Nonreactive stress test
Explain the procedure to the client and obtain informed consent.
 INTERPRETATION OF FINDINGS

NEGATIVE CST (NORMAL FINDING): Indicated if within a 10-min period, with three
uterine contractions, there are no late decelerations of the FHR. The heart rate needs to
accelerate.

POSITIVE CST (ABNORMAL FINDING): Indicated with persistent and consistent late
decelerations with 50% or more of the contractions. This is suggestive of uteroplacental
insufficiency. Variable deceleration can indicate cord compression, and early decelerations can
indicate fetal head compression.

Late deceleration is when at the peak of contraction the baby heart rate goes down and goes up
at the end of contraction.

➢ Percutaneous umbilical blood sampling (PUBS).

• When fetal blood sampling is necessary, a needle is inserted directly into the fetal umbilical
vessel under ultrasound guidance.
• Fetal heart rate monitoring is necessary for 1 hour after the procedure; a follow-up
ultrasound to check for bleeding or hematoma formation is performed 1 hour after the
procedure.

BIOPHYSICAL PROFILE SCORING AND INTERPRETATION

➢ Biophysical profile (BPP):
• A biophysical profile (BPP) uses a real-time ultrasound and NST to allow assessment of
various parameters of fetal well-being.
• A BPP includes ultrasound monitoring of fetal movements, fetal tone, and fetal
breathing and ultrasound assessment of amniotic fluid volume with or without
assessment of the FHR- NST.
• The primary objectives of the BPP are to reduce stillbirth and to detect hypoxia early
enough to allow delivery in time to avoid permanent fetal damage resulting from fetal
asphyxia.
• The BPP is a scored test with five components, each worth 2 points if present.
NURSING MANAGEMENT FOR THE COMMON DISCOMFORTS OF
PREGNANCY

FIRST TRIMESTER DISCOMFORTS

▪Urinary frequency or incontinence- The client should drink 2 quarts (4 cups)) of fluid during
the day, encourage the client to void at regular intervals, sleeping on the side may relieve
pressure on the bladder, perineal pads may be worn, if necessary, Kegel exercises will help
strengthen bladder control.
▪ Fatigue- Recommend the client arrange for frequent rest periods throughout the day, should
get regular exercise, teach client to perform muscle-relaxation and strengthening exercises for
the legs and hip joints, avoid eating and drinking foods containing stimulants throughout
pregnancy.
▪ Nausea and vomiting- Eating dry crackers before arising, eating small, frequent low-fat meals
during the day, drinking liquids between meals rather than at meals, avoiding fried and spicy
foods, acupressure (some types may require a prescription), herbal remedies, only if approved
by physician or nurse-midwife.
▪ Breast tenderness- Encourage the client to wear a supportive bra. The use of soap on the
nipples and areolar areas should be avoided to help prevent drying.
▪ Constipation- Advise client to eat high-fiber foods, should drink sufficient fluids, exercise
regularly, laxatives or enemas should not be used until client has consulted with the physician
or nurse midwife.
▪ Nasal stuffiness, bleeding gums, epistaxis.
▪ Cravings.
▪ Leukorrhea-Proper cleansing and hygiene are important. The client should wear cotton
underwear. Douching should be avoided. (It is white discharge which is normal during
pregnancy).

SECOND TRIMESTER DISCOMFORTS

▪Backache- The client should be encouraged to rest, good body mechanics and improved
posture will help alleviate pain, low-heeled shoes should be worn, taught pelvic rocking and
abdominal breathing exercises, sleeping on a firm mattress may help relieve pain.
▪ Varicosities of the vulva and legs.
▪ Hemorrhoids- The client should sit on a soft pillow, warm sitz bath may relieve discomfort,
advise client to eat high-fiber foods and avoid constipation, drink sufficient fluids, exercise,
such as walking should be increased, ointments, suppositories, or compresses may be
prescribed by the physician or nurse-midwife.
▪ Flatulence with bloating.
▪Leg cramps- result from altered calcium & phosphorus balance, pressure of the uterus on
nerves, or fatigue. The client should get regular exercise, especially walking, dorsiflexing the
foot of the affected leg relieves pain, increasing calcium intake may help prevent cramps.
THIRD TRIMESTER DISCOMFORTS

▪Return of first trimester discomforts.

▪ Shortness of breath and dyspnea- The client should plan frequent rest periods, sleeping with
the head elevated or sleeping on the side may bring relief, avoid overexertion, perform tailor-
sitting exercises.
▪ Heartburn and indigestion- Client should eat small, frequent meals, sit upright for 30
minutes after a meal, milk should be drunk between meals, fatty and spicy foods should be
avoided, perform tailor-sitting exercises, take antacids only if they are recommended by the
physician or nurse-midwife.
▪ Dependent edema- Swelling is the result of increased capillary permeability caused by
elevated hormone levels and increased blood volume. Sodium and water are retained, and thirst
increase The client should elevate her legs at least twice a day, sleep in the lateral position,
supportive stockings should be worn, avoid sitting or standing in one position for long periods.
▪ Braxton Hicks contractions- are irregular, painless contractions that occur without cervical
dilation, typically they intensify in the third trimester in preparation for labor. Rest, increase
fluids intake. (Its normal, its to prepare baby for delivery. Advice mother to stay hydrated. The
abdomen becomes harden. It is not painful and doesn’t dilate the cervix.)

NURSING MANAGEMENT TO PROMOTE SELF-CARE

▪Personal hygiene.

▪ Avoidance of saunas and hot tubs.

▪ Perineal care.

▪ Dental care.

▪ Breast care.

▪ Clothing.

▪ Exercise

▪Sleep and rest.

▪ Sexual activity and sexuality.

▪ Employment.

▪ Travel- safetest-2nd trimester, risk for DVT (see Teaching Guidelines 12.4).

▪ Immunizations and medications (see Box 12.5).

*Vaccines That Should Be Considered if Otherwise Indicated

- Hepatitis B, Influenza (inactivated) injection, Tetanus/diphtheria (Tdap), Meningococcal,

Rabies.
 * Vaccines Contraindicated During Pregnancy-

- Influenza (live, attenuated vaccine) nasal spray, Measles, Mumps, Rubella, Varicella,
BCG (tuberculosis), Meningococcal, Typhoid.

* Little is known about the effects of taking most medications during pregnancy. Based on this
lack of evidence, it is best for pregnant women not to take any medications during their
pregnancy.

NURSING MANAGEMENT TO PREPARE THE WOMAN AND HER PARTNER

FOR LABOR, BIRTH, AND PARENTHOOD

▪Perinatal education.
▪ Childbirth education:
➢Lamaze (psychoprophylactic) method: promotes the use of specific breathing and
relaxation techniques. Partner-coach involvement.
➢Leboyer: water births, minimize trauma for the newborn. Natural births.
➢Bradley (partner-coached childbirth) method: emphasizes the pleasurable sensations of
childbirth, teaching women to concentrate on these sensations while "turning on" to their
own bodies. Natural births.
➢Dick-Read (natural childbirth) method: focus on fear reduction (childbirth w/o fear) via
knowledge and abdominal breathing techniques. Seeks to interrupt the circular pattern of
fear, tension, and pain during the labor and birthing process.
▪Options for birth setting:
➢Hospitals: delivery room, birthing suite.
➢Birth centers.
➢Home birth.

▪ Options for care providers:

➢Obstetrician.
➢Midwife.
➢Doula.

▪Feeding choices:
➢Breast-feeding: advantages and disadvantages.
➢Bottle-feeding: advantages and disadvantages.
➢Teaching.

▪ Final preparation for labor and birth.

Chapter 13 - Labor and Birth Process

Factors Affecting Labor

• At least five factors affect process of labor and birth. Five P’s:
1. Passenger (fetus and placenta)
2. Passageway (birth canal)
3. Powers (contractions)
4. Position of mother
5. Psychologic response

1. Passenger
The fetus (with placenta) is the passenger.
• Fetal head (size and presence of molding);
• Fetal attitude (degree of body flexion);
• Fetal lie (relationship of body parts);
• Fetal presentation (first body part);
• Fetal position (relationship to maternal pelvis);
• Fetal station; and fetal engagement are all important factors that have an impact on
the ultimate outcome in the birthing process.
A- Suboccipitobregmatic diameter: complete flexion of head on chest so smallest diameter
enters.
B- Occipitofrontal diameter: moderate extension (military attitude) so large diameter enters.
C- Occipitomental diameter: marked extension (deflection) so largest diameter, which is too
large to permit head to enter pelvis, is presenting.

➢ Attitude
• Fetal attitude refers to the posturing (flexion or extension) of the joints and the
relationship of fetal parts to one another.
➢ Lie
• Relationship of spine of fetus to spine of mother (longitudinal and transverse)
➢ Presentation
• Fetal presentation refers to the body part of the fetus that enters the pelvic inlet
first (the “presenting part”)
➢ Position: Relationship of assigned area of presenting part to maternal pelvis (anterior,
posterior or transverse; right or left)
➢ Station
• Measurement of progress of the descent in centimeters above or below
midplane, from presenting part to ischial spine

Passenger: Fetal Attitude Fetal Lie

Fetal Presentation
Passenger: Fetal Position
• Fetal position describes the relationship of a given point on the presenting part of the fetus
to a designated point of the maternal pelvis.
• Landmarks
• Occipital bone (O): vertex presentation (Birth, best, the ideal!!)
• Chin (mentum [M]): face presentation
• Buttocks (sacrum [S]): breech presentation
• Scapula (acromion process [A]): shoulder presentation
• Three-letter abbreviation for identification
• The first letter defines whether the presenting part is tilted toward the left (L) or the right
(R) side of the maternal pelvis.
• The second letter represents the presenting part of the fetus: O for occiput, S for sacrum,
M for mentum, A for acromion process, and D for dorsal (refers to the fetal back) when
denoting the fetal position in shoulder presentations.
• The third letter defines the location of the presenting part in relation to the anterior (A)
portion of the maternal pelvis or the posterior (P) portion of the maternal pelvis. If the
presenting part is directed to the side of the maternal pelvis, the fetal presentation is
designated as transverse (T).
• For example, if the occiput is facing the left anterior quadrant of the pelvis, then the
position is termed left occiput anterior and is recorded as LOA.
• LOA and ROA are optimal positions for vaginal birth.

Fetal Position
Examples of fetal vertex (occiput) presentations in relation to front, back, or side of maternal
pelvis.

Passageway
• Passageway, or birth canal, is composed of:
• Bony pelvis
• Lower uterine segment
• Cervix (10 cm dilation ready for delivery)
• Pelvic floor muscles
• Vagina
• Introitus (external opening to the vagina)

True Pelvis Vs. False Pelvis

The true pelvis is the bony passageway through which the fetus must travel. It is made up of
three planes: the inlet, the mid-pelvis (cavity), and the outlet.
Female pelvis. A, Pelvic brim above. B, Pelvic outlet from below.
• Types of pelvis
• Gynecoid: Normal female pelvis
• Anthropoid: Oval-shaped; adequate outlet, with normal or moderately narrow pubic
arch
• Android: Wedge-shaped or angulated; not favorable for labor
• Platypelloid: Flat with oval inlet; wide transverse diameter, but short anteroposterior
diameter, making outlet inadequate
• Pelvic diameters
• Inlet, midplane, outlet

3. Powers – Uterine contractions

• Primary powers
• Effacement- shortening and thinning of the cervix during the first stage of
labor
• Dilation- enlargement (opening) of the cervical os and cervical canal during
the first stage of labor
• Ferguson reflex- enhancement of uterine activity due to mechanical stretching
of the lower uterine segment and cervix
• Secondary powers
• Bearing-down efforts
Powers /Effacement
" Uterine contractions (primary stimulus)
" Uterine contractions are responsible for thinning and dilating the cervix, then thrusting the
presenting part toward the lower uterine segment. The cervical canal reduces in length from
2 cm to a paper-thin entity and is described in terms of percentages from 0% to 100%. In
primi-gravidas, effacement typically starts before the onset of labor and usually begins
before dilation; in multiparas, however, neither effacement nor dilation may start until labor
ensues (Fig. 13.12). On clinical examination the following may be assessed:
" Cervical canal 2 cm in length would be described as 0% effaced.
" Cervical canal 1 cm in length would be described as 50% effaced.
" Cervical canal 0 cm in length would be described as 100% effaced.

Fig. 15-10. Uterus in normal labor A, in early first stage; and B, in second stage. Passive segment
is derived from lower uterine segment (isthmus) and cervix, and physiologic retraction ring is
derived from anatomic internal os. C, Uterus in abnormal labor in second-stage dystocia.
Pathologic retraction (Bandl's) ring that forms under abnormal conditions develops from the
physiologic ring.
Fig. 15-11. Cervical effacement and dilation. Note how cervix is drawn up
around presenting part (internal os). Membranes are intact, and head is not
well applied to cervix. A, Before labor. B, Early effacement. C, Complete
effacement (100%). Head is well applied to cervix. D, Complete dilation (10
cm). Cranial bones overlap somewhat, and membranes are still intact.

Effacement
Fetal Station
" Relationship of the presenting part to the level of the maternal pelvic ischial spines.
Measured in centimeters and is referred to as a minus or plus, depending on its location
above or below the ischial spines. Typically, the ischial spines are the narrowest part of the
pelvis and are the natural measuring point for the birth progress.
" Zero (0) station is designated when the presenting part is at the level of the maternal ischial
spines. When the presenting part is above the ischial spines, the distance is recorded as
minus stations. When the presenting part is below the ischial spines, the distance is
recorded as plus stations. For instance, if the presenting part is above the ischial spines by 1
cm, it is documented as being a −1 station; if the presenting part is below the ischial spines
by 1 cm, it is documented as being a +1 station.
" An easy way to understand this concept is to think in terms of meeting the goal, which is
the birth. If the fetus is descending downward (past the ischial spines) and moving toward
meeting the goal of birth, then the station is positive, and the centimeter numbers grow
bigger from +1 to +4. If the fetus is not descending past the ischial spines, then the station
is negative, and the centimeter numbers grow bigger from −1 to −4. The farther away the
presenting part from the outside, the larger the negative number (−4 cm). The closer the
presenting part of the fetus is to the outside, the larger the positive number (+4 cm).

Passenger: Fetal Station

Passenger: Fetal Engagement
• Presenting part reaching 0 station
• Floating: no engagement; presenting part freely movable about pelvic inlet
• Position of laboring woman
• Position affects woman’s anatomic and physiologic adaptations to labor
• Frequent changes in position
• Relieve fatigue
• Increase comfort
• Improve circulation
• Laboring woman should be encouraged to find positions most comfortable to her

Factors Affecting Labor: Psychologic response

• Previous birth experiences and their outcomes (complications and previous birth outcomes)
• Current pregnancy experience (planned versus unplanned, discomforts experienced, age,
risk status of pregnancy, chronic illness, weight gain)
• Cultural considerations (values and beliefs about health status)
• Support system (presence and support of a valued partner during labor)
• Childbirth preparation (attended childbirth classes and has practiced paced breathing
techniques)
• Exercise during pregnancy (muscles toned; ability to assist with intra-abdominal pushing)
• Expectations of the birthing experience (viewed as a meaningful or stressful event)
• Anxiety level (excessive anxiety may interfere with labor progress)
• Fear of labor and loss of control (fear may enhance pain perception, augmenting fear)
• Fatigue and weariness (not up for the challenge/duration of labor)

Process of Labor
• Labor: process of moving fetus, placenta, and membranes out of uterus and through birth
canal
• Various changes take place in woman’s reproductive system in days and weeks before labor
begins
• Labor can be discussed in terms of mechanisms involved in process and stages woman
moves through
➢ Signs preceding labor
• Lightening(at 36 week gestation, Engagement at school spine zero) or dropping- it is
known as engagement and occurs when the fetus descends into the true pelvis about
2 weeks before delivery. In primiparas, lightening can occur 2 weeks or more before
labor begins; among multiparas it may not occur until labor starts.
 • Breathing is much easier decrease in gastric reflux, increased pelvic pressure, leg
cramping, dependent edema in the lower legs, and low back discomfort. She may
notice an increase in vaginal discharge and more frequent urination.
➢ Onset of labor
• Onset of true labor cannot be ascribed to single cause. Many factors involved,
including changes in maternal uterus, cervix, and pituitary gland.

• Assessment
• Lightening: Fetus descends into pelvis about 2 weeks before delivery
• Braxton-Hicks contractions increase
• Vaginal show present; vaginal mucosa congested; vaginal mucus increases
• Cervical mucus plug is passed
• Cervix ripens (prostaglandin- help cervix become soft), becoming soft, partly
effaced; may begin to dilate
• Mother has sudden burst of energy, often known as “nesting”
• Loss of 1 to 3 lbs from water loss as fluid shifts secondary to hormonal changes prior
to labor
• Spontaneous rupture of membranes occurs
Premonitory Signs of Labor
• Increased energy level (nesting): It is thought to be the result of an increase in epinephrine
release caused by a decrease in progesterone
• Bloody show: onset of labor or before, the mucous plug that fills the cervical canal during
pregnancy is expelled as a result of cervical softening and increased pressure of the
presenting part. These ruptured cervical capillaries release a small amount of blood that
mixes with mucus, resulting in the pink-tinged secretions known as bloody show.
• Braxton Hicks contractions: may have been experiencing throughout the pregnancy,
become stronger and more frequent. Typically felt as a tightening or pulling sensation of
the top of the uterus. They occur primarily in the abdomen and groin and gradually spread
downward before relaxing.
• In contrast, true labor contractions are more commonly felt in the lower back. These
contractions aid in moving the cervix from a posterior position to an anterior position. They
also help in ripening and softening the cervix, 30 seconds to 2 minutes in duration.
• Spontaneous Rupture of Membranes. Rupture of membranes with loss of amniotic fluid
prior to the onset of labor is termed pre-labor rupture of membranes (PROM).
o The rupture of membranes can result in either a sudden gush or a steady leakage of
amniotic fluid. Although much of the amniotic fluid is lost when the rupture occurs, a
continuous supply is produced to ensure protection of the fetus until birth.
o After the amniotic sac has ruptured, the barrier to infection is gone and an ascending
infection is possible. In addition, there is a danger of cord prolapse if engagement has not
occurred with the sudden release of fluid and pressure with rupture.
o Due to the possibility of these complications, advise women to notify their health care
provider and go in for an evaluation.
Parameters True Labor False Labor

Contraction timing Regular, becoming Irregular, not occurring

closer together, usually close together
4–6 min apart, lasting
30–60 s
Contraction strength Become stronger with Frequently weak, not
time, vaginal pressure getting stronger with
is usually felt time or alternating (a
strong one followed by
weaker ones)
Contraction discomfort Starts in the back and Usually felt in the front
radiates around toward of the abdomen
the front of the
abdomen
Any change in activity Contractions continue Contractions may stop
no matter what or slow down with
positional change is walking or making a
made position change
Stay or go? Stay home until Drink fluids and walk
contractions are 5 min around to see if there is
apart, last 45–60 s, and any change in the
are strong enough so intensity of the
that a conversation contractions; if the
during one is not contractions diminish in
possible—then go to intensity after either or
the hospital or birthing both—stay home.
center.
Fig. 16-1. Discomfort during labor.

A-Distribution of labor pain during first stage.

B-Distribution of labor pain during later phase of first stage and early phase of second stage.

C-Distribution of labor pain during later phase of second stage and during birth.

Gray shading indicates areas of mild discomfort

Light-colored shading indicates areas of moderate discomfort. Dark-colored shading indicates
areas of intense discomfort.
• Stages of labor
❑ FIRST STAGE- is the longest-
▪ LATENT PHASE- 7-8 hrs
• Description: Assessment: Cervical dilation is 1 to 3 cm, Uterine contractions
occur every 5 to 10 minutes, are 30 to 45 seconds in duration, and are of mild
intensity
Intervention:
• Encourage mother and partner to participate in care.
• Assist with comfort measure.
• Changes of position, and ambulation.
• Keep mother and partners informed.
 • Offers fluids and ice chips.
• Encourage voiding every 1 to 2 hours.
• Application of warm/ cold packs, ambulation, or hydrotherapy if not
contraindicated to promote comfort.
Contractions help dilate the cervix and effacement. For delivery.

First Stage cont.

• DURING THE ACTIVE PHASE
Cervical dilation is 4 to 7 cm, uterine contraction occur every 2 to 5 minutes, are 45 to 60
seconds in duration, and are of moderate intensity
• DURING THE ACTIVE PHASE
• Provide client/fetal monitoring.
• Encourage frequent position changes.
• Encourage voiding at least every 2 hr.
• Encourage relaxation.
• Provide nonpharmacological comfort measures.
• Provide pharmacological pain relief as prescribed.
TRANSITION PHASE- 30 min-1.5 hrs
Cervical dilation is 8 to 10 cm, uterine occurs every 1 to 2 minutes, are 60 to 90 seconds in
duration, and are of strong intensity
Intervention:
• ● Continue to encourage voiding every 2 hr.
● Continue to monitor and support the client and fetus.
• ● Encourage a rapid pant-pant-blow breathing pattern if the client has not learned a
particular breathing pattern.
• ● Discourage pushing efforts until the cervix is fully dilated.
● Listen for client statements expressing the need to have a bowel movement. This
sensation is a finding of complete dilation and fetal descent.
● Prepare the client for the birth.
● Observe for perineal bulging or crowning (appearance of the fetal head at the perineum).
● Encourage the client to begin bearing down with contractions once the cervix is fully
dilated.
*** Assess the amniotic fluid if the membranes have ruptured because meconium-
stained fluid, green, gold-yellow, foul odor can indicate fetal distress
-If baby poops inside mother: stool is sterile but it causes inflammation in endometrium
and secondary infection. You can’t tell client to push if there are no contractions.
❑ SECOND STAGE- 30 min-2 hrs- Stage of baby expulsion
• Assessment
• Cervical dilation is complete
• Blood pressure, pulse, and respiration measurements every 5 to 30 min
• Progress is measured by the descent of the fetal head through the birth canal
• Uterine contractions occur every 2 to 3 minutes lasting 60 to 75 seconds, and
are stronger and intense
• Increase in bloody show
• Mother has urge to bear down, assist mother in pushing efforts
• Interventions
• Perform assessment every 5 minutes
• Monitor FHR before, during, and after a contraction (normal FHR is 110 to
160 beats/min)
• Monitor FHR via ultrasound doppler, fetoscope, or electronic fetal monitor
• Monitor uterine contractions by palpation or tocodynamometer, to determine
frequency, duration, and intensity
• Continue to monitor the client/fetus.
• Assist in positioning the client for effective pushing.
• Assist in partner involvement with pushing efforts and in encouraging
bearing down efforts during contractions.
• Promote rest between contractions.
• Provide comfort measures such as cold compresses.
• Cleanse the client’s perineum as needed if fecal material is expelled during
pushing.
• Prepare for episiotomy, if needed.
• Provide feedback on labor progress to the client.
• Prepare for care of neonate.
 Mechanism of Labor
• Seven cardinal movements of mechanism of labor that occur in vertex presentation
• Engagement
• Descent
• Flexion
• Internal rotation
• Extension
• Restitution and external rotation
• Expulsion (birth)
Cardinal movements. A: Engagement and descent. B: Flexion. C: Internal rotation to
occipitoanterior position. D: Extension. E: External rotation beginning (restitution). F: External
rotation

❑ THIRD STAGE- 5-30 min-Placental birth

• Assessment
• Contractions occur until the placenta is expelled
• Increase bleeding
• Increase umbilical cord lengthen
• Uterus changed shape from discoid to globular
• Placenta separation and expulsion occur (about 5 to 30 minutes after the birth
of the infant)
• Schulze mechanism: Center portion of the placenta separates first, and its
shiny fetal surface emerges from the vagina
• Duncan mechanism: margin of the placenta separates, and the dull, red, rough
maternal surface emerges from the vagina first.
•
• Clinical findings of placental separation from the uterus as indicated by
• Fundus firmly contracting

• Swift gush of dark blood from introitus

• Umbilical cord appears to lengthen as placenta descends

• Vaginal fullness on exam

• There is no way to remove the placenta without contraction. Uterus contract to

avoid blood coming out, one of the complications of postpartum and the
mother dies.
Interventions
• Assess maternal vital signs and uterine status
• Examine the placenta for cotyledons and membrane to verify that it is intact
• Assess mother for shivering and warmth
• Instruct the client to push once findings of placental separation are present. Keep
client/parents informed of progress of placental expulsion and perineal repair if
appropriate.
• Administer oxytocics as prescribed to stimulate the uterus to contract and thus
prevent hemorrhage.
• Administer analgesics.
• Gently cleanse the perineal area with warm water and apply a perineal pad or ice
pack to the perineum.
• Promote baby-friendly activities between the family and the newborn, which
facilitates the release of endogenous maternal oxytocin.
A, Placenta begins the separation process in central portion with retroplacental bleeding. Uterus
changes from discoid to globular shape. B, Placenta completes separation and enters lower
uterine segment. Uterus is globular in shape. C, Placenta enters vagina, cord is seen to lengthen,
and there may be increased bleeding. D, Expulsion (birth) of placenta, completion of third stage

❑ FOURTH STAGE- Recovery period- 1-2 hrs after delivery-

• Description
• Period 1 to 2 hours after delivery
• Post-anesthesia recovery
• Interactions with newborn
• Family-newborn relationships
• Initiation of breast-feeding
• Assessment
 • Blood pressure returns to pre labor
• Pulse is slightly lower than during labor
• Fundus remains contracted, midline, or 2(1) fingerbreadths below the
umbilicus
Uterus needs to remain contracted to prevent hemorrhage after delivery.

FOURTH STAGE: Cont Nursing Interventions

Assess maternal blood pressure and pulse every:
✓ Every 15 min for the first 2 hrs and determine the temperature at the beginning of the
recovery period,
✓ Then assess every 4 hrs for the first 8 hrs after birth,
✓ Then at least every 8 hrs.
• Assess fundus and lochia every 15 min for the first hour and then according to facility
protocol.
• Massage the uterine fundus and/or administer oxytocics to maintain uterine tone and to
prevent hemorrhage.
• Encourage voiding to prevent bladder distention.
• Assess episiotomy or laceration repair for erythema.
• Promote an opportunity for parental-newborn bonding.
• After they have had a chance to bond with their baby and eat, most new mothers are ready
for a nap or at least a quiet period of rest.

***FULL BLADDER PREVENTS UTERUS TO CONTRACT!!!***

Chapter 14 - Nursing Management During Labor and Birth

MATERNAL ASSESSMENT DURING LABOR AND BIRTH

Nursing Management of Laboring Women

◦ Assessment

◦ Comfort measures

◦ Emotional support

◦ Information and instruction

◦ Advocacy

◦ Support for the partner

◦ Maternal status(vital signs, pain, prenatal record review)

◦ Vital signs
◦ To be compared to baseline assessment values; remember vital signs change
throughout the progression of the pregnancy (increase in blood volume)
◦ Routine vaginal examinations (cervical dilation, effacement, membrane status, fetal
descent, and presentation)
◦ Woman placed on back for exam and comfort is valued; water may be used as a
lubricant (sterile procedure); assess cervix (dilation/effacement) and fetus if
applicable
◦ The vaginal examination can also determine fetal descent (station) and presenting
part; if progressive fetal descent does not occur, a disproportion between the
maternal pelvis and the fetus might exist and needs to be investigated
◦ Rupture of membranes
◦ The integrity of the membranes can be determined during the vaginal examination.
TACO- Time, Amount, Color, Odor
◦ Uterine contractions (see Figure 14.2)
◦ Uterine contractions during labor are monitored by palpation and by electronic
monitoring
◦ Assessment of the contractions includes frequency; duration, intensity, and uterine
resting tone
◦ To palpate the fundus for contraction intensity, place the pads of your fingers on the
fundus and describe how it feels: like the tip of the nose (mild), like the chin
(moderate), or like the forehead (strong); palpation of intensity is a subjective
judgment of the indentability of the uterine wall; a descriptive term is assigned (mild,
moderate, or strong)
◦ The second method used to assess the intensity of uterine contractions is electronic
monitoring, either external or internal
◦ Leopold’s maneuvers (see Nursing Procedure 14.1)
 ◦ A method for determining the presentation, position, and lie of the fetus through
the use of four specific steps

Cervical Dilation and Effacement

The width of the cervical opening determines dilation, and the length of the cervix assesses
effacement. Effacement and dilation are used to assess cervical changes as follows:
◦ Effacement:
◦ 0%: cervical canal is 2 cm long
◦ 50%: cervical canal is 1 cm long
◦ 100%: cervical canal is obliterated
◦ Dilation:
◦ 0 cm: external cervical os is closed
◦ 5 cm: external cervical os is halfway dilated
◦ 10 cm: external os is fully dilated and ready for birth passage

◦ The information yielded by this examination serves as a basis for determining which stage of
labor the woman is in and what her ongoing care should be

Performing Leopold’s Maneuvers

◦ Leopold maneuvers consist of performing external palpations of the maternal uterus through
the abdominal wall to determine the following.
➢ Number of fetuses
➢ Presenting part, fetal lie, and fetal attitude
➢ Degree of descent of the presenting part into the pelvis
➢ Location of the fetus’s back to assess for fetal heart tones
◦ Vertex presentation: Fetal heart tones should be assessed below the client’s
umbilicus in either the right- or left-lower quadrant of the abdomen.
◦ Breech presentation: Fetal heart tones should be assessed above the client’s
umbilicus in either the right- or left-upper quadrant of the abdomen.
FIGURE 14.2 Nurse palpating the woman’s fundus during a contraction.

❑ Presentation: Portion of fetus that enters pelvic inlet first.

❑ Position: Relationship of assigned area of presenting part to maternal pelvis.
❑ Attitude: Relationship of fetal body parts to one another.
❑ Lie: Relationship of spine of fetus to spine of mother (longitudinal and transverse).

Leopold’s Maneuvers
◦ ● Identify the fetal part occupying the fundus. The head should feel round, firm, and move
freely. The breech should feel irregular and soft. This maneuver identifies the fetal lie
(longitudinal or transverse) and presenting part (cephalic or breech).
◦ ● Locate and palpate the smooth contour of the fetal back using the palm of one hand
and the irregular small parts of the hands, feet, and elbows using the palm of the other
hand. This maneuver validates the presenting part.
◦ ● Determine the part that is presenting over the true pelvis inlet by gently grasping the
lower segment of the uterus between the thumb and fingers. If the head is presenting and
not engaged, determine whether the head is flexed or extended. This maneuver assists in
identifying the descent of the presenting part into the pelvis.
◦ ● Face the client’s feet and outline the fetal head using the palmar surface of the fingertips on
both hands to palpate the cephalic prominence. If the cephalic prominence is on the same side
as the small parts, the head is flexed with vertex presentation. If the cephalic prominence is on
the same side as the back, the head is extended with a face presentation. This maneuver
identifies the fetal attitude.
Rupture of Membranes
◦ If intact, the membranes will be felt as a soft bulge that is more prominent during a
contraction
◦ If the membranes have ruptured, the woman may have reported a sudden gush of fluid;
membrane rupture also may occur as a slow trickle of fluid
◦ When membranes rupture, the priority focus should be on assessing fetal heart rate
(FHR) first to identify a deceleration, which might indicate cord compression secondary
to cord prolapse
◦ Prolonged ruptured membranes increase the risk of infection as a result of ascending
vaginal pathological organisms for both mother and fetus
 ◦ Signs of intrauterine infection to be alert for include maternal fever, fetal and
maternal tachycardia, foul odor of vaginal discharge, and an increase in white blood
cell count
◦ To confirm that membranes have ruptured, a sample of fluid is taken from the vagina via a
nitrazine yellow dye swab to determine the fluid’s pH
◦ Vaginal fluid is acidic, whereas amniotic fluid is alkaline and turns a nitrazine swab
blue
◦ False-positive results can occur, especially in women experiencing a large amount of
bloody show, because blood is alkaline
◦ The membranes are most likely intact if the nitrazine swab remains yellow to olive
green, with pH between 5 and 6
◦ The membranes are probably ruptured if the nitrazine swab turns a blue-green to
deep blue, with pH ranging from 6.5 to 7.5
◦ If the nitrazine test is inconclusive, an additional test, called the Fern test, can be used to
confirm rupture of membranes
◦ A sample of vaginal fluid is obtained, applied to a microscope slide, and allowed to dry
◦ Using a microscope, the slide is examined for a characteristic fern pattern that
indicates the presence of amniotic fluid
◦ TACO: T- time, A- amount, C- color, O- odor

Fetal Assessment During Labor and Birth

◦ Amniotic fluid analysis
◦ Rupturing of membranes is either spontaneous or artificial by means of an amniotomy,
during which a disposable plastic hook (an amnihook) is used to perforate the amniotic
sac. SROM- expontaneous or AROM- artificial
◦ Amniotic fluid should be clear when the membranes rupture. Cloudy or foul-smelling
amniotic fluid indicates infection. Green fluid may indicate that the fetus has passed
meconium secondary to transient hypoxia, prolonged pregnancy, cord compression,
intrauterine growth restriction (IUGR), maternal hypertension, diabetes, or
chorioamnionitis; however, it is considered a normal occurrence if the fetus is in a
breech presentation
◦ If it is determined that meconium-stained amniotic fluid is due to fetal hypoxia, try
to prevent meconium aspiration syndrome. This would necessitate suctioning after
the head is born before the infant takes a breath and perhaps direct tracheal
suctioning after birth if the Apgar score is low. In some cases, an amnioinfusion
(introduction of warmed, sterile normal saline or Ringer’s lactate solution into
 the uterus) is used to dilute moderate to heavy meconium released in utero to assist
in preventing meconium aspiration syndrome
◦ Fetal heart rate monitoring
◦ Handheld versus electronic; intermittent versus continuous; external versus
internal; fetoscope versus Doppler
◦ Traditionally, a fetoscope was used to assess FHR, but the handheld Doppler device has
been found to have a greater sensitivity than the fetoscope
◦ Intermittent FHR monitoring allows the woman to be mobile in the first stage of labor,
however, doesn’t provide continuous monitoring of fetal heart rate
◦ Intermittent FHR auscultation can be used to detect FHR baseline and rhythm and
changes from baseline. However, it cannot detect variability and types of decelerations,
as electronic fetal monitoring (EFM) can
◦ During intermittent auscultation to establish a baseline, the FHR is assessed for a full
minute after a contraction. From then on, unless there is a problem, listening for 30
seconds and multiplying the value by two is sufficient. If the woman experiences a
change in condition during labor, auscultation assessments should be more frequent.
Changes in condition include ruptured membranes or the onset of bleeding. In addition,
more frequent assessments occur after periods of ambulation, a vaginal examination,
administration of pain medications, or other clinically important events
◦ Fetal heart rate patterns
◦ Baseline, baseline variability, periodic changes (see Table 14.1)
◦ Other assessment methods
◦ Fetal scalp sampling, pulse oximetry, stimulation
FIGURE 14.4 Locations for auscultating fetal heart rate based on fetal position. A. Left occiput
anterior (LOA). B. Right occiput anterior (ROA). C. Left occiput posterior (LOP). D. Right
occiput posterior (ROP). E. Left sacral anterior (LSA)

Guidelines for Assessing Fetal Heart Rate

◦ Initial 10- to 20-minute continuous FHR assessment on entry into labor/birth area
◦ Completion of a prenatal and labor risk assessment on all clients
◦ During latent phase: every 30 to 60 min
◦ Active labor- intermittent auscultation every 30 minutes for low-risk women and every 15
minutes for high-risk women
◦ Second stage of labor- intermittent auscultation every 15 minutes for low-risk women and
every 5 minutes for high-risk women and during the pushing stage
◦ FHR and contraction characteristics should be assessed before and after any digital vaginal
examinations, membrane rupture, medication administered, and ambulation to the
restroom
◦ Nursing Procedure 12.1 lists detailed steps for using a Doppler device to assess FHR. In
brief, a small amount of water-soluble gel is applied to the woman’s abdomen or ultrasound
device before auscultation with the Doppler device to promote sound wave transmission.
Usually the FHR is best heard in the woman’s lower abdominal quadrants; if the FHR is not
found quickly, it may help to locate the fetal back by performing Leopold’s maneuvers
Continuous External Electronic Fetal Monitoring
◦ EFM uses a machine to produce a continuous tracing of the FHR. Produce a graphic record
of the FHR pattern
◦ Primary objective
◦ To provide information about fetal oxygenation and prevent fetal injury from impaired
oxygenation
◦ To detect fetal heart rate changes early before they are prolonged and profound
◦ In external or indirect monitoring, two ultrasound transducers, each of which is attached
to a belt, are applied around the woman’s abdomen:
◦ One transducer is called a Tocotransducer, a pressure-sensitive device that is applied
against the uterine fundus (placed over the uterus). It detects changes in uterine pressure
(contractures) and converts the pressure registered into an electronic signal that is
recorded on graph paper
◦ The other ultrasound transducer records the baseline FHR, long-term variability,
accelerations, and decelerations. It is positioned on the maternal abdomen in the midline
between the umbilicus and the symphysis pubis
◦ External monitoring can be used while the membranes are still intact and the cervix is
not yet dilated, but also can be used with ruptured membranes and a dilating cervix. It is
noninvasive and can detect relative changes in abdominal pressure between uterine resting
tone and contractions. External monitoring also measures the approximate duration and
frequency of contractions, providing a permanent record of FHR
◦ However, external monitoring can restrict the mother’s movements. It also cannot detect
short-term variability. Signal disruptions can occur due to maternal obesity, fetal
malpresentation, and fetal movement as well as by artifact.
◦ The term artifact is used to describe irregular variations or absence of the FHR on the
fetal monitor record that result from mechanical limitations of the monitor or electrical
interference
FIGURE 14.5 Continuous external electronic fetal monitoring device applied to the woman in
labor.

Criteria for Using Continuous Internal Monitoring of the FHR

◦ Continuous internal monitoring is usually indicated for women or fetuses considered to be
at high risk
◦ It involves the placement of a spiral electrode into the fetal presenting part, usually the
head, to assess FHR, and a pressure transducer placed internally within the uterus to
record uterine contractions
◦ The fetal spiral electrode is considered the most accurate method of detecting fetal
heart characteristics and patterns because it involves receiving a signal directly from the
fetus
◦ Internal monitoring does not have to include both an intrauterine pressure catheter and a
scalp electrode. A fetal scalp electrode can be used to monitor the fetal heartbeat without
monitoring the maternal intrauterine pressure
◦
◦ Four specific criteria must be met for this type of monitoring to be used:
◦ Ruptured membranes
◦ Cervical dilation of at least 2 cm to 3 cm
◦ Present fetal part low enough to allow placement of the scalp electrode
◦ Skilled practitioner available to insert spiral electrode
◦ Compared with external monitoring, continuous internal monitoring can accurately detect
both short-term (moment-to-moment) changes and variability (fluctuations within the
baseline) and FHR dysrhythmias
◦ Maternal position changes and movement do not interfere with the quality of the tracing
FIGURE 14.6 Continuous internal electronic fetal monitoring.

Determining FHR Patterns

◦ Assessment parameters of the FHR include baseline FHR and variability, presence of
accelerations, periodic or episodic decelerations, and changes or trends of FHR patterns
over time
◦ The nurse must be able to interpret the various parameters to determine if the FHR pattern is
(Table 14.1):
◦ Category I, which is strongly predictive of normal fetal acid–base status at the time of
observation and needs no intervention
◦ Category II, which is not predictive of abnormal fetal acid–base status and but does
require evaluation and continued monitoring
◦ Category III, which is predictive of abnormal fetal acid–base status at the time of
observation and requires prompt evaluation and interventions, such as giving maternal
oxygen, changing maternal position, discontinuing labor augmentation medication, and/
or treating maternal hypotension
◦ Baseline fetal heart rate refers to the average FHR that occurs during a 10-minute segment
that excludes periodic or episodic rate changes, such as tachycardia or bradycardia. It is
assessed when the woman has no contractions, and the fetus is not experiencing episodic FHR
changes. The normal baseline FHR ranges between 110 and 160 beats per minute (bpm)
◦ Fetal bradycardia occurs when the FHR is below 110 bpm and lasts 10 minutes or
longer. It can be the initial response of a healthy fetus to asphyxia. Causes include fetal
hypoxia, prolonged maternal hypoglycemia, fetal acidosis, administration of analgesic
drugs to the mother, hypothermia, anesthetic agents (epidural), maternal hypotension,
fetal hypothermia, prolonged umbilical cord compression, and fetal congenital heart
block. Bradycardia may be benign if it is an isolated event; considered an ominous sign
when accompanied by a decrease in baseline variability and late decelerations
 ◦ Fetal tachycardia is a baseline FHR greater than 160 bpm that lasts for 10 minutes
or longer. It can represent an early compensatory response to asphyxia. Other causes of
fetal tachycardia include fetal hypoxia, maternal fever, maternal dehydration, amnionitis,
drugs (e.g., cocaine, amphetamines, nicotine), maternal hyperthyroidism, maternal
anxiety, fetal anemia, prematurity, fetal infection, chronic hypoxemia, congenital
anomalies, fetal heart failure, and fetal arrhythmias. Fetal tachycardia is considered an
ominous sign if it is accompanied by a decrease in variability and late decelerations

Fetal Bradycardia
◦ Fetal bradycardia FHR is below 110 bpm and lasts 10 minutes or longer.
◦ It can be the initial response of a healthy fetus to asphyxia. Causes include:

CAUSES/COMPLICATIONS : Uteroplacental insufficiency , Umbilical cord prolapse

◦ Maternal hypotension, Prolonged umbilical cord compression
◦ Fetal congenital heart block, Anesthetic medications, Viral infection,
◦ Maternal hypoglycemia, Fetal heart failure, Maternal hypothermia
NURSING INTERVENTIONS
◦ Discontinue oxytocin if being administered.
◦ Assist the client to a side-lying position.
◦ Administer oxygen by mask at 10 L/min via nonrebreather face mask.
◦ Insert an IV catheter if one is not in place and administer maintenance IV fluids.
◦ Administer a tocolytic medication.
◦ Notify the provider.

Fetal Tachycardia
◦ FHR greater than 160/min for 10 min or more
CAUSES/COMPLICATIONS
◦ Maternal infection, chorioamnionitis
◦ Fetal anemia
◦ Fetal cardiac dysrhythmias
◦ Maternal use of cocaine or methamphetamines
◦ Maternal dehydration
◦ Maternal or fetal infection
◦ Maternal hyperthyroidism
NURSING INTERVENTIONS
◦ Administer prescribed antipyretics for maternal fever, if present.
◦ Administer oxygen by mask at 10 L/min via nonrebreather face mask.
◦ Administer IV fluid bolus.
TABLE 14.1 INTERPRETING FHR PATTERNS
Category I: normal Predictive of normal fetal acid–base status and do not require intervention
• Baseline rate (110–160 bpm)
• Baseline variability moderate
• Present or absent accelerations
• Present or absent early decelerations
• No late or variable decelerations
Can be monitored with intermittent auscultation during labor

Category II: Not predictive of abnormal fetal acid–base status, but require evaluation
indeterminate and continued surveillance
• Fetal tachycardia (>160 bpm) present
• Bradycardia (<110 bpm) not accompanied by absent baseline variability
• Absent baseline variability not accompanied by recurrent decelerations
• Minimal or marked variability
• Recurrent late decelerations with moderate baseline variability
• Recurrent variable decelerations accompanied by minimal or moderate
baseline variability; overshoots, or shoulders
• Prolonged decelerations >2 min but <10 min

Category III: abnormal Predictive of abnormal fetus acid–base status and require intervention
• Fetal bradycardia (<110 bpm)
• Recurrent late decelerations
• Recurrent variable decelerations—declining or absent
• Sinusoidal pattern (smooth, undulating baseline

Four Categories of Baseline Variability

◦ Baseline variability is defined as irregular fluctuations in the baseline fetal heart rate, which is
measured as the amplitude of the peak to trough in bpm It represents the interplay between the
parasympathetic and sympathetic nervous systems
◦ Absent: fluctuation range undetectable

◦ Minimal: fluctuation range observed at <5 beats per minute

◦ Typically is caused by fetal acidemia secondary to uteroplacental insufficiency, cord
compression, a preterm fetus, maternal hypotension, uterine hyperstimulation,
abruptio placenta, or a fetal dysrhythmia
◦ Interventions to improve uteroplacental blood flow and perfusion through the umbilical
cord include lateral positioning of the mother, increasing the IV fluid rate to improve
maternal circulation, administering oxygen at 8 to 10 L/min by mask, considering internal
fetal monitoring, documenting findings, and reporting to the health care provider; may
need to perform a surgical birth (caesarean delivery)
◦ Moderate: (normal) fluctuation range from 6 to 25 beats per minute
◦ Moderate viability indicates that the autonomic and central nervous systems (CNSs) of
the fetus are well developed and well oxygenated. It is considered a good sign of fetal
well-being and correlates with the absence of significant metabolic acidosis
◦ Marked: fluctuation range >25 beats per minute
◦ Causes of this include cord prolapse or compression, maternal hypotension, uterine
hyperstimulation, and abruptio placenta
 ◦ Interventions include determining the cause if possible, lateral positioning, increasing
intravenous fluid rate, administering oxygen at 8 to 10 L/min by mask, discontinuing
oxytocin infusion, observing for changes in tracing, considering internal fetal monitoring,
communicating an abnormal pattern to the health care provider, and preparing for a
surgical birth if no change in pattern is noted

FIGURE 14.7 Examples of fetal monitoring strips. A. Long-term variability (average or

moderate). B. Minimal variability. C. Moderate variability. D. Marked variability.

Periodic Baseline Changes

◦ Periodic baseline changes:
◦ Accelerations, decelerations
◦ Temporary, recurrent changes made in response to a stimulus such as a contraction
◦ Can demonstrate patterns of acceleration or deceleration in response to most stimuli
◦
◦ Fetal accelerations are transitory abrupt increases in the FHR above the baseline that last
<30 seconds from onset to peak. They are associated with sympathetic nervous
stimulation. They are visually apparent, generally considered reassuring and require
no interventions. Accelerations denote fetal movement and fetal well-being and are the
basis for non-stress testing
◦
 ◦ A deceleration is a transient fall in FHR caused by stimulation of the parasympathetic
nervous system. Decelerations are described by their shape and association to a uterine
contraction. They are classified as early, late, and variable only:
◦ Early decelerations are visually apparent, usually symmetrical, and characterized by
a gradual decrease in the FHR, occurs at the peak of the contraction (mirror
images). They are thought to be a result of fetal head compression that results in a
reflex vagal response with a resultant slowing of the FHR during uterine
contractions. Early decelerations are not indicative of fetal distress and do not
require intervention
◦ Late decelerations are visually apparent, usually symmetrical, transitory decreases in
FHR that occur after the peak of the contraction. The FHR does not return to
baseline levels until well after the contraction has ended. Late decelerations are
associated with uteroplacental insufficiency, which occurs when blood flow within
the intervillous space is decrease with elevations of FHR of more than 15 bpm
above the baseline, and their duration is >15 seconds, but less than 2 minutes
eased to the extent that fetal hypoxia or myocardial depression exists. Recurrent or
intermittent late decelerations are always category II (indeterminate) or category III
(abnormal) regardless of depth of deceleration. Acute episodes with moderate
variability are more likely to be correctable, whereas chronic episodes with loss of
variability are less likely to be correctable
◦ Variable decelerations present as visually apparent abrupt decreases in FHR below
baseline and have an unpredictable shape on the FHR baseline, possibly
demonstrating no consistent relationship to uterine contractions. The shape of
variable decelerations may be U, V, or W, or they may not resemble other patterns.
Variable decelerations usually occur abruptly with quick deceleration. They are the
most common deceleration pattern found in the laboring woman and are usually
transient and correctable. Variable decelerations are associated with cord
compression. However, they are classified either as category II or III depending on
the accompanying change in baseline variability. The pattern of variable deceleration
consistently related to the contractions with a slow return to FHR baseline warrants
further monitoring and evaluation

Early deceleration of FHR

◦ Slowing of FHR at the start of contraction with return of FHR to baseline at end of
contraction

CAUSES/COMPLICATIONS
◦ Compression of the fetal head resulting from uterine contraction
◦ Uterine contractions
◦ Vaginal exam
◦ Fundal pressure
 NURSING INTERVENTIONS: No intervention required.

Late deceleration of FHR : Slowing of FHR after contraction has started with return of FHR to
baseline well after contraction has ended
CAUSES/COMPLICATIONS
◦ Uteroplacental insufficiency causing inadequate fetal oxygenation
◦ Maternal hypotension, placenta previa, abruptio placentae, uterine hyperstimulation with
oxytocin
◦ Preeclampsia
◦ Late- or post-term pregnancy
◦ Maternal diabetes mellitus
NURSING INTERVENTIONS
◦ Place client in side-lying position.
◦ Insert an IV catheter if not in place and increase rate of IV fluid administration.
◦ Discontinue oxytocin if being infused.
◦ Administer oxygen by mask at 8 to 10 L/min via nonrebreather face mask.
◦ Elevate the client’s legs.
◦ Notify the provider.
◦ Prepare for an assisted vaginal birth or cesarean birth.
Variable deceleration of FHR
◦ Transitory, abrupt slowing of FHR 15/min or more below baseline for at least 15 seconds,
variable in duration, intensity, and timing in relation to uterine contraction
CAUSES/COMPLICATIONS
● Umbilical cord compression
● Short cord
● Prolapsed cord
● Nuchal cord (around fetal neck)

NURSING INTERVENTIONS
● Reposition client from side to side or into knee-chest.
● Discontinue oxytocin if being infused.
● Administer oxygen by mask at 8 to 10 L/min via nonrebreather face mask.
● Perform or assist with a vaginal examination.
● Assist with an amnioinfusion if prescribed.
FIGURE 14.8 Decelerations. A. Early. B. Variable. C. Late.
Early Deceleration

Late Deceleration
Variable Deceleration

Other Fetal Assessment Methods

◦ Umbilical Cord Blood Analysis
◦ Neonatal and childhood mortality and morbidity, including cerebral palsy, are often
attributed to fetal acidosis, as defined by a low cord pH at birth. Umbilical cord blood
acid–base analysis drawn at birth provides an objective method of evaluating a newborn’s
condition, identifying the presence of intrapartum hypoxia and acidemia
◦ The normal mean pH value range is 7.2 to 7.3
◦ The pH values are useful for planning interventions for the newborn born with low 5-
minute Apgar scores, severe FGR, Category II and III patterns during labor, umbilical
cord prolapse, uterine rupture, maternal fever, placental abruption, meconium-stained
amniotic fluid, and post-term births
◦ The interventions needed for the compromised newborn might include providing an
optimal extrauterine environment, fluids, oxygen, medications, and other treatments
◦ Fetal Scalp Stimulation
◦ An indirect method used to evaluate fetal oxygenation and acid–base balance to identify
fetal hypoxia is fetal scalp stimulation or vibroacoustic stimulation. If the fetus does not
have adequate oxygen reserves, carbon dioxide builds up, leading to acidemia and
hypoxemia
◦ A well-oxygenated fetus will respond when stimulated (tactile or by noise) by moving in
conjunction with an acceleration of 15 bpm above the baseline heart rate that lasts at least
15 seconds. This FHR acceleration reflects a pH of more than 7 and a fetus with an intact
CNS. Fetal scalp stimulation is not done if the fetus is preterm, or if the woman has an
 intrauterine infection, a diagnosis of placenta previa (which could lead to hemorrhage), or
a fever (which increases the risk of an ascending infection)
◦ If no acceleratory response by the fetus is exhibited with either scalp stimulation or
vibroacoustic stimulation, further evaluation of the fetus is warranted

PROMOTING COMFORT AND PROVIDING PAIN MANAGEMENT DURING LABOR

Comfort and Pain Management

◦ Pain as universal experience; intensity highly variable

◦ Mandate for pain assessment in all clients admitted to health care facility

◦ Numerous non-pharmacologic and pharmacologic choices available

◦ The techniques used to manage the pain of labor vary according to geography and culture

Nonpharmacologic Measures for Pain Management

◦ Cognitive strategies
❖ Childbirth education
❖ Childbirth preparation methods (Lamaze, patterned breathing exercises) promote
relaxation and pain management.
❖ Doulas can assist clients using methods for nonpharmacological pain management.
❖ Hypnosis
❖ Biofeedback
◦ Sensory Stimulation:
❖ Based on the gate-control theory to promote relaxation and pain relief
❖ Aromatherapy
❖ Breathing techniques
❖ Imagery
❖ Music
❖ Use of focal points
❖ Subdued lighting

Cutaneous stimulation strategies: Based on the gate-control theory to promote relaxation and
pain relief.
❖ Therapeutic touch and massage: back rubs and massage
❖ Walking
 ❖ Rocking
❖ Effleurage: Light, gentle circular stroking of the client’s abdomen with the fingertips
in rhythm with breathing during contractions
❖ Sacral counterpressure: Consistent pressure is applied by the support person using
the heel of the hand or fist against the client’s sacral area to counteract pain in the
lower back
❖ Application of heat or cold
❖ Transcutaneous electrical nerve stimulation (TENS) therapy
❖ Hydrotherapy
❖ Acupressure
❖ Frequent maternal position changes to promote relaxation and pain relief

FIGURE 14.9 Various positions for use during labor. A. Ambulation. B. Leaning forward. C.
Sitting in a chair. D. Using a birthing ball.

FIGURE 14.10 Nurse massaging the client’s back during a contraction while she ambulates
during labor.
Pharmacologic Measures
Opioid analgesics
Opioid analgesics : Opioid analgesics (meperidine hydrochloride, fentanyl, butorphanol,
nalbuphine) act in the CNS to decrease the perception of pain without the loss of consciousness.
Butorphanol and nalbuphine provide pain relief without causing significant respiratory
depression in the mother or fetus. Both IM and IV routes are used.
ADVERSE EFFECTS
➢ Respiratory depression in the neonate if mother medicated too close to time of delivery
➢ Reduction of gastric emptying; increased risk for nausea and emesis
➢ Increased risk for aspiration of food or fluids in the stomach
➢ Bladder and bowel elimination can be inhibited
➢ Sedation, Altered mental status
➢ Tachycardia, Hypotension
➢ Decreased FHR variability
Naloxone, an opioid antagonist, should be readily available for reversal of opioid-induced
respiratory depression.

Pudendal block
Consists of a local anesthetic (lidocaine, bupivacaine) administered transvaginal into the space in
front of the pudendal nerve.
This type of block has no maternal or fetal systemic effects, but it does provide local anesthesia
to the perineum, vulva, and rectal areas during delivery, episiotomy, and episiotomy repair.
ADVERSE EFFECTS
◦ Broad ligament hematoma
◦ Compromise of maternal bearing down reflex
NURSING ACTIONS
◦ Instruct the client about the method.
◦ Coach the client about when to bear down.
◦ Assess the perineal and vulvar area postpartum for hematoma.

FIGURE 14.12 Pudendal nerve block.

Epidural Block
Consists of a local anesthetic along with an analgesic, injected into the epidural space at the level
of the fourth or fifth vertebrae.
This eliminates pain from the level of the umbilicus to the thighs, relieving the discomfort of
uterine contractions, fetal descent, and stretching of the perineum. It is administered when the
client is in active labor and dilated to at least 4 cm.
ADVERSE EFFECTS
◦ Maternal hypotension
◦ Fetal bradycardia
◦ Fever
◦ Itching
◦ Inability to feel the urge to void
◦ Urinary retention
◦ Loss of the bearing down reflex

Epidural Block
Epidural Block Nursing Intervention
◦ NURSING ACTIONS
◦ Help position and steady the client into a sitting or side-lying modified Sims’ position
with the back curved to widen the intervertebral space for insertion of the epidural
catheter.
◦ Encourage the client to remain in the side-lying position after insertion of the epidural
catheter to avoid supine hypotension syndrome with compression of the vena cava.
◦ Monitor maternal blood pressure and pulse, and observe for hypotension, respiratory
depression, and decreased oxygen saturation.
◦ Assess FHR patterns continuously.
◦ Assess for orthostatic hypotension. Be prepared to administer an IV vasopressor (such as
ephedrine), position the client laterally, increase the rate of IV fluid administration, and
initiate oxygen.
◦ Provide for client safety, such as by raising the side rails of the bed. Do not allow the
client to ambulate unassisted.
◦ Assess the bladder for distention at frequent intervals and catheterize if necessary to
prevent discomfort and interference with uterine contractions.
◦ Monitor for the return of sensation and motor control in the client’s legs after delivery but
prior to standing.

FIGURE 14.11 Epidural catheter insertion. A. A needle is inserted into the epidural space. B. A
catheter is threaded into the epidural space; the needle is then removed. The catheter allows
medication to be administered intermittently or continuously to relieve pain during labor and
childbirth.
Spinal anesthesia (block)
Consists of a local anesthetic that is injected into the subarachnoid space into the spinal fluid at
the third, fourth, or fifth lumbar interspace.
ADVERSE EFFECTS
Maternal hypotension
Fetal bradycardia
Loss of the bearing down reflex in the client with a higher incidence of operative births
Potential headache from leakage of cerebrospinal fluid at the puncture site
Higher incidence of maternal bladder and uterine atony following birth
NURSING INTERVENTIONS!!!
Assess maternal vital signs every 10 min.
Manage maternal hypotension by administering an IV fluid bolus as prescribed.
Assess uterine contractions.
Assess level of anesthesia.
Assess FHR patterns.
Provide client safety to prevent injury by raising the side rails of the bed, and assisting the
client with repositioning.

Spinal versus Epidural Anesthesia

General anesthesia
Rarely used for vaginal or cesarean births when there are no complications present. It is used
only in the event of a delivery complication or emergency when there is a contraindication to
nerve block analgesia or anesthesia.
NURSING ACTIONS
◦ Monitor maternal vital signs.
◦ Monitor FHR patterns.
◦ Apply anti-embolic stockings or sequential compression devices.
◦ Pre-medicate the client with oral antacid to neutralize acidic stomach contents.
◦ Administer a histamine2-receptor antagonist, such as ranitidine, to decrease gastric acid
production. .
◦ Place a wedge under one of the client’s hips to displace the uterus.
◦ Maintain an open airway and cardiopulmonary function.
◦ Assess the client postpartum for decreased uterine tone, which can lead to hemorrhage and
be produced by pharmacological agents used in general anesthesia.

NURSING CARE DURING LABOR AND BIRTH

First Stage of Labor: Phone Assessment

◦ Estimated date of birth
◦ Fetal movement; frequency in past few days
◦ Other premonitory signs of labor experienced
◦ Parity, gravida, and previous childbirth experiences
◦ Time frame in previous labors
◦ Characteristics of contractions
◦ Bloody show and membrane status (whether ruptured or intact)
◦ Presence of supportive adult in household or if she is alone

Nursing Care During First Stage of Labor

◦ General measures
◦ Obtain admission history
◦ Check results of routine laboratory tests and any special tests
◦ Ask about childbirth plan
 ◦ Complete a physical assessment

◦ Initial contact either by phone or in person

Assessment in the First Stage of Labor

First Stage of Labor: Admission Assessment

◦ Maternal health history (see Figure 14.13 and Box 14.2)
◦ Physical assessment (body systems, vital signs, heart and lung sounds, height and weight)
◦ Fundal height measurement
◦ Uterine activity, including contraction frequency, duration, and intensity
◦ Status of membranes (intact or ruptured)
◦ Cervical dilatation and degree of effacement
◦ Fetal heart rate, position, station
◦ Pain level
◦ Fetal assessment
◦ Lab studies
◦ Routine: urinalysis, CBC
◦ Syphilis screening, HbsAg screening, GBS, HIV (with woman’s consent), and possible
drug screening if not included in prenatal history
◦ Assessment of psychological status
◦ Woman’s knowledge, experience, and expectations
◦ Vital signs
◦ Vaginal examinations
◦ Uterine contractions
◦ Pain level
◦ Coping ability
◦ FHR
◦ Amniotic fluid (see Table 14.3)
◦ NURSING CARE PLAN 14.1 Overview of a Woman in the Active Phase of the First Stage of
Labor
 Nursing Management: Second Stage

Assessment
◦ Typical signs of second stage
◦ Contraction frequency, duration, intensity
◦ Maternal vital signs
◦ Fetal response to labor via FHR
◦ Amniotic fluid with rupture of membranes
◦ Coping status of woman and partner

Interventions
◦ Supporting woman and partner in active decision making
◦ Supporting involuntary bearing-down efforts; encouraging no pushing until strong desire
or until descent and rotation of fetal head well advanced
◦ Providing instructions, assistance, pain relief
◦ Using maternal positions to enhance descent and reduce pain
◦ Preparing for assisting with delivery

An episiotomy is an incision made in the perineum to enlarge the vaginal outlet and theoretically
to shorten the second stage of labor. Alternative measures such as warm compresses and
continual massage with oil have been successful in stretching the perineal area to prevent cutting
it. Certified nurse midwives can cut and repair episiotomies, but they frequently use alternative
measures if possible.

FIGURE 14.14 Location of an episiotomy. A. Midline episiotomy. B. Right and left mediolateral
episiotomies.
 Nursing Management: Second Stage (cont.)
◦ Interventions with birth
◦ Cleansing of perineal area and vulva
◦ Assisting with birth, suctioning of newborn, and umbilical cord clamping
◦ Providing immediate care of newborn
◦ Drying
◦ Apgar score
◦ Identification

FIGURE 14.16 Suctioning the newborn immediately

after birth.

FIGURE 14.17 An example of a security sensor

applied to a newborn’s arm.
 Nursing Management: Third Stage
◦ Assessment
◦ Placental separation; placenta and fetal membranes examination; perineal trauma;
episiotomy; lacerations
◦ Interventions
◦ Instructing to push when separation apparent; giving oxytocin if ordered; assisting
woman to comfortable position; providing warmth; applying ice to perineum if
episiotomy; explaining assessments to come; monitoring mother’s physical status;
recording birthing statistics; documenting birth in birth book

FIGURE 14.18 Placenta. A. Fetal side. B. Maternal side.

Nursing Management: Fourth Stage

◦ Assessment
◦ Vital signs, fundus, perineal area, comfort level, lochia, bladder status
◦ Interventions
◦ Support and information
◦ Fundal checks; perineal care and hygiene
◦ Bladder status and voiding
◦ Comfort measures
◦ Parent–newborn attachment
◦ Teaching