Maternity Review for nursing students 2024
Stages of labor:
- Full term: 37-42 Weeks
- Preterm Labor: Before 37 Weeks
- 4 Stages of labor:
- Stage 1: Get to 10 cm
- Stage 2: Delivery of the Baby
- Stage 3: Placenta Delivery
- Stage 4: Post Partum Recovery Stage (Don’t let your client bleed to death!)
- TRUE LABOR SIGNS:
- Bloody Show: Mucus and Blood
- Water Breaking: Amniotic Sac Rupture
- True Labor Contractions
- Increased Frequency (Regular and Rhythmic)
- Increased Intensity and Duration
- Cervix
- Dilatation: how wide is the cervix (10cm)
- Memory trick is:
- D-Dilation
- D-Door Opening
- Measured in cm 0-10cm
- Effacement: Cervix gets thinner and shorter
- Memory Trick is:
- Effacement
- Elastic cervix gets thinner and shorter
- Measured in percentages from 0 to 100%
Braxton Hicks Contraction:
- False Labor Contractions
- Disappear with Walking or Position change
- No dilatation of Cervix
| TRUE LABOR | FALSE LABOR | |
| CONTRACTIONS | Regular (increasing frequency, duration, intensity) | Irregular |
| PAIN | Does NOT decrease with rest | Alleviated with rest or changing position |
| CERVIX | Progressive change: Dilation and Effacement | No change |
SIGNS OF PREGNANCY
- Presumptive Signs: Subjective “self-reported”
- Amenorrhea (no period)
- Nausea and vomiting
- Quickening (movement)
- Urinary Frequency
- Breast tenderness and Fatigue
- Probable Signs: Objective Signs
- Goodell’s Sign: Cervical Softening. “a soft cervix is a Good Sign”
- Chadwick’s Sign: Blue/Purple birth canal.
- Hegar’s Sign: Softening of the lower uterine segment
- Positive Signs:
- Confirmation of Pregnancy
- Fetal heartbeat
- Visualization of fetus
FETAL HEART RATE MONITOR
- External Fetal Monitor:
- Find POINT OF MAXIMAL IMPULSE (PMI) “this is point where the baby’s heart rate can be heard the loudest.
- Contraction monitor sensor
- Internal fetal monitor: (FSE) Fetal Scalp Electrode: Only use in high-risk pregnancy. Reading not affected by monitor. (High risk infection chances). Cervical dilation of at least 2 cm before initiating internal fetal monitoring.
FETAL HEART RATE KEY TERMS:
- Baseline: Normal FHR 110-160 BPM
- Variability
- Absent Variability: Not Good
- Minimal Variability: Flatter line, that looks “sleepy and sad”
- Moderate Variability: Normal and desired finding.
- Marked Variability: Stressed baby
- Accelerations:
- Temporary increase in FHR.
- Indicates great oxygenation for the baby!
- “Happy little mountains”
- Decelerations:
- Early Decelerations: Excellent and Good
- Shallow, bowl shaped dips that mirror mother’s contractions
- Indicates head compression
- Variable Decelerations: Very Concerning
- Fetal Heart Rate: V shaped
- Push then Position
- Push:
- Push babies head back up to relieve cord pressure and reestablish blood circulation until C-Section.
- then,
- Position:
- Reposition mother Knee-Chest
| V: Variable Deceleration | C: Cord Compression |
| E: Early Deceleration | H: Head Compression |
| A: Accelerations | O: Okay |
| L: Late Decelerations | P: Placental Insufficiency (Concern) |
Intervention for Late Decelerations: LIONS
L: Lie on left sides
I: IV Fluids
O: Oxygen
N: Notify Provider
S: Stop Pitocin Infusion
OXYTOCIN:
To contract
Labor Drug
Used to stimulate uterine contractions
Administration 6-12 hours after last dose of dinoprostone
Monitor contraction regularly
Contraction should be less than 60 seconds, happening 2-3 minutes apart
Discontinue Oxytocin if contractions last longer than 60 seconds
Maintain one on one care with patient
Piggyback the oxytocin into the main IV fluids
Stop Oxytocin infusion for contractions sustained over 2 minutes
Priority action for 3 consecutive late decelerations = Turn off oxytocin.
Turn the client to the side if late decelerations are noted.
KEY POINTS:
IF LATE DECELERATIONS NOTED: THEN TURN TO THE SIDE
IF 3 CONSECUTIVE LATE DECELERALATIONS: Priority: TURN OFF OXYTOCIN.
TERBUTALINE: May be used for 48 hours to suppress Preterm Labor. Only DELAY labor.
Placental Abruption:
Placenta prematurely detaches from the uterine wall while the baby is still inside.
Signs and Symptoms: REPORT TO THE HCP
Dark red vaginal bleeding
Severe continuous abdominal pain
Rigid and tender uterus
Decreased H&H and hypovolemic shock
For the baby:
Abnormal Fetal Heart Patterns
Uterine tachysystole
INTERVENTIONS:
1. Anticipate emergent Cesarean Birth
2. Apply continuous external fetal monitoring
3. IV access and draw blood for type and screen - blood transfusion
4. Monitor for signs of hypovolemic shock: Pallor, Tachycardia, Hypotension.
- Large particles such as bacteria cannot pass through the placenta, but nutrients, medications, alcohol, antibodies, and viruses can pass through the placenta.
- When assessing fundal height, monitor the client closely for supine hypotension when placed in supine position.
- During pregnancy, a woman’s pulse rate may increase about 10 to 15 beats per minute; the blood pressure slightly decreases in the second trimester, then increases in the third trimester, but not above the pre-pregnancy level and the respiratory rate remains unchanged or slightly increases.
- During pregnancy, postural changes occur as the increased weight of the uterus causes a forward pull of the bony pelvis. It is important for the nurse to encourage the client to implement measures that maintain safety and correct posture to prevent a backache.
- The nurse needs to instruct the pregnant woman to avoid lying in the supine position, particularly in second and third trimesters. The supine position places the woman at risk for supine hypotension, which occur as a result of pressure of the uterus on the inferior vena cava.
- Women of childbearing age should take folic acid supplements to prevent neural tube defects and orofacial clefts in the fetus.
- The usual schedule for antepartum health care visits is every 4 weeks for the first 28 to 32 weeks, every 2 weeks from 32 to 36 weeks, and every week from 36 to 40 weeks.
- Rubella Vaccine is not given during the pregnancy because the live attenuated virus may cross the placenta and present a risk to the developing fetus.
- After chorionic villus sampling and amniocentesis, instruct the client that if chills, fever, bleeding, leakage of fluid at the needle insertion site, decreased fetal movement, uterine contractions, or cramping occurs, she must notify the PHCP.
- The newborn of a diabetic mother is at risk for hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, hypocalcemia and congenital anomalies.
- In true labor, contractions increase in duration and intensity and cervical dilation and effacement are progressive, with engagement and descent of the fetus.
- In False Labor, contractions are irregular, and do not produce dilation, effacement, or descent.
- If fetal bradycardia or tachycardia occurs, change the position of the mother, administer oxygen, and assess the mother’s vital signs. Notify the primary health care providers as soon as possible.
- If variable decelerations occur, discontinue oxytocin if infusing, change the position of the mother, administer oxygen, and assess the mother’s vital signs. Notify the PHCP. Assist with amnioinfusion (intrauterine instillation of warmed saline to decrease compression on the umbilical cord) if prescribed.
- General anesthesia presents a maternal danger of respiratory depression, vomiting, and aspiration.
- An oxytocin infusion is discontinued if uterine contraction frequency is less than 2 minutes or duration is longer than 90 seconds, or if fetal distress is noted.
- If the mother is Rh negative, ensure that Rho(D) immune globulin was given at 28 weeks of gestation.
- In the event of fetal distress, prepare the client for emergency cesarean delivery.
- Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to monitor fetal heart rate, maternal vital signs, and administer an antibiotic.
- When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The nurse never attempts to push the cord into the uterus. If the umbilical cord is protruding from the vagina, the cord is wrapped loosely in a sterile towel saturated with warm sterile normal saline. This situation is an emergency and delivery must occur usually via a cesarean section.
- Placenta Previa: This condition involves the abnormal placement of the placenta low in the uterus, which may encroach on or cover the cervical os.
- Complete Placenta Previa: The placenta entirely covers the cervical os.
- Partial (Marginal) Placenta Previa: The placenta only partially covers the cervical os.
- Symptoms of Placenta Previa: Bleeding in placenta previa is usually painless and rarely fatal initially but tends to increase with each subsequent episode.
- Abruptio Placentae: This is the premature detachment of a normally positioned placenta, which can be either partial or complete.
- Symptoms of Abruptio Placentae: It typically causes abdominal pain, vaginal bleeding, and a firm, board-like abdomen.
- Pain: A key difference from placenta previa is that abruptio placentae causes significant pain, while placenta previa does not.
- Nursing Interventions for Placenta Previa:
- Positioning: Place the patient on her left side to maximize blood flow to the fetus.
- Monitoring: Continuously monitor fetal heart tones to assess fetal well-being.
- Supportive Care: Administer intravenous fluids and oxygen as prescribed to maintain maternal and fetal stability.
- Treatment for Abruptio Placentae: Immediate cesarean delivery is usually required to manage this condition effectively.
- Placental Function: The placenta acts as the fetal lung, facilitating gas exchange. Any disruption in normal blood flow to or from the placenta can increase fetal arterial carbon dioxide levels and decrease fetal pH, indicating distress.
- Preeclampsia is defined as a blood pressure increase of 30/15 mm Hg over baseline or a blood pressure of 140/95 mm Hg on two occasions at least 6 hours apart, along with edema and proteinuria, occurring after 20 weeks of gestation.
- Symptoms of Preeclampsia: The classic triad includes hypertension, edema, and proteinuria. Severe cases may present with hyperreflexia, cerebral and visual disturbances, and epigastric pain.
- Nursing Care with Magnesium Sulfate:
- Monitoring: When administering magnesium sulfate for hypertension or preterm labor, the nurse must closely monitor the patient’s respiratory rate and deep tendon reflexes to detect potential complications.
- Eclampsia: This condition involves the onset of seizures in a patient with pregnancy-induced hypertension, not attributable to other cerebral disorders.
- Progression: Preeclampsia can escalate to eclampsia, characterized by seizures and potentially leading to coma.
- HELLP Syndrome: An uncommon but serious variant of pregnancy-induced hypertension, HELLP syndrome involves hemolysis, elevated liver enzymes, and low platelets, requiring immediate medical attention.
- Urgency of Epigastric Pain:
- Critical Symptom: In patients with preeclampsia, epigastric pain is a late-stage symptom necessitating prompt medical intervention to prevent further complications.
- Key Points on Contraceptive Use and Sperm Count Preparation
- The failure rate of a contraceptive is measured based on the experiences of 100 women over the course of one year, expressed as the number of pregnancies per 100 woman-years.
- Preparing for a Sperm Count: Before providing a sperm sample, a patient should avoid ejaculation for 48 to 72 hours to ensure accurate results.
- Missed Menstrual Periods on Oral Contraceptives:
- Action: If a patient misses two consecutive menstrual periods while on an oral contraceptive, she should stop taking the contraceptive and take a pregnancy test.
- Missed Dose of Oral Contraceptive:
- Single Dose: If a patient misses one dose of an oral contraceptive, she should take it as soon as she remembers. If she doesn’t remember until the next scheduled dose, she should take two pills at that time and then continue with her regular schedule.
- Two Consecutive Doses: If a patient misses two consecutive doses, she should take two pills per day for the next two days and then resume her regular schedule. Additionally, she should use an extra method of birth control for one week.
- Labor Phases and Actions:
- Supine Hypotension:
Trick: “Turn Left for Nausea Lift”
Explanation: If the laboring mother feels nauseous, pale, and vomits while lying down, turn her onto her left side to relieve supine hypotension.
- Supine Hypotension:
- Transition Phase of First Stage:
Trick: “8 to 10, Contractions Begin”
Explanation: During the transition phase of the first stage of labor, the cervix dilates from 8 to 10 cm with contractions 2-3 minutes apart, lasting 60 seconds. - Stages of Labor:
- First Stage:
Trick: “Start to Ten”
Explanation: Begins with the onset of labor and ends with full cervical dilation at 10 cm. - Second Stage:
Trick: “Ten to Baby’s When”
Explanation: Begins with full cervical dilation and ends with the birth of the neonate. - Third Stage:
Trick: “Baby to Placenta Out”
Explanation: Begins after the neonate’s birth and ends with the expulsion of the placenta. - Fourth Stage:
Trick: “Four Hours to Stable More”
Explanation: Lasts up to 4 hours after the placenta is delivered to stabilize the mother.
- First Stage:
- True vs. False Labor:
Trick: “True is Bloody, Regular, and New”
True labor has regular rhythmic contractions, abdominal discomfort, fetal descent, bloody show, and progressive effacement and dilation. False labor doesn’t cause cervical changes and contractions are irregular. - Fetal Descent and Monitoring:
- Floating vs. Engagement:
- Floating:
Trick: “Floating, freely boating”
The presenting part is not engaged in the pelvic inlet and is movable. - Engagement:
Trick: “Engaged, largest part staged”
The largest diameter of the presenting part has passed through the pelvic inlet.
- Floating:
- Fetal Stations:
Trick: “Minus Up, Plus Down”- Negative stations (-1 to -5) are above the ischial spines.
- Positive stations (+1 to +5) are below the ischial spines, with 0 at the level of the ischial spines.
- Vaginal Bleeding:
Trick: “Bleeding? Stop proceeding!”
Any vaginal bleeding during pregnancy should be considered a complication until proven otherwise. - Delivery and Postpartum:
- Umbilical Cord Issue:
Trick: “Cord around neck, clamp and check”
If the umbilical cord can’t be loosened from around the neonate’s neck, it should be clamped and cut between the clamps. - Post-Delivery Uterus Massage:
Trick: “Massage to Contract, No React”
Massaging the uterus helps to stimulate contractions after the placenta is delivered. - Nitrazine Paper:
Trick: “Paper for pH, Check Amnio Way”
Nitrazine paper is used to test the pH of vaginal discharge to determine the presence of amniotic fluid. - Uterine Contractions and Monitoring:
- Uterine Contractions:
Trick: “Increment, Acme, Decrement”
The three phases of a uterine contraction are increment (building up), acme (peak), and decrement (letting down). - Contraction Intensity:
Trick: “Mild Tense, Moderate More, Strong Board”
Explanation: The intensity is assessed by the indentability of the uterine wall at the peak:- Mild: Somewhat tense
- Moderate: Moderately tense
- Strong: Board like.
- Braxton Hicks vs. True Labor:
Trick: “Hicks in Abdomen, True Back and Front”
Braxton Hicks contractions are usually felt in the abdomen and do not cause cervical changes. True labor contractions are felt in the front of the abdomen and back, leading to progressive cervical dilation and effacement. - Emergency Delivery:
Trick: “Pressure Guide, No Rapid Slide”
During an emergency delivery, apply enough pressure to the emerging fetus’s head to guide the descent and prevent a rapid change in pressure. - Rh Incompatibility: Rh-negative mother, Rh-positive fetus; prevent with Rho(D) immune globulin.