CH 5

Wednesday, November 04, 2009

5:10 AM

MATERNAL-NEONATAL NURSING LECTURE NOTES

CHAPTER 5 - NURSING CARE OF WOMEN WITH COMPLICATIONS DURING
PREGNANCY
ASSESSMENT OF FETAL HEALTH
Causes of high-risk pregnancies
Relate to the pregnancy itself
Occur because the woman has a medical condition or injury that complicates the
pregnancy
Result from environmental hazards that affect the mother or the fetus
Arise from maternal behaviors or lifestyles that negatively impact the mother or fetus

ASSESSMENT OF FETAL HEALTH

Nursing responsibilities during assessment of fetal health
Prepare the patient for testing
Explain reasons for procedures
Clarify and interpret results of tests in collaboration with other health care team
members
Provide psychosocial support during and after testing
Danger signs in pregnancy
Sudden gush of fluid from vagina
Vaginal bleeding
Abdominal pain
Persistent vomiting
Epigastric pain
Edema of face and hands
Severe, persistent headaches
Blurred vision or dizziness
Chills with fever over 100.4 F
Painful urination or reduced urine output
Fetal diagnostic tests
Ultrasound visualizes and allows measurement of fetal structures
Amniotic fluid volume measurement of fluid in pockets surrounding fetus
Estimation of gestational age by ultrasound measures crown-rump length or
biparietal and thigh measurements
MRI used with high suspicion of anomaly
Kick count 3 kicks/hr is desired
Doppler ultrasound blood flow determines adequacy of blood through placenta and
cord
Alpha-fetoprotein test test of maternal blood sample to determines risk for neural
tube defects, done around 15-19 weeks.
anencephaly, gastroschisis and Down syndrome
Chorionic villus sampling collection of placental part for chromosomal studies,
neural tube , (help detects anichephly- no head).
defects, or anencephaly
Amniocentesis collection of amniotic fluid using US guidance for chromosomal
studies, biochemical disorders, neural tube defects, anencephaly, and Down syndrome
Non-stress test tests for fetal compromise in conditions such as gestational diabetes,
hypertension, and posterm gestation; positive result desired. we want baby
heart rate to go up 15 beats for 15 sec.
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heart rate to go up 15 beats for 15 sec.

Vibroacoustic stimulation test used with NST to stimulate fetal movement
Contraction stress test tests for likelihood of fetus to withstand labor; negative
results desired
Biophysical profile tests for reduced fetal oxygenation; uses NST and US
observation of FHR, fetal breathing movements, fetal body movements, fetal tone,
and amniotic fluid volume
Percutaneous umbilical blood sampling tests fetal blood for anemia caused by blood
incompatibility, placenta previa, and abruption placenta. check for
different enemia's!!!
Lecithin-to-sphingomyelin (L/S) ratio 2:1 required for sufficient surfactant
production. (by amnio, to check lung function/ development)
PREGNANCY-RELATED COMPLICATIONS
Hyperemesis gravidarum
Excessive N/V which severely hinders nutritional status, usually self-limiting
May result in low-birth-weight baby
Dehydration impairs perfusion of the placenta
Manifestations:
Persistent N/V with complete inability to retain food and fluids
Significant weight loss
Dehydration AEB dry tongue and mucous membranes, decreased skin
turgor, scant and
concentrated urine, high hct
Electrolyte and acid-base imbalances
Psychological factors: unusual stress, emotional immaturity, passivity or
ambivalence
about the pregnancy
Treatment:
Correct dehydration and electrolyte imbalances: oral &/or IV fluids, TPN
Antiemetic drugs: Phenergan usually suppository form if hospitalized IV
Zofran.
TPN in severe cases
FLUID AND ELECTROLYTE IMBALANCE IS PARAMOUNT
Nursing care:
Discover and reduce triggers (odors, emesis basin)
Accurate I&O
including Daily Weight
Frequent small meals with easily digested carbohydrates
Crackers, baked potatoes
Foods served attractively with positive reinforcement
Encourage fluid intake between meals instead of with meals
Emotional support
Bleeding disorders of early pregnancy
Spontaneous abortion - Intentional or non-intentional termination of pregnancy before
20 weeks gestation - all will have bleeding and cramping
Spontaneous abortion occurs in 15% of all pregnancies
Lay people terminology is "miscarriage"
Most cases is due to fetal or placental abnormalities
Maternal factors influencing SAb: infections, endocrine disorders,
abnormalities of the reproductive organs, immune factors
Manifestations:
Threatened abortion: usually before 12 weeks of gestation
Intermittent light bleeding
*Closed cervix
*No tissue is passed
1/2 will inevitably abort
Pelvic rest - nothing in the vagina is treatment
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Pelvic rest - nothing in the vagina is treatment

bed rest
Inevitable abortion:
Increased bleeding and cramping
*Cervix dilates
Membranes may rupture
*No tissue is passed- yet
Incomplete abortion
Same as Inevitable, but *some tissue is passed - but not all of
it...still bleeding and cramping.
Complete abortion
*All POC are passed
*Bleeding and cramping decrease
*Cervix closes
Missed abortion - past 8 weeks
Fetus dies within the uterus but is not expelled for many weeks
Changes of early pregnancy cease
Recurrent abortion (habitual abortion)
3 or more consecutive abortions
Common causes:
Genetic factors
Structural abnormalities such as incompetent cervix
Inadequate progesterone levels to sustain pregnancy
Immunologic factors
Medical conditions such as diabetes mellitus or
infections
Induced abortion
Therapeutic intentional to preserve the health of the mother
Elective intentional for reasons other than the health of the mother (such
as fetal anomaly)
Pregnancy termination procedures
Vacuum aspiration first trimester abortion or to remove POC after
spontaneous abortion
Dilation and curettage uses gentle scraping of endometrium to remove
POC
Mifepristone (RU486) oral med used up to 5 wks gestation, given with
prostaglandin to induce bleeding and termination of pregnancy within 5
days
Methotrexate oral or IM med given with misoprostol (Cytotec), a
prostaglandin, vaginally that causes termination of pregnancy within 1-2
days
Prostaglandins intravaginal gel or intrauterine injection used in second
trimester, has unpleasant side effects
Hypertonic intrauterine infusion used in early second trimester to cause
uterine contractions to occur within 12-24 hours, usually given with
misoprostol or oxytocin; complications include sepsis and bleeding
Treatment
Ultrasound to see if fetus is living
No intercourse, douching, tampons, lifting until bleeding stops for at
least 2 weeks
Bed rest for at least 48 hours after each bleeding episode
May require D&C for missed Abs
May need to induce labor if spontaneous labor does not occur
Recurrent abortions requires investigation into cause
Drugs that may be required
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Drugs that may be required

Oxytocin to control blood loss after D&C
Rh immune globulin if mom is Rh negative
Nursing care
Physical care
Document amount and character of bleeding
Pad count and examination of bleeding
Report any tissue loss an send to lab for
identification of POC
VS during D&C recovery
NPO during active bleeding

Teaching for self-care at home after D&C:

Report increased bleeding - do not use tampons
Take temp q 8 hr x 3 days
Report s&s of infection
Take iron supplements are prescribed
Resume sexual activity as MD directs after all
bleeding has
stopped
Return for follow up contraception information
Pregnancy can occur before the first menstrual
period
Emotional care
Support through grief which may be longer and deeper than
people expect
Provide spiritual support as indicated
Refer to support groups
Ectopic pregnancy-Zygote implants outside the uterus (95% are in the tube)
Usually caused by obstruction, scarring, deformity, or inhibition of
tube to propel zygote into uterus from:
Hormonal abnormalities
Inflammation
Infection
Adhesions
Congenital defects
Endometriosis
Smoking
Previous ectopic pregnancies
IUD
Zygotes implanted outside the uterus cannot survive due to
inadequate blood supply
Manifestations:
Low (vague )abdominal pain
Light vaginal bleeding
Sometimes signs of shock if the tube ruptures
Shoulder pain referred pain from bleeding into the abdomen
Treatment:
Positive pregnancy test for hCG
Transvaginal US to see if fetus is in uterus
Culdocentesis (abdominal puncture to detect tube rupture)
Laparoscopy
Goal is to preserve tube but is not always possible
No action is pregnancy is being reabsorbed by body
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No action is pregnancy is being reabsorbed by body

Administer methotrexate (inhibits cell division in the embryo
and allows it to be reabsorbed)
Salpingectomy- cut into the tube take out the poc and let the
tube heal by itself
possible hysterectomy
Nursing care:
Monitor VS and observe for hypovolemic shock, bleeding
FHR changes
Tachycardia
Tachypnea
Shallow, irregular respirations
Falling blood pressure
Decreased or absent urine output
Pale skin or mucous membranes
Cold, clammy skin
Faintness
Thirst
Assess lung and bowel sounds
IV fluids and blood replacement prn
Monitor for pain
NPO-clear liquids-advance when bowel sounds return
Monitor urinary output, cath prn
Assist with ambulation
Emotional support for grieving
Hydatiform mole (gestational trophoblastic disease): - Occurs when the chorionic villi
develop vesicles (sacs) that resemble grape-like clusters
Complications of mole are: hemorrhage, clotting abnormalities,
hypertension, and later development of cancer (only 1% chance of future
molar pregnancy)
Manifestations:
Bleeding from spotting to hemorrhage; cramping may be present
Uterus larger than expected for gestational age; rapid uterine growth
Failure to detect fetal heart activity
Signs of hyperemesis gravidarum
Unusually early development of gestational hypertension
Unusually high levels of hCG
US shows "snowstorm" pattern but no developing fetus within the
uterus
Treatment:
Vacuum aspiration and D&E
hCG monitoring q week X 6 months, then q 6 mo X 1 year or longer
if at risk for carcinoma
hCG should not be detected after 16 weeks
Persistently high hCG indicates retained vesicle or malignant
changes
Delay pregnancy attempts until follow-up care is completed
Tests would be confusing and possible dangerous if cancer
would develop
Rho Gam is given to Rh- moms
Nursing care:
Observe for bleeding and shock
Provide grieving care
Reinforce need for follow-up care
Teach importance of contraception during care
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Teach importance of contraception during care

Bleeding disorders of late pregnancy
Placenta previa - Occurs when the placenta develops in the lower part of the uterus
rather than the upper part of the uterus
Three degrees of placenta previa:
Marginal: placenta reaches the edge of the cervical opening
Partial: partly covers the cervical opening
Total: completely covers the cervical opening
A low-lying placenta does not cover the opening of the cervix, may
or may not be accompanied by bleeding
Usually discovered with US early or late in gestation
Manifestations:
*Painless vaginal bleeding
Risk of hemorrhage increases as term approaches and the
cervix begins to dilate and thin
These normal changes disrupt placental attachment
Uterus is soft; no abdominal contractions or irritability
Fetus is often in abnormal presentation
Fetus is prevented from normal head-down presentation
Placenta occupies normal fetal location
Fetus may have anemia or hypovolemic shock since some of blood
loss may be fetal blood loss
Mom is more likely to have infection or hemorrhage after birth
Treatment
Depends on gestational age and amount of bleeding
Bedrest
C-sect if previa is partial or total
Nursing care:
Observe for bleeding and signs of shock
VS q 15 min if actively bleeding
NO vaginal exam
Continuous fetal monitoring
Abruptio placentae- Is the premature separation of a normally implanted placenta
Accompanies:
Hypertension
Cocaine or alcohol use
Smoking and poor nutrition
Blows (trauma) to the abdomen
Prior history of abruptio
Folate deficiency
Classifications: marginal, central, partial, total
Manifestations:
Bleeding accompanied by abd or low back pain
Bleeding may be concealed behind the placenta
Firm, board-like abd because blood leaks into muscle fiber
Uterine irritability causes cramp-like contractions
Fetus is compromised due to loss of fetal blood as well as maternal
blood losses
May be complicated by DIC (disseminated intravascular
coagulation)
Clotting factors are concentrated behind the placental,
depleting the rest of the mom's body
Clot formation and anticoagulation occur simultaneously
throughout the body
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throughout the body

May bleed from all orifices because clotting factors are
depleted
Prone to pp hemorrhage because injured uterine muscle does not
contract effectively to control blood loss
Susceptible to infection
Treatment:
Immediate C/S
Blood and clotting factor replacement to tx DIC
Mother's clotting quickly returns to normal after birth
Nursing care:
Close observation shock and bleeding
Observe gums, nose, and other sites for signs of bleeding
Close monitoring of fetal well-being
Support for the family if fetus and/or mother dies
Therapeutic communication
Hypertension during pregnancy
May exist before pregnancy, can complicate pregnancy, and may worsen
with pregnancy if mom has chronic hypertension
Occurs in 7% of all pregnancies
Old term is "toxemia"; may be called preeclampsia which progresses to
eclampsia when accompanied by convulsions
Cause is unknown, but birth is the cure
Vasospasm is the main characteristic
Risk factors:
First baby
Obesity
Maternal age over 40 or under 19
Multifetal pregnancy
Family or personal history of PIH
Chronic hypertension
Chronic renal disease
Diabetes mellitus
Manifestations:
Hypertension
Defined as 140/90+
Increases over baseline should be seriously considered
Edema
Occurs because fluid leaves the vessels for the tissue and
decreases blood flow to the maternal organs and placenta
Characterized by sudden excessive weight gain
Edema above the waist suggests PIH
Usually resolves quickly after birth as excessive fluid returns to
the circulation and is excreted in urine
Proteinuria
Develops later as reduced blood flow damages the kidneys that
allows protein to leak into the urine
Must use clean catch or cath specimen due to false positives
from vaginal secretions
Others:
CNS: Severe, unrelenting headache due to brain edema and
small cerebral hemorrhages
DTRs become hyperactive due to CNS irritation
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DTRs become hyperactive due to CNS irritation

Eyes: Blurred, double vision, spots due to arterial spasm and
edema
GU: Decreased urine production causes aggravated
hypertension
Respiratory: Pulmonary edema from fluid accumulation in the lungs
GI and Liver: Elevated liver enzymes due to reduced
circulation, edema, and small hemorrhages
Epigastric pain and nausea due to liver edema;
Often precede seizures
Clotting: HELLP syndrome (Hemolysis, Elevated Liver
enzymes, Low Platelets)
Low platelets cause clotting problems
Eclampsia
Occurs when woman has one or more tonic-clonic seizures
Begins with facial twitching
Followed by tonic-clonic seizures
An eclamptic seizure may result in cerebral hemorrhage,
abruptio placenta, fetal compromise, or death of the mother or
fetus.
Effects on the fetus
Decreased blood flow through the placenta and decreases
oxygen available to the fetus
Results in meconium passage
Growth retardation
Long birth process
Thin, peeling skin of the fetus
Fetal death
Treatment
Prevention
Women at risk take low-dose ASA or calcium
Correction of some of the risk factors
Improving diet, especially in teens
Early and regular prenatal care to manage early detected PIH
Management focuses on:
Maintaining blood flow to the woman's vital organs and
the placenta
Preventing convulsions
Conservative treatment: Hospitalization is common due rapid
deteriorization
Activity restriction is essential bedrest, side-lying allows
blood to be diverted from skeletal muscles to vital organs
Kick counts (report decreased activity or no movement in 4 hours)
BP measurement 2-4 X/d
Daily weight
Measure urine protein
Salt is not restricted, but high-salt foods are discouraged
Fetal diagnostic tests that may be considered:
Sono to detect IUGR or decreased amniotic fluid
Amniocentesis to determine lung maturity
Biophysical profile, nonstress test, and contraction stress test to
evaluate placental functioning
Mag sulfate:
CNS depressant used as anticonvulsant
Given per infusion pump
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Given per infusion pump

Continued 12-24 hrs postpartum for continued risk
of seizures

Excreted by the kidneys, so reduced kidney function can cause

toxicity:
Absence of DTRs
Respiratory depression
Circulatory collapse
Death
Antidote is calcium gluconate
Therapeutic level is 4-8 mg/dl (abnormal level for normal
persons) Causes drowsiness but maintains reflexes and
respiratory function while preventing seizures
Inhibits uterine contractions so may also receive oxytocin to
strengthen contractions during labor
At risk for pp hemorrhage because uterus does not contract
firmly on bleeding vessels after delivery
Useful for stopping preterm labor
Notify nursery to prevent drug interaction in neonate with
some antibiotics that can cause paralysis in the neonate
Antihypertensive drugs
Used if BP is higher than 160/100
Usual drugs of choice: hydralazine (Apresoline) or labetalol
(Normodyne)
New drugs like nifedipine (Procardia) or verapamil (Calan)
now being used but do not have FDA approval for hypertensive
control
Nursing care
Promoting prenatal care
Allows risk identification and early detection
Coping with therapy
Daily weights to identify sudden weight gain
Stress importance of bedrest, diversional activities
Caring for the acutely ill woman
Requires intensive nursing care with constant monitoring
Quiet, low-light environment to reduce risk of seizures
Bed rest on left side
Padded side rails and protect from injury with seizure activity
Emergency drugs and C/S prep kit
Oral airways and oxygen equipment for
Administering medications (common protocols)
VS q 1 with T Q 4
DTRs q 1-4
I&O q 1 (may have indwelling cath for accuracy)
Protein dip with q void
Mag levels q 4 hrs
Deteriorating condition noted by:
Increasing BP
Signs of CNS irritation: facial twitching, hyperactive DTRs
Decreased urinary output
Abnormal FHR
Symptoms which commonly precede seizures: severe
headache, visual disturbances, epigastric pain
Recognizing mag toxicity signs, report to charge nurse, administer
calcium
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calcium
gluconate:
Absent DTRs
Respirations under 12
Urine output < 30 ml/hr
Serum mag > 8 mg/dl
Postpartum care
Must be monitored at least 48 hours during postpartum time
Mom is still at risk for seizures for 72 hours after the birth of the baby
Antihypertensive drugs may adversely affect milk production for
breastfeeding
Diuretics reduce milk production and are not given to breastfeeding
mothers
Blood incompatible between the pregnant woman and fetus mom is RH- and baby is RH+
Placenta allows maternal and fetal blood to exchange nutrients and wastes but not
intermingle
Bloods do mingle with leaks in placenta or placental detachment at
delivery
If incompatible types, mom will form antibodies that are harmful to
subsequent pregnancies
Rh incompatibility
Rh factor is protein either present of the surface of RBCs (Rh+) or not
(Rh-) 15% of Caucasians and 5% of African Americans are RhRh positive can have 1+ and 1- gene and be positive, that is how 2 Rh+
parents can have an Rh- child
Rh- means there are no antibodies against the Rh factor
Exposure to the factor causes the person to form antibodies which
destroy the Rh+ erythrocytes that enter the circulation later called
isoimmunization
Because the response usually occurs at birth, the first Rh+ baby is rarely
affected
Subsequent Rh+ babies are at risk for harm due to the rapid
production of antibodies which are small enough to cross the
placental and destroy the fetal Rh+ erythrocytes
Manifestations:
Rising antibody titers in mom
*New maternal plasma test available to determine fetal Rh status
Fetus will have erythroblastosis fetalis if antibodies cross placenta
Fetus becomes anemic
Accumulated bilirubin causes jaundice present at birth
Detected by amniocentesis testing bilirubin
May have heart failure and severe edema (hydrops fetalis)
Treatment
Primary treatment is prevention of antibody formation by RhoGam
IM injection at 28 weeks and within 72 hrs postpartum
Given after amniocentesis, placental previa, abruption, and
abortion
If mom already has antibodies from prior sensitization:
Frequent testing including:
Indirect Coombs detects previous sensitization
Amniocentesis detects fetal well-being
Percutaneous umbilical blood sampling tests for
fetal anemia
May require intrauterine transfusion
O- RBCs injected into fetal umbilical vessels by US
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O- RBCs injected into fetal umbilical vessels by US

guidance
May be required q 2 weeks from week 28 -term
Phototherapy may be required for the jaundiced infant
ABO incompatibility
Occurs if the mom is O and the babe is A, B, or AB
Baby rarely has severe problems because fewer antibodies can cross
the placenta
Infant may develop jaundice within the first 24 hours, usually
treated with phototherapy
Nursing care for pregnancy-related blood incompatibilities
Administer RhoGam every time it is indicated
Careful observation and assessment of fetus especially during first 24 hrs

PREGNANCY COMPLICATED BY MEDICAL CONDITIONS

Diabetes mellitus
Pregnant woman has one of 2 types of diabetes:
Pregestational diabetes Type 1 (pancreas pathology) or Type 2 (insulin
resistance with strong genetic predisposition)
Gestational diabetes glucose intolerance during pregnancy that usually
resolves with 6 weeks after delivery
Pathophysiology of diabetes mellitus
Disorder in which there is too little insulin to move glucose into the cell
Pancreas produces little or no insulin
The woman's body starves because it cannot utilize glucose
To compensate, the body metabolizes protein and fat for energy
Causes ketones and acids to accumulate
To dilute the blood glucose, polydipsia, increases leading to polyuria and
glycosuria
Classic signs:
Polyuria (with glycosuria)
Polyphagia (with weight loss)
Polydipsia
Effect of pregnancy on glucose metabolism
Hormones (estrogen and progesterone) and an enzyme (insulinase)
produced by the placenta have two effects:
Increase resistance of cells to insulin
Increase speed of insulin breakdown
Most women respond to these changes by secreting more insulin
If unable to secrete more insulin, will have hyperglycemia
Maternal effects of diabetes
Fetal effects of diabetes
Spontaneous abortion
Congenital anomalies
Gestational hypertension
Macrosomia
Preterm labor and PROM
IUGR
Hydramnios
Birth injury
Infections
Delayed lung maturity
Vaginitis
Neonatal hypoglycemia
UTI
Neonatal hypocalcemia
Complications of large fetus
Neonatal hyperbilirubinemia/jaundice
Birth canal injuries
Neonatal polycythemia
Forcep-assisted or cesarean
Perinatal death
Ketoacidosis
Gestational diabetes
Usually resolves quickly after birth
Usually do not have all the classic signs
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Usually do not have all the classic signs

Factors related to gestational diabetes
Maternal obesity (>198 lbs)
Large infant, over 9 lbs
Previous unexplained stillbirth or infant having congenital defects
Chronic hypertension
Maternal age over 25
Gestational diabetes in previous pregnancy
Family history of diabetes
Treatment
Screening 24-28 weeks gestation
50 gm of glucola
Blood work in 1 hr after ingestion
>140 is indication for 3 hr GTT
Diet modification
Diabetic dietician is recommended
Balanced food intake in 3 meals with at least 2 snacks
throughout day
Monitoring of blood glucose levels
Usually self-testing is done keeping records at least qid
Hemoglobin A1C shows long-term glucose control
Ketone monitoring of the urine
Ketonuria accompanied by hyperglycemia could indicate
ketoacidosis
Can be rapidly fatal to the fetus
Insulin
Insulin preferred because it does not cross the placenta
Oral glyburide considered after the first trimester
Not always indicated if diet and exercise control
hyperglycemia
IDDM insulin requirements may initially decrease, but increase
as
pregnancy progresses until delivery
when insulin requirements
return to pre-preg
level
Exercise
Mild exercise is recommended and usually decreases insulin
needs
Is recommended after meals
BS should be monitored before, during, and after exercise
Fetal assessments
US to identify IUGR, macrosomia, and
polyhydramnios/oligohydramnios
Nonstress test, contraction stress test and biophysical profiles
indicate placental functioning
Tests for fetal lung maturity, if delivery is considered
Care during labor
IV dextrose solutions with Reg Insulin with blood glucose
monitoring q 2 hrs and adjustment prn
Continuous fetal monitoring
Macrosomic babies may require cesarean delivery
Care of the neonate
Complications may include: hypoglycemia, respiratory
distress, injury from macrosomia, growth retardation
Usually a neonatologist is present for birth
Nursing care:
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Nursing care:
Self care
Teach self-monitoring skills
Teach food choices
Teach to recognize signs of hypoglycemia
Emotional support
May be anxious over outcome of pregnancy
Hard to live with strict diet controls
Open therapeutic communication techniques
Praise all attempts to make necessary modifications
Breastfeeding
New studies show breastfeeding infants born to women with
gestational diabetes have lower incidence of developing
diabetes later in life

Heart disease
Most heart disease during pregnancy results from rheumatic fever, congenital heart
defects, or mitral valve prolapse
Manifestations:
Palpitations and heart murmurs are common during pregnancy and mimic
heart disease
Increased blood volume and cardiac output impose greater burden on the
heart
Increased levels of clotting factors predispose to thrombosis
CHF if heart unable to meet demands
CHF postpartum until circulating blood volume returns to normal
Treatment
Frequent antepartum visits
Avoid excessive weight gain; sodium is restricted
Frequent rest periods
Drug therapy
Iron supplements to prevent anemia
Heparin to prevent clot formation
Beta-blockers for hypertension and arrhythmia
Antibiotics intrapartum
Vaginal birth is preferred due to less risk of infection
Forceps or vacuum extraction decrease need for maternal pushing
(valsava )
Nursing care
Teach need to change to heparin from Coumadin
Monitor PTT, aPTT, platelet counts
Teach signs of bleeding to report
Teach signs of CHF to report
Teach diet to meet nutritional needs yet prevent excessive weight gain
Discuss stress management techniques
Anemia
Reduced ability of the blood to carry oxygen
Hgb <10 indicate anemia
Nutritional anemias
Iron-deficiency anemia
Pregnant woman needs additional iron during pregnancy for
increasing blood volume necessary at delivery
Prevention
Iron supplements
Take with vitamin C to enhance absorption
Avoid taking with milk or antacids because calcium
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Avoid taking with milk or antacids because calcium

impairs
absorption
Discuss dark green/black stool that occur
Treatment
Elemental iron supplements which continue for 3 mo after
anemia corrected
Folic acid-deficiency anemia
Essential for normal fetal growth and prevention of neural tube
defects
Often present with iron-deficiency anemia
Woman complains of sore tongue
Prevention
400g folic acid supplement q d for all fertile women
Treatment
1 mg or more qd for women with previous deliveries of babies
with NTD
Sickle cell disease
Abnormal shape of RBC during hypoxia or acidosis
Abnormal cells do not flow well and become clotted in small vessels
Sickled cells are destroyed faster and result in anemia
Most common in African or Mediterranean descent
Pregnancy can cause sickle cell crisis
Massive RBC destruction
Vessel occlusion
Pregnant women more likely to have:
Infections
Heart disease
PIH
Risk to fetus Is occlusion of vessels that supply the placenta
Growth retardation
Preterm labor
Fetal death
Treatment:
Frequent prenatal visits
Treat anemia
Fetal growth and placental evaluations
O2 and fluids during delivery to prevent crisis
Thalassemia
Genetic trait that produces abnormality in 1 of the 2 chains of hemoglobin
(usually
chain)
If mom has inherited 2 genes, she has thalassemia major (Cooley's
Disease)
Generally, this client has died in early childhood
If mom has inherited 1 gene, she has thalassemia minor and her fetus
is not
affected
Treated by careful monitoring and immediate treatment of infections
Iron supplements are not usual, because the body absorbs and stores
more iron
than usual
Nursing care for anemia during pregnancy
Diet teaching for high-iron foods and vitamin C to enhance absorption
Supplements
Teach not to drink milk with iron supplements
Teach to expect dark green/black stools with iron supplements
Teach to keep all anointments for follow-up
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Teach to keep all anointments for follow-up

Infections
Torch infections: Toxoplasmosis, Rubella, Cytomegalovirus, Herpes simplex
Do not adversely effect mom, but is devastating to fetus

Viral infections
Cytomegalovirus
May be asymptomatic in mom
Babe may present with: petechiae, deafness, blindness, mental
retardation,seizures, dental abnormalities
Treatment and nursing care
No effective treatment is currently available
Therapeutic abortion may be offered if contracted early in
pregnancy
Rubella
Mom presents with low-grade fever and rash
Effects on developing fetus are devastating: microcephaly,
mental retardation, cardiac defects, deafness, congenital
cataracts, IUGR, malformation of major body systems
Treatment and nursing care
Immunization at least 3 mo prior to planning pregnancy
Therapeutic abortion may be offered
Varicella-Zoster Virus (chicken pox or shingles)
If infected during pregnancy, may cause mom to become critically ill
May also cause: preterm labor, encephalitis, and varicella
pneumonia
Effects on the fetus: intrauterine infection associated with
abnormalities, variable
infection severity, shingles that appear months or years after
birth
Treatment and nursing care
Report any respiratory symptoms
If contracted: full respiratory support, hemodynamic
monitoring, and fetal surveillance
Immunization is now available
Immune globulin for infant
Herpesvirus
Type 1 = cold sores and fever blisters; Type 2 = genital herpes
After primary infection, virus lies dormant along a nerve root
Can reactivate anytime thereafter
Initial infection during first half of pregnancy can cause spontaneous
abortion, IUGR, and preterm labor
Infant is infected by: ascending to fetus after membranes rupture,
fetal contact during delivery
Disseminated infection of the fetus results in high mortality
rate (60%)
Survivors may have neurologic complications
Treatment and nursing care
Avoid neonatal contact with lesions
If mom has active lesions, do cesarean section
Hepatitis B
Virus can be transmitted by: blood, saliva, vaginal/seminal
secretions, breast milk, and crosses the placenta
Infant is more likely than an adult to become a chronic carrier
Treatment and nursing care
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Treatment and nursing care

Should be screened at initial prenatal visit and during 3rd
trimester
Infants born to positive moms should have immune globulin
followed by hep B immunization
CDC recommends immunization for all newborns, 1-2 months,
and 6-18 months
Immunization during pregnancy is contraindicated
Injections should be delayed until after the babe's
first bath to prevent virus from mom being
introduced under the skin
All nurses should have immunization
HIV - the causative organism of AIDS
Virus cripples immune system which eventually results in death
Women of childbearing age usually become infected by:
Sexual contact with an infected person
Parenteral or mucus exposure to infected blood or tissue
Perinatal exposure
Infant infected by
Transplacental
Contact with infected mother's secretions during birth
Breast milk
Infants will be HIV+ at birth but may convert to HIV- by 3-6 months
Infected infants have a short life-span 1-5 years
Treatment and nursing care
There is no immunization or cure
Prenatal screening labs
History for high-risk behaviors
Evaluate symptoms associated with AIDS/HIV
AZT given PO to reduce transmission to fetus
baby may be born positive but will seroconvert to
negative.
Regular prenatal visits
Assist with anticipatory grieving
Teach avoidance of situations likely to cause opportunistic
infections
Educate methods of safe sex
Consistent use of universal precautions
Nonviral infections
Toxoplasmosis
Protozoal infection from cat feces, raw meat, or transplacental infection
Mom has mild symptoms
Fetal presentations: low birth weight, enlarged liver and spleen, jaundice,
anemia, inflammation of the eye structures, neurologic damage
Treatment and nursing care
Therapeutic abortion may be offered if infected during first half of
pregnancy
Preventative teaching:
Cook all meat thoroughly
Wash hands and all surfaces after handling raw meat
Avoid touching mucous membranes of eyes or mouth when
handling raw meat
Avoid uncooked eggs and unpasteurized milk
Wash fruits and vegetables well
Unit 2 Page 16

Wash fruits and vegetables well

Avoid materials contaminated with cat feces (litter boxes, sand
boxes, garden soil)
Group B Strep
Normally found in GI tract, but may be found in urine, vagina, cervix,
throat, and skin
Most common cause of neonatal sepsis in the US with high neonatal
mortality rate
Also associated with postpartum maternal infection, especially after
cesarean birth
Treatment and nursing care
Screening during prenatal care and between 35-37 weeks gestation
If positive screening or presence of following risk factors, give IV
antibiotics
to mom and newborn
Previous infant with GBS infection
Presence of GBS in urine cultures
Birth before 37 weeks
Maternal fever during labor
Membranes ruptured for more than 18 hours before birth
Tuberculosis
Mom should be screened and X-rayed with abdomen shield if positive
Sputum cultures confirm the diagnosis
Newborns infected from contact with untreated mom after birth
Congenital TB signs: failure to thrive, lethargy, respiratory distress,
enlarged
liver or spleen or lymph nodes
Treatment and nursing care
Mom treated with isoniazid and rifampin with pyridoxine for 9
months
Ethambutol may be necessary for drug-resistant TB
Infant may have preventative therapy with isoniazid for 3 mo after
birth
Teaching transmission and importance of long-term compliance
STI
Infections include: syphilis, gonorrhea, chlamydia, trichomoniasis,
condylomata acuminata
Genital herpes results in 50-60% mortality rate for infants!!!!!!
Screening and treatment according to the causative organism is required
Vaginal infections
Candidiasis
Most common cause of "Yeast" infection
Causes: itching and occasional painful urination and intercourse,
and cottage cheese discharge
Neonate may be infected during delivery; presents as thrush
Treated with miconazole (Monistat)
Bacterial vaginosis
Gardnerella vaginalis causes profuse "fishy" discharge
Fetus is usually unaffected
Treated with Ampicillin for patient and partner
May also use Flagyl after first trimester due to potential fetal
defects
Nursing care for women with vaginal infections
Taught measures to reduce discomfort
Sitz baths followed by warm air from blow dryer
Unit 2 Page 17

Sitz baths followed by warm air from blow dryer

Cotton underwear
Avoid tampons and pads with plastic backing
UTI
Pregnancy alters self-cleaning action of urinary tract due to pressure which
prevents
complete emptying
Asymptomatic UTI may cause ascension to cystitis or pyelonephritis

Can cause maternal septic shock and preterm labor

High fever can decrease O2 supply to fetus
S&S of cystitis
Burning with urination
Increased frequency and urgency
Normal or slightly elevated temp
S&S of pyelonephritis
High fever
Chills
Flank pain or tenderness
Nausea and vomting
Treatment
Antibiotic therapy which may be IV
Nursing care
Teach good hygiene practices to prevent self-contamination
Adequate fluid intake
Urinate before and after intercourse
Teach signs and symptoms of infection and seek treatment ASAP
ENVIRONMENTAL HAZARDS DURING PREGNANCY
Bioterrorism and the pregnant patient
Categories of biologic agents
A: easily transmitted from person to person (smallpox, anthrax, tularemia)
B: spread via food and water (Q fever, brucellosis, Staph enterotoxin B)
C: spread via manufactured weapons designed to spread disease (Hantavirus
and tickborne encephalitis)
Nursing responsibilities
Observe for unusual symptoms in large numbers of young, healthy pregnant
patients
Report symptoms to health department or CDC
Follow established protocols and standard precautions
Standard Precautions: botulism, anthrax, tularemia
Airborne and Contact Precautions: smallpox
Droplet precautions: plague
Airborne, Droplet, and Contact Precautions: hemorrhagic fever
Participate in community awareness programs
Continuing education mandates for healthcare workers
Substances abuse
Smoking
Causes IUGR, abruptio placenta, preterm labor, stillbirth, increases
neonatal death, and SIDS
Alcohol
Most commonly abused drug available
Causes FAS: prenatal and postnatal growth retardation, facial
abnormalities (flat, thin upper lip border, and downslant eyes)
Marijuana
Unit 2 Page 18

Marijuana
Users also ingest other harmful substances that may be harmful when
combined with it
Cocaine
Powerful CNS stimulant and highly addictive
Causes euphoria and vasoconstriction: also tachycardia, hypertension,
seizures, stroke,
MI, and sudden death
Potential effects on fetus: spontaneous abortion, abruptio placenta, IUGR,
preterm birth,
and abnormalities of the heart, urinary tract,
and abdominal wall
Heroin

Addicted woman is particularly exposed to HIV

Fetal effects: spontaneous abortion, hyperactivity, hypoxia, meconium
passage, and
stillbirth
Neonatal absence syndrome presents within 24 hours: prolonged high-pitch
crying,
high need for sucking, tremulousness, seizures, hyperactivity, disturbed
sleepwake cycles
Maintaining mom on methadone can prevent serious effects to the fetus
but do not
eliminate neonatal abstinence effects
Anticonvulsants
For women with history of seizures and on anticonvulsants,
MD will prescribe drug that is least teratogenic
Phenobarb has lowest risk than other anticonvulsants
Anticoagulants
Heparin is the only anticoagulant that does not cross the placenta
Acne meds
isotretinoin (Accutane) causes serious fetal defects
Acne meds are not essential and should not be taken during pregnancy and
when
considering pregnancy, should be stopped and other form
of contraception used
until drug is eliminated up to 11months
Treatment
Identify substance abuser early in pregnancy to minimize effects
Screen for infections
Dietary support
Referral for substance abuse cessation
Nursing care
Education of public
Initiate therapeutic, trusting relationship
Screen for drug use in nonthreatening way
Support the woman who is trying to stop drug use
Praise woman for all efforts to improve her health and healthy pregnancy
TRAUMA IN PREGNANCY
Three leading causes of death:
Automobile accidents
Use care when performing ordinary tasks
Use seat belts in automobiles
Homicide
Suicide
Most common cause of fetal death is maternal death
Women abused during pregnancy are more likely to have:
Miscarriages
Stillbirths
Unit 2 Page 19

Stillbirths
Low-weight babies
Enter prenatal care late in pregnancy
Have increased risk of homicide with greatest risk when she leaves her abuser
Manifestations of battering
Late or erratic prenatal care
Bruises or lacerations in various stages of healing
Old fractures on x-ray
Assumes responsibility for injuries
Treatment of the pregnant woman experiencing trauma
Interview for possible battering
Assess level of danger to patient if admits to abuse
Care of the life-threatening injuries
Management depends on gestational age
Nursing care
Therapeutic non-judgemental communication
Assess factors that increase the risk for severe injuries or homicide
Assess status of children that may be abused
Refer to shelters and other services
Supplement medical treatment
EFFECTS OF HIGH-RISK PREGNANCY ON THE FAMILY
Disruption of usual roles
When bedrest is ordered, others assume the roles of the patient
Nurse helps identify sources of support to maintain reasonable normal household
Financial difficulties
Social service referrals may help family cope with expenses when a salary is lost
Delayed attachment to the baby
High-risk pregnancy halts planning for the baby and mom may withdraw emotionally
to protect
herself from pain and loss if the outcome is poor
Loss of expected birth experience
Allow parents to remain together in privacy
Accept behaviors related to grieving
Develop plan of care to provide support to family
Offer momentos: footprints, ID band, lock of hair, picture
Prepare parents for appearance of infant
Provide parents with educational materials and support groups
Discuss wishes concerning religious and cultural rituals
Pasted from <file:///C:\Documents%20and%20Settings\Kris\My%20Documents\Downloads\Chapter_5.doc>

Unit 2 Page 20

CH 6
Wednesday, November 04, 2009
5:10 AM

MATERNAL-NEONATAL NURSING LECTURE NOTES

CHAPTER 6 - NURSING CARE DURING LABOR AND BIRTH
CULTURAL INFLUENCE ON BIRTH PRACTICES
American Indian stoic, indigenous plants in room, special necklaces, meditation/chants
Arabic passive, expressive, keeps body covered, protective amulets, low pain tolerance,
values males
more than females, expects 20 days of rest after birth, husband whispers praises in
infants ears
African-American participates actively, vocal, prefers sponge bath postpartum, avoids
hair washing
until lochia ceases
Central America vocal, prefers to wear red, prefers bottle feeding if affluent, avoids cold
foods
Chinese vocal, does not pause in doorways when walking during labor, do not use first
name of
women, does not shower for 30 days, prefers breastfeeding, needs encouraging to ask
questions
Hindu, Sikh, Muslim, Pakistanian passive role, keeps head covered, prenatal care not
started until
120th day of gestation, gender of infant not revealed until placenta delivered, sponge
bath postpartum, seclusion for 40 days
Orthodox Jewish prefers nurse midwife, maintains modesty, no intimacy with husband
until 7 days
after lochia stops, males circumcised on 8 th day, females named on first Saturday after
birth
Mexican American prefers privacy, will not shower postpartum, ambulates only to
bathroom, avoids beans postpartum, uses alternative therapies for mom and baby
Japanese modesty important, infant bathed twice daily with loud noise and music to ward
off evil
spirits, assertive during labor but may not ask for pain relief
Vietnamese woman expected to suffer in silence, prefers warm fluids to drink, sponge
bath for 2
weeks postpartum, prefers female family member present, sex is prohibited during
pregnancy and puerperium

SETTINGS FOR CHILDBIRTH

Hospitals
Traditional setting - labors, delivers, and recovers in 3 separate rooms then pp
Birthing room - labors, delivers, and recovers (LDR) in the same room then pp
Has more home-like appearance
Has functional birthing bed that breaks away for delivery
Have adaptive devices for items such as squat bars
May also have birthing chairs available
Single-room birth setting - labors, delivers, recovers, pp (LDRP) same room
Infant stays in the same room during entire stay
Advantages of hospital settings:
Pre-registration
Easy access to sophisticated services
Ability to have family-centered care for complicated pregnancy
Unit 2 Page 21

Ability to have family-centered care for complicated pregnancy

Disadvantages of hospital settings
Higher overall costs
Limited choice of birth attendants
Free-standing birth centers
Usually geographically close to hospitals
Similar to outpatient surgical centers
CNMs often attend the birth
Advantages
Home-like setting for low-risk deliveries
Lower costs
Disadvantages:
Slight delay in emergency care is life-threatening complications develop
Home
Advantages:
Control over those who attend delivery, including children
No risk of acquiring microorganisms
Low-tech birth
Disadvantages:
Limited choice of birth attendants
Significant delay in reaching emergency care if life-threatening
complications develop
No pre-established relationship with MD if hospitalization is required
COMPONENTS OF THE BIRTH PROCESS
The powers the forces that cause cervix to open and propel fetus downward through the
birth canal
Uterine contractions
The primary power of labor during the first stage of labor
Def - involuntary smooth muscle contractions
Intensity and effectiveness are influenced by: walking, drugs,
anxiety, vaginal exams
Effects if cntx on the cervix
Effacement (thinning)
Cervix is tubular structure 2 cm long
Cntx push fetus down and pull cervix up
Described as percentage
When 100% effaced, cervix feels like thin, slick membrane
over the fetus mom doesn't push until she is 100% effaced
Dilation (opening)
Described in cm (fully dilated is 10 cm)
Estimated by touch rather than precisely measured
Phases of contractions
Phases:
Increment - increasing strength
Acme - peak of greatest strength
Decrement - decreasing strength
Frequency:
Elapsed time form the beginning of one cntx to beginning of
the next cntx
Described in minutes
Cntx occurring more frequently than q 2 min may reduce fetal
O2 and should be reported
Duration:
Elapsed time from the beginning of one cntx to the end of the
Unit 2 Page 22

Elapsed time from the beginning of one cntx to the end of the
same cntx
Described in seconds
Cntx longer than 90 sec reduce fetal O2 supply because the
placenta is unable to refill with blood and should be reported
Intensity:
Approximate strength of the cntx
Describes uterus as:
Mild - nose
Moderate - chin
Strong - forehead
Interval
The amount of time the uterus relaxes between cntx
Persistent cntx with intervals shorter than 60 sec can reduce
fetal O2 supply and should be reported
Maternal pushing
Voluntary pushing is begun only when the cervix is fully dilated
Feeling of need to push can be decreased or eliminated by:
Maternal exhaustion
Epidural anesthesia
Most women feel need to push before cervix is fully dilated due to fetus
pressing on rectum - if so they need to blow with an open mouth.
The passage
Bony pelvis
False pelvis
Upper flaring part of pelvis
True pelvis
Directly involved with childbirth
Pelvic inlet
Pelvic cavity (midpelvis)
Pelvis outlet
Soft tissues
Consist of cervix, muscles, ligaments, fascia
Yield more readily if mom has had previous vaginal deliveries
Yield less if:
Older mother
Cervix scarred by cervical procedures
Many years between births
The passenger (usually in cephalic presentation)
Fetal head
Composed of several bones linked by connective tissue (sutures)
Fontanels form where sutures meet:
Anterior fontanel
Diamond-shaped
Posterior fontanel
Triangular-shaped
Sutures and fontanels allow fetal head to change shape as it passes through
pelvis
Process is called molding
Fontanels are important landmarks for determining how fetus is oriented
within the mother's pelvis
Diameters
Transverse - measured between two parietal bones on each side of
the head
Anteroposterior - measure varies depending on how much the head
Unit 2 Page 23

Anteroposterior - measure varies depending on how much the head

is flexed or extended

Lie
Describes how the fetal body is oriented to the mother's spine
Most common lie is longitudinal (>99%) - fetus is parallel to the spine
Transverse - fetus is at right angles to the spine
Also called shoulder presentation
Oblique - fetus is between longitudinal and transverse
Attitude
Normal is flexion with head flexed forward and limbs flexed
Flexed fetus is compact and efficiently occupies space in the uterus and
pelvis
Presentation
Refers to the fetal part that enters the pelvis first
Cephalic is most common (95%)
Vertex - head is completely flexed with chin on chest (most desirable
because the smallest possible diameter of the head enters the pelvis)
Military - moderate head flexion
Brow - extension of head
Face - full extension (hyperextension)
Breech presentation (3-4%)
Frank - buttocks are visible with legs flexed at the hips toward the
shoulders
Complete - buttocks visible with legs flexed at the knees and arms
crossed
Footling - one or both feet descending through the pelvis
Many breech presentations result in c/s since head (which is largest
part of fetus)
may not pass through the pelvis
Transverse (shoulder enters pelvis first)
Requires c/s for delivery
Position
Refers to how a fetal reference point is oriented within the mom's pelvis
Occiput
Used when head is first
Sacrum
Used when fetus is breech
Shoulder or back
Used when fetus is in shoulder presentation
Mentum
Used when face is first
Pelvis is divided into 4 quadrants: anterior, posterior, left, right
Abbreviations:
1st - L or R (omitted if fetal reference point is directly anterior or
posterior)
2nd - O, M, S (occiput, mentum, sacrum)
3rd - A, P, T (front or back of mother's pelvis)
The psyche
Childbirth involves the mom's entire being
Birth described in emotional terms like those used to describe marriage,
anniversaries, religious events, and deaths
Families having fewer children with greater expectations about the birth experience
Woman's mental state can influence course of labor
Relaxed and optimistic better tolerates discomfort
Anxiety increased perception of pain and reduced tolerance
Unit 2 Page 24

Anxiety increased perception of pain and reduced tolerance

Anxiety and fear inhibited cntx and divert blood from the placenta
Cultural and values influences how birth is viewed and coping with delivery
Culture that promotes stoicism endurance of labor and delivery without
complaints
Culture that promotes expression of feelings loud response to labor
NORMAL CHILDBIRTH
Signs of impending labor
Braxton-Hicks Cntx
Irregular cntx that begin during early pregnancy and intensify as term
approaches
May become regular and somewhat uncomfortable but do not cause
cervical changes
Increased vaginal discharge
Clear, non-irritating mucus secretions caused by fetal pressure
Bloody show
Mucus plug that has sealed the cervix is dislodged, and tears small
capillaries
Bloody show is thick mucus mixed with pink or dark-brown blood
May occur after vaginal exam or intercourse
May begin a few days before labor, or when labor begins
ROM
Amniotic sac ruptures and fluid is expelled and/or leaked
May cause umbilical cord to be expelled and become compressed
Looses the protective seal against organisms
Women should go to hospital when membranes rupture
Energy spurt
"Nesting" is sudden burst of energy just before labor begins
Teach to conserve energy even if they feel unusually energetic
Weight loss
Loses 1-3 pounds before labor begins as hormone changes cause excretion
of extra water
True and false labor
False labor
Cntx without cervical changes
Cntx are irregular and do not increase in frequency, intensity, or duration
Walking relieves discomfort
Discomfort is in abdomen and groin
True labor
Cntx that efface and dilate cervix
Cntx become regular and develop a pattern with increased frequency,
duration, intensity
Cntx become stronger and more effective with walking
Discomfort felt in lower back and low abdomen
Mechanisms of labor (cardinal movements of fetus as it descends into the pelvis)
Descent
Required for all other mechanisms to occur
Station describes the level of the presenting part (head) in the pelvis
Measured from the level of the ischial spines (0 station)
Minus stations are above the ischial spines
Plus stations are below the ischial spines
Engagement
Occurs when the fetal presenting part is at 0 station or lower
Often occurs before labor's onset in the nullipara
Unit 2 Page 25

Often occurs before labor's onset in the nullipara

May not occur until after labor begins in multipara

Flexion
Flexed head allows fetus to pass most easily through the pelvis
Cntx increase the amount of flexion until the chin is on the chest

Internal rotation
When the fetus is in the pelvis, the occiput of the head is toward the
mom's right/left side
Curved cylindrical shape of the pelvis causes head to turn until the occiput
is directly under the symphysis pubis
Extension
Fetal head changes from flexion to extension
To negotiate the curve under the symphysis pubis
Fetal neck stops under the symphysis pubis which acts as pivot
Head swings anteriorly as it extends with each maternal push
Head is born in extension
External rotation
Shoulders are now crosswise in the pelvis and the head is twisted in
relation to the shoulders
Head spontaneously turns to one side as it realigns with the shoulders
(restitution)
Head rotates further toward one of the mother's thighs and the shoulders
turn within the pelvis so they can emerge
Expulsion
The anterior shoulder and then the posterior shoulder is born and quickly
the rest of the body is expelled
ADMISSION TO THE HOSPITAL OF BIRTH CENTER
When to go to the hospital or birthing center
Cntx - have developed a pattern and 5 min apart for primigravida or 10 min apart for
1 hour in multigravidas
ROM - anytime membranes rupture or she thinks they have ruptured
Bleeding other than bloody show
Decreased fetal movement - can be indication of fetal compromise
Any other concern - require professional evaluation
Admission data collection Admission assessments
Infection control in the intrapartum area
Universal precautions for blood, amniotic fluid, and vaginal secretions
Many drugs are administered parenterally so risk for injury increases
Guidelines:
Wear clean gloves when contact with body substance is anticipated
Wear sterile ones if appropriate
Wear water-repellent cover gown when exposure to large amts of
substances is likely (like holding the newborn)
Wear mask and eyeshields if splashing is likely
Establishment of therapeutic relationship
In welcome
During labor by determining her expectations and helping to achieve
Includes partner and family
Fetal condition
FHR (110-160)
Is irregular and fluctuates 5-15 bpm
Unit 2 Page 26

Is irregular and fluctuates 5-15 bpm

Preterm fetus has faster HR; mature fetus has slower HR
FHR may slow during cntx and returns to baseline by end of each
cntx
BOW
When BOW ruptures our first action is to check the baby heart rate
listen for one full minute.
When BOW ruptures, check color, odor, and amount of fluid
WNL is clear with flecks of white vernix
Abnml fluid:
Green - passed some meconium and may indicate some fetal
distress or newborn respiratory problems after birth
Cloudy or yellow indicates infection
Amount is variable from intermittent trickle to gush
Odor is distinctive, but not offensive
Foul or strong-smelling indicates infection
Maternal condition
VS assessed for complications: infection, hypertension
Impending birth
Behaviors to observe for:
Sitting on one buttock
Making grunting sounds
Bearing down with cntx
Stating "the baby's coming"
Bulging of the perineum
Don gloves and call for help on the call bell
Gather precip tray for delivery
Additional data collection
Basic information for admission to facility
Woman's plans for birth
Status of labor
Vaginal exam by the RN
Cntx assessment and application of fetal monitoring
General condition of the mom
Admission procedures
Permits
For herself and care of the babe
Permission for C/S if necessary
Laboratory tests
H&H, urine for glucose and protein and other dx tests if no prenatal care
IV infusion
May be continuous or heplock
Perineal shave
Not done anymore because studies show it does not reduce incidence of
infection
May be indicated for repair of lacerations or episiotomies
Abdominal shave done for cesareans
Determining fetal position and presentation
May assist with Leopolds maneuver and placement of EFM
Nursing care of the woman in false labor (prodromal labor)
Placed on fetal monitoring for 20 min to document fetal well-being
After observation period, woman is sent home until true labor begins as determined
by cervical status
Factors to consider:
Number and duration of previous labors
Unit 2 Page 27

Number and duration of previous labors

Distance from the facility
Availability of transportation
If BOW is ruptured, mom is kept due to risk of infection or prolapsed cord
Mom's reactions:
Frustrated that it is not the real thing
Requires generous reassurance that true labor is going to start soon
Encouraged not to be reluctant to return should cntx change

NURSING CARE BEFORE BIRTH

Monitoring the fetus
FHR assessment (110-160 BPM)
Intermittent auscultation with fetoscope or doppler
Allows mom greater freedom of movement
Allows mom to shower or whirlpool
Used most frequently at home or in birthing centers
Does not provide continuous recording to detect fetal changes
Performed:
When BOW ruptures
Before and after ambulation
Before and after medication
At peak time of med action
After vaginal exam
After expulsion of enema
If cntx are abnormal or excessive
Continuous EFM
Allows keeping permanent record of fetal status
Hampers ambulation but new telemetry monitors allow walking
Intermittent monitoring promotes walking during labor
Can be done with external or internal devices after BOW ruptures
Cntx can also be monitored with toco monitor
Evaluating FHR patterns (see p 133-135)
Baseline rate is WNL at 110-160
Variability describes fluctuations in baseline and gives sawtooth
appearance
Is desired but may be affected by narcotic analgesics
Accelerations
Increases in FHR of 15 bpm for at least 15 min
Indicate well-oxygenated fetus
Only require reassurance of mother
Early decelerations
FHR drops during cntx but return to baseline by end of cntx
Caused by fetal head compression and are normal
Only require continued observation
Variable decelerations
Begin and end abruptly and look like a V, W, or U
Suggest cord compression, cord around fetal neck, or
inadequate fluid to cushion it well
Inconsistent with cntx pattern
Requires positioning mom on side and administering O2 Other
positions include knee-chest and T-berg Amnioinfusion is
alternative to increase fluid for cushioning of cord
Indicates need for continued monitoring
Unit 2 Page 28

Indicates need for continued monitoring

Late decelerations
FHR drops below baseline but does not return to baseline until after
cntx ends
1. Require repositioning
2. IV fluid increase,
3. stop Pit
4. O2
5. notify MD
6. administer tocolytic drugs
7. know baseline and what it is dipping too
Suggest placental insufficiency and requires close monitoring
Reassuring FHR Patterns
Non-reassuring FHR
Patterns
Stable rate between
110-160
Tachycardia 10
minutes
Variability present
Bradycardia 10
minutes
Accelerations
present
Decreased or absent
variability
Frequency >2
minutes
Late decelerations
Duration <90
seconds
Variable
decelerations
Interval >60
seconds
Inspection of amniotic fluid
May rupture spontaneously or be ruptured in amniotomy
Requires monitoring for 1 full min after rupture
Note color, amount, and odor of fluid
Nitrazine test or fern test will be positive if amniotic fluid is present
Observing the woman
VS: T q 4 hrs (q2 if elevated or ROM) and report if > 100.4
P, R, BP monitored q 1 hr
Contractions: Assessed by palpation on fundus or EFM
Progress of labor
Periodic vaginal exam to determine progress; limit frequency to prevent
infection
Cervical changes
Descent of fetus in relation to ischial spines
Note changes in behavior
Intake and output
May not sense need to void so palpate bladder area q 1-2 hrs
Can impede progression of fetal descent
Oral intake policies vary
Unit 2 Page 29

Oral intake policies vary

Response to labor
Breathing techniques
Relaxation techniques
Support adaptive responses
Nonverbal behaviors that suggest difficulty coping with labor
Tense body posture
Thrashing in bed
Assess signs that suggest rapid labor progress
Helping the woman cope with labor
Promoting comfort
Positioning
Medication as ordered
Good hygiene
Adjust the temperature of the room for comfort of mom
Use fan or warm blanket as needed
Soft, indirect lighting promotes relaxation
Regular changing of disposable underpads
Provide oral fluids as ordered
Lip balm for mouth breathing
Lemon-glycerine swabs to moisten mouth
Bathe or shower if not contraindicated
Positioning
Regularly change position
Avoid supine position to prevent supine hypotensive syndrome
Main risk is reduction of placental blood flow and fetal O2
supply
Upright positions add force of gravity to cntx
Promote pressure of presenting part of cervix to make changes
Leaning forward shifts fetus away from spine for back discomfort
Side-lying left reduces pressure and constant strain on muscles
Squatting uses gravity and straightens pelvic curves and may provide extra
room to push
baby out
Teaching
Ongoing task
Teach to avoid pushing before cervix is completely dilated
Causes swelling and slows progress
Cleansing breath, exhale, deep inbreathe and push while exhaling and
pulling back of thighs or knees
Providing encouragement
Powerful tool to help woman summon inner strength and courage
Use liberal praise for coping abilities
Encourage partner as well
Supporting partner
Give teaching and support liberally
Encourage taking breaks and meals
Stages and phases of labor
First stage
Stage of dilation form onset of labor to complete dilation
Usually the longest stage (6-10 hours)
Phases:
Latent
Usually complete before mom enters hospital
Extends from labor onset to 4 cm
Cervix effaces almost completely in nullipara
Unit 2 Page 30

Cervix effaces almost completely in nullipara

Often remains thick in multiparas
Cntx increase in strength and intensity and become 5 min
apart
Woman is sociable and excited, cooperative but somewhat
anxious,
relatively comfortable
Active
Cervix dilates from 4-7 cm
Effacement is completed
Cntx become 3 min apart, last 45 sec, moderate to firm
Woman becomes less sociable but still cooperative
Turns inward to concentrate on giving birth
Requests analgesia if giving IV give during the contraction
Transition
Intense, short phase of labor
Cervix completes dilating from 8-10 cm
Cntx are firm and 2-3 min apart, with duration of 90 sec
Woman feels loss of control and thinks it will never be over
Becomes uncooperative and hostile
Second stage
Stage of expulsion
Lasts from complete dilation to birth of baby (1 1/2-2 hr-nullipara & 20-45
min-multipara)
Firm cntx that may be less frequent and shorter than transition
Has involuntary urge to push as fetus presses on rectum
Epidurals can suppress this urge and prolong second stage
Woman regains control and describes pushing as feeling useful, may push
intensely and be oblivious to surroundings when cntx ends, and is
simultaneously tired and excited
Third stage
Expulsion of placenta is the shortest stage (5-30 min)
Lasts from birth of babe to expulsion of placenta
Expelled as:
Schultze mechanism - shiny, fetal side exits first
Duncan mechanism - rough maternal side exits first
Uterus must cntx promptly and remain cntx to control bleeding from
vessels
Pit is given to mom IV, IVP, or IM
Infant's suckling also aids cntx by causing release of posterior
pituitary oxytocin
Pain is minimal, with brief cramping as placenta is expelled
She is excited and wants to see the babe
Fourth stage
Recovery stage for first few hours after birth
Uterus should be felt as firm round grapefruit-sized ball
Felt halfway between umbilicus and symphysis pubis then swells to
umbilicus
Should be in the midline center of abdomen
Assess fundus and massage to maintain firm contraction
Displaced fundus indicates full bladder
Chill for 20-30 min that stops spontaneously is normal
Discomfort is minimal and perceived as burning/throbbing sensation ( get
ice to help with comfort and slowed bleeding from vasoconstriction, and
lessens swelling.)
May have afterpains (cramping) as uterus cntx and relaxes
Unit 2 Page 31

May have afterpains (cramping) as uterus cntx and relaxes

Bladder fills rapidly due to IV fluids and return to circulation of fluid from
tissues
Full bladder can cause excess bleeding as pushes uterus upward
Interferes with cntx
Woman is tired, but eager to see and hold babe
Ideal time to promote family bonding
Reminders for immediate general care:
Identify and prevent hemorrhage
Evaluate and intervene for pain
Observe for bladder function and urine output
Evaluate recovery from any type of anesthesia
Provide initial care to the newborn
Promote bonding and attachment
VBAC
60-80% of previous C/S can have VBAC
Nursing care is similar to that for women who have had no C/S
Main concern is uterine rupture
Disrupts placental supply and hemorrhage
May need more emotional support: anxious about their ability to cope with
labor's demands
Nursing care during birth
Woman is prepared for birth when 3-4 cm of head is visible (crowning) at the vaginal
opening
Multip is prepared when cervix is fully dilated
Transfer to delivery room PRN early enough to prevent rushing
When delivering in supine position, place both legs in stirrups simultaneously to
prevent muscle strains
Well pad stirrups to prevent compression and development of blood clots
Place in high Fowler's position or in position of choice side-lying, squatting,
standing, or others
Nursing responsibilities during birth
Prepare delivery instruments and infant equipment
Do perineal scrub prep
Give drugs to mom or babe PRN
Provide initial care to infant: suction airway, dry skin, place in warmer
Assess infant APGAR scores at 1 and 5 minutes after birth
Assess infant for abnormalities
Note if infant urinates or defecates
Examine placenta and note whether Schultz or Duncan side emerges
Identify mom, dad, others, and babe with matching armbands/legbands
Footprints and moms fingerprints are taken
Promote parent-infant bonding and observe: eye contact, fingertip or palm touch of
infant, talking in high-pitched tones which are associated with initial bonding
Immediate postpartum period: the third and fourth stages of labor
Examine placenta and monitor vital signs
General care in the fourth stage
Identify and prevent hemorrhage
Evaluate and intervene for pain
Observe bladder function and urine output
Evaluate recovery from anesthesia
Provide initial care to newborn
Promote bonding and attachment between infant and parents

NURSING CARE IMMEDIATELY AFTER BIRTH

Unit 2 Page 32

NURSING CARE IMMEDIATELY AFTER BIRTH

Care of the mother
Observe for hemorrhage with VS
q 15 min X 1 hour
q 30 min X 1 hour
q 1 hour X 4 hours
Assessments include:
VS with T
Skin color
Location and firmness of fundus
Amount and color of lochia
Presence and location of pain
IV infusion and mediations
Fullness of bladder or urine output from a catheter
Condition of the perineum for vaginal birth
Condition of dressing for cesarean birth or tubal ligation
Level of sensation and ability to move lower extremities if epidural/spinal
used
Observing for hemorrhage
Vaginal bleeding
Lochia rubra (dark red)
No more than 1 pad q hour - first massage the fundus to help it
contreact
Continuous trickle of bright red bleeding suggests bleeding
laceration
VS identify shock risk
Bladder assessment
Mom may not sense need to void
If full, will displace uterus to one side
Full bladder inhibits uterine cntx and promotes bleeding
May cath if unable to void
Promoting comfort
Shaking chill is normal and expected so apply warm blanket
Ice pack to perineum to reduce swelling for at least first 12 hours
Care of the infant
Care of the newborn immediately after delivery
First phase: from birth to 1 hour
Maintain thermoregulation
Dry infant to prevent heat loss from evaporation
Place infant in radiant warmer
Place hat on infants head
Wrap infant or have skin-to-skin contact with mother
Maintain cardiorespiratory function
Wipe face, nose, and mouth
Bulb suction of mouth (mouth first because that is where the initial
breath is taken) and nose
Apply cord clamp when stabilized under radian warmer
Monitor signs of respiratory distress
Persistent cyanosis
Grunting respiration
Flaring of nostrils
Sternal or rib retractions
Sustained respiratory rate higher than 60 breaths per minute
Sustained heart rate above 160 or below 110
Keep Narcan available to reverse narcotic-induced respiratory
Unit 2 Page 33

Keep Narcan available to reverse narcotic-induced respiratory

depression
Perform APGAR scoring at 1 and 5 minutes after birth is to identify
need
for respiratory resuscitation and consists of:
Heart rate
Respiratory effort
Muscle tone
Reflex response to suction or gentle stimulation
Skin color
Observing for urination and/or passage of meconium
Passage must be noted on chart
Identify the mother, father, and newborn
Wristbands placed on mom, dad, infant
Footprints of infant and fingerprints of mother
Promoting maternal-infant bonding by handing baby to mom ASAP
Administering medications
Eye care erythromycin ointment to eyes to prevent ophthalmia
neonatorum (blindness related to chlamydia and
gonorrhea)
Vitamin K to assist in blood clotting; IM in vastus lateralis muscle
Observing for major anomalies
Note infants movements and symmetry of movement
Spina bifida, cleft lip, cleft palate, extremities assessments
Second phase: 1-3 hours after birth, usually in nursery or PP unit
Third phase: 2-12 hours after birth, PP unit or rooming-in
CORD BLOOD BANKING
Cord blood contains stems cells use for transplants and treating malignant and genetic
diseases in children and adults
Costs for storage not usually covered by insurances yet
Requires informed consent for cord blood banking and storage
Collection performed by phlebotomist and transported with 48 hours for
cryopreservation
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Unit 2 Page 34

CH 7
Wednesday, November 04, 2009
5:11 AM

MATERNAL-NEONATAL NURSING LECTURE NOTES

CHAPTER 7 - NURSING MANAGEMENT OF PAIN DURING LABOR AND
BIRTH
EDUCATION FOR CHILDBEARING
Types of classes available: gestational diabetes, early pregnancy, exercises for pregnancy,
infant care,
breastfeeding, sibling, grandparenting
Variations of childbirth preparation classes
Refresher courses review info from previous pregnancies, include ways to help
siblings adjust
Cesarean birth classes explores expectations, prepares for care
VBAC classes explores feelings about previous C/S
Adolescent childbirth preparation tailored to special needs, usually are peer-related
classes in Schools
Content of childbirth preparation classes
Benefits of exercise
Pain control methods for labor (skin stimulation like effleurage, diversion/distraction,
breathing)
CHILDBIRTH AND PAIN
How childbirth pain differs from other pain
Part of a normal body process
Makes her feel vulnerable and seek shelter and help
Motivates her to assume different body positions
Can facilitate normal descent of the fetus
Woman has several months to prepare for pain management
Time to develop skills and knowledge for managing pain
Pain is self-limiting and rapidly declines after birth
Pain of labor ends with the birth of the baby
Factors that influence labor pain
Pain threshold
Least amount if sensation that a person perceives as painful
Fairly constant
Varies little under different circumstances
Pain tolerance
Amount of pain one is willing to endure
Can change under different circumstances
Sources of pain during labor
Dilation and stretching of the cervix
Reduced uterine blood supply during contractions
Pressure of the fetus on pelvic structures
Stretching of the vagina and perineum
Physical factors that modify pain
CNS factors:
Gate Control Theory
Pain is transmitted through small nerve fibers
Stimulating large nerve fibers temporarily interferes with pain
conduction through the small fibers
Techniques include:
Firm massage
Unit 2 Page 35

Firm massage
Palm and fingertip pressure
Heat and cold applications
Endorphins
Natural body substances similar to morphine
Increase during pregnancy and peak during labor
May explain why laboring women usually need smaller doses
of pain meds
Maternal condition
Cervical readiness
If cervix does not "ripen", more cntx are necessary to cause
effacement and dilation
Pelvis
Pelvic abnormalities can result in longer labor and greater maternal
fatigue
Fetus may remain in an abnormal presentation or position which
interferes with
the mechanisms of labor
Labor intensity
Short, intense labor causes more pain than woman with more gradual
labor
Fatigue
Reduces tolerance and coping skills
Fetal presentation and position
Presenting part acts as wedge to efface and dilate the cervix
Fetal head is smooth and rounded and causes the most effective
wedge
If fetal occiput is posterior, cntx push against maternal sacrum
Results in persistent and poorly relieved back pain
Labor is longer
Interventions of caregivers
Common interventions that may contribute to pain:
IV lines
Continuous EFM, especially if it hampers mobility
Amniotomy
Vaginal exams
Psychosocial factors that modify pain
Culture
Influences how she feels about pregnancy and birth
Influences how she reacts to pain
Anxiety and fear
Moderate anxiety can motivate her to learn techniques to increase pain
tolerance and is less likely to interpret labor sensations as dangerous or
sign that something is wrong
Excessive anxiety:
Reduces uterine blood flow
Makes uterine cntx less effective
Causes muscle tension that counteracts the expulsion powers of cntx
and maternal pushing
Previous experiences
Previous experiences influence reactions to current labor
May have learned coping strategies
Previous births make one less likely to interpret sensations with
injury or
abnormality
Previous long and difficult labors may feel apprehensive
Unit 2 Page 36

Previous long and difficult labors may feel apprehensive

Previous C/S may feel uneasy about attempting vaginal birth
Planned C/S may be apprehensive if foes into early labor
Childbirth preparation
Classes, self-study, or other knowledge makes less anxiety and fear
Realistic preparation provides:
Variety of coping skills
Reasonable expectations
Support of significant others
Usually husband or baby's father
Well-prepared partner is valuable teammate for helping with coping
Family and friends assist in coping if they relate accurate information
about childbirth
NONPHARMACOLOGICAL PAIN MANAGEMENT
Advantages
Do not harm mother or fetus
Do not slow labor
Carry no risks
Limitations
Unpreparedness
Methods of childbirth preparation
Dick-Read Method (English physician)
Fear-tension-pain cycle theory
Fear of childbirth contributed to tension which results in pain
Methods include education and relaxation techniques to interrupt the cycle
Bradley Method (husband-coached childbirth)
First to include father as integral part of labor
Emphasizes abdominal breathing and relaxation techniques
Lamaze Method (psychoprophylactic method)
Basis of most childbirth classes
Uses mental and breathing techniques to condition women to respond to
cntx with
relaxation
Techniques occupy mind to limit brain's ability to sense pain
Nonpharmacological techniques
Relaxation techniques require concentration, thus occupies mind while reducing
muscle tension
Progressive relaxation contract-release different muscle groups
Differential relaxation contract one muscle group while relaxing all others
Touch relaxation contract muscle group and relax it when partner
strokes/massages it
Relaxation against pain increase/decrease pressure against arm or leg
Skin stimulation variations of massage
Effleurage woman strokes abdomen in circular motion during contraction
Sacral pressure firm pressure against lower back
Thermal stimulation heat applied with warm blanker or warm water glove,
cool cloth to face
Massage feet, hands, shoulders
Positioning frequent changes of position, avoid back
Diversion/distraction direct mind away from pain
Focal point woman fixes eyes on selected object or close eyes during
contraction
Imagery create a tranquil mental environment
Music relaxation recordings or music, rainfall, wind, ocean, etc.
Television provides background noise
Unit 2 Page 37

Television provides background noise

Breathing most effective with practice
All breathing begins and ends with cleansing breath

First-stage breathing
Slow paced breathing as in sleep
Modified paced breathing breathes more rapidly and slowly
Patterned paced breathing rapid breaths followed by intermittent blow
Second-stage breathing
Cleansing breath, deep breath, push while exhaling slowly to count of 10
Nurses role in nonpharmacological techniques
How to recognize and correct hyperventilation
Signs and symptoms
Dizziness
Tingling of hands and feet
Cramps and muscle spasms of hands
Numbness around nose and mouth
Blurring of vision
Correct measures
Breathe slowly, especially in exhalation
Breathe into cupped hands or paper bag
Place moist washcloth over mouth and nose while breathing
Hold breath for a few seconds before exhaling
Determine degree of preparedness
Teach simple breathing techniques
Make close eye contact when necessary to enhance focusing
Minimize environmental irritants
Use caution not to over- or underestimate pain
PHARMACOLOGIC PAIN MANAGEMENT
Physiology of pregnancy and its relationship to analgesia and anesthesia
Pregnant woman more at risk for hypoxia caused by pressure of uterus on diaphragm
Sluggish GI system results in increased risk for vomiting and aspiration
Aortocaval compression increases risk of hypotension and development of shock
Effect on fetus must be considered
Pharmacologic methods: Advantages
Reduce and relieve pain
Help her to be more active participant
Helps relax and work with cntx
Pharmacologic methods: Limitations
Two persons are medicated
Effects may be prolonged in the fetus after birth
May slow progress of labor
May have drug interactions with other meds she takes
Analgesics and adjunctive drugs
Narcotics: butorphanol (Stadol), nalbuphine (Nubain), meperidine (Demerol),
fentanyl (Sublimaze)
Primary risk is newborn respiratory depression due to opioids crossing
placenta
Usually given in small amts IVP
Avoided if birth is expected within the hour
Narcotic antagonist: naloxone (Narcan)
Used to reverse respiratory depression in the neonate
May be given IV or through endotracheal tube in resuscitation
Has a shorter duration than the drugs it reverses
Unit 2 Page 38

Has a shorter duration than the drugs it reverses

Adjunctive drugs: promethazine (Phenergan), hydroxizine (Vistaril only given z-track

IM)Enhance pain-relief and reduce nausea
Regional analgesics and anesthetics
Local infiltration
Injected into perineal area for episiotomy or laceration repair
Pudendal block
Used less commonly than epidural for vaginal births
Does not block pain from cntx and is given just prior to birth
Injects nerves on each side of the pelvis through the vagina or perineum
with a long
needle
Adverse effects
Vaginal hematoma
Formation of abscesses
Epidural block
Give a bolus of fluid to prevent hypotension to which is the most common side
effect of the epidural
Used for labor and birth, C/S, and post delivery BTL
Position mother on side or sitting up relatively straight to prevent
compression of the epidural space
Fine catheter is threaded into the epidural space
Test for level of numbness
Numbness or loss of movement after test dose indicates dura mater
was penetrated as in subarachnoid anesthesia
Numbness around mouth, ringing in the ears, visual disturbances,
jitteriness suggest injection into a vein
Catheter is continuously infused with local anesthetics with small doses of
narcotics or re-injected intermittently
Can sometimes ambulate, assume most any position
May feel urge to push with second stage labor
Long acting narcotics may be used after C/S for continued pain relief
Dural puncture
Some spinal fluid is lost and headache results
Treated with blood patch
Limitations prevent use if:
Abnormal blood clotting
Infection in area of injection or systemically
Hypovolemia
Adverse effects:
Maternal hypotension which compromises fetal oxygenation
Prevented by IV bolus before procedure
Urinary retention may result
Requires voiding/catheterization
May have prolonged second stage labor if loss of urge to push
Subarachnoid (spinal) block
Position mother in C-shape with back curled around uterus
Anesthetic is injected into subarachnoid space after site confirmation by
spinal fluid leak
Anesthesia takes place quickly with loss of sensation and movement
below the block
Remains common one-shot block for C/S but not for vag deliveries
Adverse effects
Hypotension
Unit 2 Page 39

Hypotension
Urinary retention
Postspinal headache (lie flat for at least 4 hours)
Blood patch done to form gelatinous seal to prevent spinal fluid
loss for postspinal headache
General anesthesia used in:
Emergency C/S when there is no time for spinal or epidural
C/S for contraindications or refusal of epidural
Adverse effects for mom
Regurgitation and aspiration which can be fatal
Can cause uterine relaxation
Adverse effects in neonate
Respiratory depression
Time of induction of anesthesia to clamping cord is kept as short as
possible
All is ready before anesthesia is begun
PHARMACOLOGICAL TECHNIQUES: THE NURSES ROLE
The nurse's role in pharmacologic techniques
Good medical and pharmacologic history on admission
Safety measures: side rails up, no ambulation without assistance
Observe for respiratory depression and hypotension
Have Narcan for use after delivery of fetus prn
Observe for late respiratory depression if she had an epidural
Reinforce instructions for procedures
Assist in positioning for medication and anesthesia administration
Coach in pushing if loss of sensation to push
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Unit 2 Page 40

CH 8
Wednesday, November 04, 2009
5:11 AM

MATERNAL-NEONATAL NURSING LECTURE NOTES

CHAPTER 8 - NURSING CARE OF WOMEN WITH COMPLICATIONS

DURING LABOR AND DELIVERY
OBSTETRIC PROCEDURES
Amnioinfusion
Injection of warmed saline solution or lactacted Ringers solution into the uterus
during labor after the membranes have ruptured
Indications for procedure
Oligohydramnios
Umbilical cord compression
Variable decelerations
Dilute meconium-stained amniotic fluid
Requires continuous EFM
Amniotomy (AROM)
Performed to stimulate or enhance cntx
Performed to permit internal fetal monitoring
Technique: vag exam to determine effacement, station, and effacement
Snagging of membrane with disposable plastic hook
Complications:
Prolapse of the umbilical cord - look for variable decelerations ...move
mom's position to try to move the baby off the cord.
Infection
Abruptio placenta
Nursing care
Observe for complications
Record FHR for at least 1 minute
Large amount of fluid poses greater risk for prolapse
Note color, amount and character of fluid
Should be clear with flecks of vernix
Cloudy, yellow or malodorous means infetion
Take Temp q 2-4 hrs after rupture of membranes
Meconium (green staining) means post-term or placenta not
functioning well
Meconium is associated with fetal compromise
Promote comfort
Need several disposable pads to absorb fluid
Frequent changing of fluids
Induction (initiation) or augmentation (stimulation) of labor
Indications (if continuing pregnancy is more hazardous than delivery)
Gestational hypertension
ROM without onset of labor
Uterine infection
Medical problems: diabetes, kidney disease, heart or pulmonary disease
Fetal problems: IUGR, prolonged pregnancy, maternal/fetal
incompatibility
Placental insufficiency
Fetal death
Contraindications
Unit 2 Page 41

Contraindications
Placental previa
Cord prolapse
Abnormal fetal presentation
High station of the fetus: preterm fetus, small maternal pelvis
Active herpetic lesions
Abnormal size or structure of the mom's pelvis
Previous classic C/S
Technique
Cervical ripening
Prostaglandin gel or vaginal insert softens cervix
Cytotec (misoprostol) under study is not labeled use of drug
Laminaria insertion into the cervix (narrow cone of substance that
absorbs water and swells to expand the cervix)
Nonpharmacological methods to stimulate uterine contractions
Walking
Stimulates contractions
Eases pressure of fetus on mothers back
Adds gravity to downward force of contractions
Nipple stimulation
Causes release of oxytocin from posterior pituitary to improve
contractions
Stimulation achieved by:
Rolling or pulling nipples one at a time
Gently brushing nipples with dry washcloth
Using water in a whirlpool tub or shower
Applying suction with a breast pump
Oxytocin induction and augmentation
oxytocin (Pitocin) given in IVPB solution per pump
Amount adjusted per cntx pattern
Continuous EFM monitors fetal status to induction/augmentation
Complications:
Fetal compromise
Blood flow to placental is reduced if cntx are
excessive
Late decels and loss of variability indicate fetal
compromise
Uterine rupture
Water intoxication because oxytocin inhibits urine excretion
and promotes fluid retention
Excessive cntx (can progress to uterine tetany)
Frequency less than 2 minutes
Durations longer than 90 seconds
Resting intervals less than 60 seconds
Treatment
Stop oxytocin (Pitocin) infusion
Increasing nonmedicated IV solution
Change position, avoiding supine
Administer O2 by facemask at 8-10 L/min
Nursing care
Baseline maternal VS and FHR
Monitor EFM for FHR and contractions for tetany
Monitor VS q 30-60 min
I&O

Unit 2 Page 42

Version (changing the fetal presentation from breech to cephalic)

Risks and contraindications
Pelvic-fetal disproporton
Abnormal uterine or pelvic size or shape
Abnormal placental placement
Previous C/S with vertical uterine incision
Active herpetic lesion
Inadequate amniotic fluid
Poor placental function
Multifetal gestation
Fetus entangled in umbilical cord
Technique
Requisites
After 37 weeks
Nonstress test and/or biophysical profile
Tocolytic drug to quiet uterus
US guide to move buttocks up and out of the pelvis, while moving head
down toward
pelvis
Internal version is emergency procedure during vaginal birth of twins to
change fetal
presentation of second twin
Nursing care
Baseline maternal VS and EFM strip
Monitor 1-2 hrs after version
Vag leaking of fluid indicates membrane tears
Notify MD if cntx do not stop after version
Review signs of labor with mom
Episiotomy (surgical enlargement of vagina) and lacerations (tears of perineum/vagina)
Degrees
First degree involves superficial vaginal mucosa or perineal skin
Second degree involves the vaginal mucosa, perineal skin, and deeper
perineal tissues
Third degree extend into the anal sphincter
Fourth extends through the anal sphincter
Indications
Better control over direction and amount that the vagina is enlarged
Clean edge to the opening rather than jagged
Risks: Infection and extension of episiotomy with laceration into rectal sphincter
Technique
Blunt tipped scissors to cut perineum
Median/midline
Directly downward toward anus
Easier to repair but does not enlarge opening as much as m-lat
More easily extended into rectal sphincter
Mediolateral
Lower vaginal border to right or left
More room but has greater scarring and may cause painful
intercourse later
Nursing care
Cold packs
Sitz baths
Analgesics
Forceps and vacuum extraction births
Unit 2 Page 43

Forceps and vacuum extraction births

Used to aid pushing efforts
Indications
Maternal exhaustion
Maternal cardiac/pulmonary disorders
Minor degrees of placental disruption
Questionable fetal heart rate patterns
Contraindications: fetus too high in the pelvis or too large for vaginal delivery
Risks: Trauma to maternal (hematoma)/fetal tissues; lacerations, cephalohematoma,
or intracranial hemorrhage, chignon where vacuum applied
Technique
Emptying of bladder with catheter
Episiotomy prn
Application of forceps or extractor
Nursing care
Cath to empty bladder
Usual postpartum care
Exam newborn head for lacerations/bruising/facial asymmetry
Cesarean birth
Indications
Abnormal labor
CPD (inability of fetus to pass through the mom's pelvis)
Maternal conditions (Gestational hypertension, diabetes, etc)
Active maternal herpes lesions
Previous uterine surgery or C/S
Fetal compromise
Placenta previa or abruption
Contraindications
Fetal demise
Premature fetus
Abnormal clotting
Risks
Maternal risks
Anesthesia risks
Respiratory complications
Hemorrhage
Injury to urinary tract
Blood clots
Paralytic ileus (delayed peristalsis)
Infection
Newborn risks
Inadvertant premature birth
Respiratory problems due to fluid in lungs
Injury
Technique
Preparations
Labs
Drug to decrease gastric acid
Prophylactic antibiotics
Abdominal prep
Foley insertion
Types of incisions
Skin incisions
Vertical
Best for large baby or obese mom
Unit 2 Page 44

Best for large baby or obese mom

Transverse (Pfannensstiel)
Best to disguise incision
Uterine incisions
Low transverse
Preferred due to less likely to rupture during
another birth
Less blood loss
Easier to repair
Makes VBACs possible
Low vertical
Minimal blood loss
Allows delivery of large fetus
More likely to rupture during another birth
Classic
Rarely used due to more blood loss
Most likely to rupture with subsequent birth
May be only choice for transverse lie, scarring,
or placenta previa
Sequence of events in C/S
Prepped and draped
Anesthesia
Skin incision
Uterine incision
ROM with suction of fluid
Lift out fetal head and suction mouth and nose
Removal of fetus and clamping of cord
Removal of placenta
Sponging of uterus (most commonly done with uterus on abdomen)
Suturing of uterus and skin
Nursing care
Emotional support
Post-op care
Postpartum assessments
VS
IVF check
Fundal check
Dressing check
Lochia check
Urinary output
Respiratory status of mother
Pain relief

ABNORMAL LABOR
Problems with powers of labor
Hypertonic labor dysfunction
Characteristics
Frequent, cramplike, poorly coordinated cntx
Painful and nonproductive
Usually occur during latent phase (before 4 cm)
Less common than hypotonic
Medical treatment
Unit 2 Page 45

Medical treatment
Mild sedation to allow rest
Tocolytic drugs (terbutaline) to reduce high uterine resting tone
Nursing care
Emotional support
Promote rest
Provide pain relief
Hypotonic labor dysfunction
Cntx are too weak to be effective, usually after 4 cm dilation in active
phase of labor
More likely to occur if uterus is overdistended
Twins
Polyhydramnios
Multipara
Medical treatment
Amniotomy
Augmentation
Force fluids (oral or IV)
Nursing care
Emotional support
Initiate augmentation and monitor VS and EFM
Position changes to promote comfort
Ineffective maternal pushing
Coaching effective techniques
Instruction during pushing stage if anesthetized
Problems with the fetus
Fetal size
Macrosomia (>4000 gm)
May not fit through passage
Contributes to hypotonic labor due to overdistention
Shoulder dystocia is common
Is emergency because fetus needs to breathe
Nurse may apply pressure downward just above symphysis to
push shoulders toward pelvic canal
Nursing care
Observe mom for lacerations
Observe newborn for shoulder fractures
Abnormal fetal presentation
Breech or face
Prevent smooth dilation of the cervix and interfere with mechanisms of
labor
Most require C/S
If breech is vaginal delivery, head must be delivered quickly so babe can
breathe
Delay can cause brain damage or death
External versions can sometimes prevent C/S, if fetus does not return to
abnormal presentation
Abnormal positions
Rotation does not occur in every woman so labor is likely to be longer
when occiput is
posterior
Most women with average sizes pelvis cannot deliver babe in occiput
posterior position
Forceps may be useful to turn to anterior position
C/S is likely
Nursing care
Unit 2 Page 46

Nursing care
Positioning to facilitate rotation and descent
Sitting, standing or kneeling forward on a support
Rocking on hands and knees
Side-lying
Squatting
Lunging with one foot on chair or lunging sideways
Postpartum observe for trauma to mom and fetus
Multifetal pregnancy
Reasons for dysfunctional labor
Uterine overdistention contributes to poor cntx quality
Abnormal presentation and position of one or all fetuses
One fetus delivered in cephalic position, the other is breech unless
version done
Nursing care
Monitor each fetus separately
Avoid lying on back
Observe for hypotonic labor
Neonatal pedi present at delivery
Problems with pelvis and soft tissue
Bony pelvis
Ultimate test is whether baby fits through pelvis at delivery
Soft tissue obstructions
Full bladder is biggest obstruction
Tumors and fibroids
The psyche
Stress initiates "fight or flight" mechanism that interferes with labor by:
Using glucose the uterus needs for energy
Diverting blood flow from the uterus
Increasing tension of pelvic muscles which impede fetal descent
Increasing perception of pain which worsens the cycle
Nursing care
Promote rest and relaxation techniques
Promote comfort
Abnormal duration of labor
Prolonged labor
Problems
Maternal or newborn infection, especially if membranes are ruptured
Maternal exhaustion
Postpartum hemorrhage
Anxious about subsequent pregnancies
Nursing care
Observe for signs of infection
Precipitate labor (less than 3 hours)
Characteristics
Frequent and intense cntx
May be prone to:
Uterine rupture
Cervical lacerations
Hematomas
Birth injuries of fetus
Intracranial hemorrhages
Nerve damage
Nursing care
Methods to promote fetal oxygenation
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Methods to promote fetal oxygenation

Side-lying positioning
O2 to mom
Tocolytic drug to slow cntx
Pain control
Avoid narcotics within 1 hr of delivery due to respiratory
depression in the
newborn
Observe for signs of injury
PREMATURE RUPTURE OF MEMBRANES (PROM)
Membranes rupture at term more than one hour before cntx begin
Preterm PPROM occurs when membranes rupture before 37 weeks, with or without cntx
Causes
Vaginal or cervical infection
Nutritional deficiency association
Medical treatment depends on gestation and presence of complications
Confirm presence of amniotic fluid with nitrazine paper or ferning test
Risks:
Chorioamnionitis
Sepsis in the newborn
Oligohydramnios-related fetal pulmonary and skeletal defects
Umbilical cord compression
Nursing care teaching includes
Monitor and report: VS report temp, fetal tachycardia, tenderness over
uterus
Anticipate antibiotic and corticosteroid therapy, labor induction or C/S
Teaching:
Report temperature > 100.4
Avoid intercourse or anything in the vagina
Avoid orgasm which can stimulate contractions
Avoid breast stimulation which can stimulate contractions from release of
oxytocin
Maintain activity restrictions
Report: uterine contractions, reduced fetal activity, signs of infection
Record kick counts; report < 10 kicks in 12-hour period
PRETERM LABOR
Characteristics
Occurs after 20 weeks and before 37 weeks
Main risk is immaturity of fetus
Signs of impending labor
Cntx that are uncomfortable or painless
Feeling that baby is "balling up" frequently
Menstrual-like cramps
Constant backache
Pelvic pressure or feeling that the baby is pushing down
Change in the vaginal discharge
Abdominal cramps with or without diarrhea
Vulvar or thigh pain
"Feeling bad" or "coming down with something
Tocolytic therapy
Magnesium sulfate
Drug of choice to stop labor
IV followed by oral therapy
Baby may experience respiratory depression if born during therapy
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Baby may experience respiratory depression if born during therapy

Calcium gluconate is antidote
Beta-adrenergic
terbutaline (Brethine)
May be given orally or subcutaneously through a pump
Has tachycardia as side-effect
Propranolol overcomes side effects
Ritodrine (Yutopar) rarely ever used
Give IV
Causes hypotension, arrhythmia, pulmonary edema
Prostaglandin synthesis inhibitors indomethacin
Given orally or rectally
Can cause ductus arteriosus to close prematurely, causing fetal demise
Calcium channel blockers like nifedipine (Procardia)
Causes vasodilation, so flushing and hypotension could be side effect
Antibiotic therapy usually begun to treat potential subclinical chorioamnionitis
Contraindications preeclampsia, placenta previa, abruptio placenta,
chorioamnionitis, fetal demise
Stopping preterm labor
Speeding fetal lung maturation
Steroids increase lung maturation and may be repeated in one week
Betamethasone IM given to mother q 24 hr X 2
Thyroid-releasing hormone enhance pulmonary maturation in fetuses < 28
weeks
Activity restrictions
Resting as much as possible
May have BRP
Nursing care
Teach symptoms of preterm labor, especially in moms at risk
Help maintain bedrest and reduce complications of prolonged inactivity
Diversional activity
TCDB
Reinforce activity restrictions as directed by MD
Anticipate temptations and emphasize maintaining rest
Have pt set up two rooms to facilitate rest
Keep telephone nearby and pack picnic basket so she does not have to get up
Assist to identify assistance with children at home
PROLONGED PREGNANCY
Risks
Placenta aging decreases nutrients and O2 to fetus
Fetus does not tolerate labor well
Places additional stress on fetus
Meconium passage is greater
Causes respiratory problems
Macrosomia is greater if placental is healthy
Fetal hypoglycemia
Mom's emotional state may be compromised with long pregnancy
Medical treatment
Evaluate if really is postterm
Difficult if LMP is uncertain, infrequent prenatal care
Evaluate NSTs, AFI, BPP, kick counts
Pregnancy lasting longer than 40 weeks requires:
Twice-weekly NST, AFI, biophysical profile, kick counts
Oligohydramnios is indication for labor induction
Induction of labor after cervical ripening
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Induction of labor after cervical ripening

Nursing care
Emotional support
Identify signs of placental aging
US for macrosomia
Observe newborn for respiratory problems and hypoglycemia
EMERGENCIES DURING CHILDBIRTH
Prolapsed umbilical cord
Interrupts blood flow to placenta and fetus
Classified by:
Complete: cord is visible at the vaginal opening
Palpated: pulsating structure is palpated on vag exam
Occult: suspected on basis of abnormal FHR
Risk factors:
Fetus does not completely fill space in pelvis
Fluid pressure is great when membranes rupture
Fetus is high in pelvis when ROM
Very small, premature, fetus
Abnormal presentation
Hydramnios
Medical treatment
Position mom knee-chest or Trendelenberg to use gravity assistance in
displacing fetus
Manually push fetus up off cord
Administer O2 and tocolytic druts
Deliver babe, usually C/S
Nursing care
Remain calm and take action
Give clear, precise instructions
Provide emotional support
Uterine rupture
Variations
Complete: Hole through entire uterus
Incomplete: Uterus tears into nearby structure but not all the way into
abdominal cavity
Dehiscence: old uterine scar separates, may be bloodless
Relatively common experience
Risk factors
Previous uterine surgery
Low-transverse is least likely to rupture
Classic is most likely to rupture
May occur in unscarred mom if:
Grand multiparity
Intense labor cntx
Blunt abdominal trauma (MVA or battering)
Characteristics (may be asymptomatic or sudden onset of severe symptoms)
Shock due to bleeding into the abdomen
Abdominal pain
Pain in chest, between scapula, or with inspiration
Cessation of cntx
Abnormal or absent FHR
Palpation of fetus outside the uterus
Medical treatment
Surgery to stop bleeding and remove fetus
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Surgery to stop bleeding and remove fetus

Hysterectomy likely
Nursing care
Monitor VS
Monitor bleeding
Emotional support
Uterine inversion
Uterus turns inside out after babe is born
Characteristics
Minor depression in top of uterus
Uterus protrudes from vagina
Rapid onset of shock
More likely to occur if uterus is boggy
Medical treatment
Replace uterus under general anesthesia
Use of anesthesia that causes uterine relaxation (tocolytic)
Administer oxytocic after replacement
Hyst if not successful replacement
Nursing care
2 IV lines to give fluids and combat shock
Reassess firmness q 15 minutes
Monitor VS and vag bleeding
Cath to maintain empty bladder and monitor output
Provide emotional support
Amniotic fluid embolism
Fluid and particulate enters blood stream and obstructs blood vessels of lungs
Shows abrupt and severe respiratory distress and circulatory collapse
DIC may develop
Cardiac and respiratory support is required
Likelihood of death is high, especially if meconium is in fluid
May occur before or after babe is born
Treatment:
Provide respiratory support (mechanical ventilation likely)
Treat shock with electrolytes and plasma expanders
Replace clotting factors
Administer blood as necessary
Monitor I&O
ICU monitoring likely
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