Chapter 19 Nursing Care of the Family During Labor and Birth

First

Stage of Labor
Begins with regular uterine contractions
Ends with full cervical effacement and dilation
Three phases: if the patient has an epidural the 3 phases wont
occur.
(1) Latent phase: up to 3 cm of dilation. She is fairly comfortable, may
be able to hide it
(2) Active phase: 4-7 cm of dilation. She is uncomfortable, crabby, and
doesnt want to talk to anyone.
(3) Transition phase: 8-10 cm of dilation. She is mad and in pain and
beyond ready to give birth. Sometime she will have vomiting.

Assessment and Nursing Dx:

o Determination if woman is in true labor or false labor
(contractions, cervix, fetus)
o Obstetric triage and EMTALA (Emergency Medical
Treatment and Active Labor Act). A woman is considered to
be in true labor until a qualified provider determines she is
not.
o Admission to the labor unit
o Admission data
Prenatal data: has your bag broken? (What time,
amount, color, odor) When the bag breaks you have
a time limit on labor.
Interview (spontaneous rupture of membranes,
bloody or pink show): if the mucous plug presents as
a bloody show before labor starts its not a big deal.
Psychosocial factors (woman with Hx of sexual
abuse):
Stress in labor:
Cultural factors (woman may have a preconceived
idea of the right way to behave, cultural and father
participation, non-English speaking woman in labor):
o Physical exam
General systems assessment: heart, lungs and skin
and an exam to determine the presence and extent
of edema of the face, hands, sacrum, and legs. Note
the womans weight. Where is the babys head?
What is the babys HR?
Vital signs: if BP is elevated, reassess 30 minutes
later. Encourage her to lie on her side to prevent
supine hypotension and the resulting fetal hypoxia.

Plan
o
o
o

Monitor temperature to identify signs of infection.

She may have a drop in BP.
Leopold maneuvers: abdominal palpation with
woman briefly lying on her back to help answer 3
questions. (1) What fetal part is in the uterine
fundus? (2) Where is the fetal back located? (3) What
is the presenting fetal part?
Assessment of FHR and pattern: Variability and
accelerations are good, early decells are okay but
late are not good!
Assessment of uterine contractions: frequency,
intensity (mild, moderate, strong), duration, resting
tone. Ensure tachysystole isnt happening!
Vaginal examination: cervical effacement, dilation,
fetal descent (station)
Laboratory and diagnostic tests:
Analysis of urine specimen
Blood tests (group B streptococci)
Assessment of amniotic membranes and fluid
(TACO): infection, Nitrazine or fern test.
The Nitrazine test involves placing small
amounts (a drop or two) of vaginal fluid onto
paper strips prepared with Nitrazine dye. A
chemical reaction occurs and the strips change
color, indicating the pH of the vaginal fluid. If
the color shows the pH is greater than 6.5, it's
likely the membranes have ruptured.
Signs of potential problems
of care and interventions:
Standards of care
Physical nursing care during labor: general hygiene,
nutrient and fluid intake (oral and IV), elimination (will have
a foley with an epidural), ambulation and positioning.
Supportive care during labor and birth
Nurse: help maintain control and participate to her
wishes, provide continuity of care that is
nonjudgmental and respectful of culture/religion,
meeting her expected outcomes, listening to her
concerns and encourage to express feelings, acting
as her advocate, helping her conserve her energy
and cope effectively with pain and discomfort,
acknowledging her efforts including her strength and
courage as well as those of her partner, providing
positive reinforcement, protecting her privacy,
modesty, and dignity.

 Father/partner: RN must realize he is a person of

value, he can be a partner in the womans care, and
childbearing is a team effort. (table 19-9)
Doulas: focus on the laboring woman and provide
physical and emotional support by using soft,
reassuring words of praise and encouragement;
touching; stroking; and hugging.
Grandparents: they can be encouraged to help as
long as their actions dont compromise the status of
the mother or fetus.
Siblings during labor and birth: prepare them for
acceptance of a new sibling and teach them that
their mother will be working hard during birth and
she wont be able to talk to them during
contractions, and that although she will appear in
pain and uncomfortable that her body is built for this
job.
o Emergency interventions: meconium-stained amniotic
fluid, shoulder dystocia, prolapsed umbilical cord, ruptured
uterus, and amniotic fluid embolus (discussed in chapter
22). Emergencies include labor being stalled too long,
decelerations on the monitor, separated placenta,
breached baby.
Second Stage of Labor
Infant is bornbeings with full cervical dilation (10 cm),
complete effacement, ends with infants birth
Two phases
(1) Latent: relatively calm with passive descent of baby through birth
canal (Laboring Down).
(2) Active: pushing and urge to bear down (Ferguson reflex, fetal
station is 1+).
Care Management
Preparing for birth
o Maternal position no single position for childbirth exists
o Bearing-down efforts Valsalva maneuver is discouraged
because it increases intrathoracic and cardiovascular
pressure. Recommend letting the women push the way she
feels.
o Fetal heart rate and pattern must check FHR frequently;
if baseline rate begins to slow, if absent or minimal
variability occurs, or if deceleration patterns develop, turn
the woman onto her side to reduce the pressure of the
uterus against the ascending vena cava and descending

aorta. A nonrebreather mask at 10 L/min can administer

oxygen.
o Support of father or partner woman needs continuous
support and coaching during second stage and this can be
tiring, so the nurse offers the nourishment, refreshments,
and short breaks as needed.
o Supplies, instruments, and equipment make sure
everything is working before a woman arrives. (Oxygen,
tubing, IV pump, etc.)
Birth in a delivery room or birthing room
Mechanism of birth: vertex presentation
o Crowning
o Nuchal cord: umbilical cord wrapped around the baby,
typically around the neck.
Use of fundal pressure pushing on a womens fundus. You
will never do this!
Immediate assessments and care of newborn
Perineal trauma r/t childbirth
o Lacerations:
Perineal
Vaginal and urethral
Cervical injuries
o Episiotomy:
Should be avoided if at all possible
Emergency childbirth: giving birth in an unexpected place
with no proper equipment. Just catch the baby

Third Stage of Labor

Birth of the baby until the placenta is expelled
o Firmly contracting fundus
o Change in uterus
o Sudden gush of dark red blood from the introitus
o Apparent lengthening of the umbilical cord
o Vaginal fullness
o Placental examination and disposal
Cultural preferences
Fourth stage of Labor
Care management
o First 1-2 hours after birth
o Assessment of maternal physical status. Physiologic
changes back to pre-pregnancy status.
o Signs of potential problems
Excessive blood loss:
Alterations in vital signs and consciousness

o Care of new mother and her family

Key Points
Onset of labor may be difficult to determine for nulliparous and
multiparous women
Familiar environment of home is most often the ideal place for a
woman during latent phase of first stage of labor
Nurse assumes much of the responsibility
Assessing progress of labor
Keeping primary health care provider informed about
progress in labor and deviations from expected findings
FHR and pattern reveal fetal response to stress of labor process
Assessment of laboring womans urinary output and bladder is
critical to ensure progress and prevent injury to bladder
Womans level of anxiety may increase when she does not
understand the medical terminology used or because of a
language barrier
Coaching, emotional support, and comfort measures assist
woman to use energy constructively in relaxing and working with
the contractions
Progress of labor is enhanced when a woman changes her
position frequently during the first stage of labor
Doulas provide continuous supportive presence during labor that
can have a positive effect on childbirth
Cultural beliefs and practices of woman and her significant
others can have a profound influence on their approach to labor
and birth
Nurse who is aware of particular sociocultural aspects of helping
and coping acts as an advocate for the woman or couple during
labor
Quality of the nurse-client relationship is a factor in the womans
ability to cope with the stressors of the labor process
Women with a history of sexual abuse often experience profound
stress and anxiety during childbirth
Inability to palpate the cervix during vaginal examination
indicates complete effacement and full dilation and is the only
certain, objective sign that second stage has begun
Women may have an urge to bear down at various times during
labor
Before cervix is fully dilated
Not until active phase of second stage of labor
When responding to rhythmic nature of the second stage of
labor, the woman normally:
Changes body positions
Bears down spontaneously

Vocalizes (open-glottis pushing) when she perceives urge

to push (Ferguson reflex)
Women should bear down several times during a contraction
using open-glottis pushing method
Sustained closed-glottis pushing should be avoided
because oxygen transport to fetus will be inhibited
Nurses can use the role of advocate to prevent routine use of
episiotomy and to reduce incidence of lacerations
Empowering women to take an active role in their birth
Educating health care providers about approaches to
managing childbirth that reduce incidence of perineal
trauma
Objective signs indicate that the placenta has separated and is
ready to be expelled
Excessive traction on umbilical cord before placenta has
separated can result in maternal injury
Siblings present for labor and birth need preparation and support
for the event
During the fourth stage of labor, the womans fundal tone, lochia,
and vital signs should be assessed frequently
Most parents/families enjoy being able to handle, hold, explore,
and examine the baby immediately after birth
Nurses observe the progress in the development of parent-child
relationships and are alert for warning signs during the
immediate postpartum period
A woman benefits from reviewing her childbirth experience with
the nurse who managed her care during labor and birth

Chapter 18 Fetal Assessment During Labor

Basis for Monitoring
Fetal response
o Maintenance of oxygen supply to prevent fetal compromise
o Decrease in oxygen supply can be due to:
Reduction of blood flow through maternal vessels
(HTN, hypovolemia, supine maternal positon)
Reduction in oxygen content in maternal blood
(hemorrhage or anemia)
Alterations in fetal circulation (cord compression,
abruption, vagal nerve stimulation)
Reduction in blood flow to intervillous space in
placenta (tachysytole, HTN, DM, post-term)
Normal FHR patterns described as reassuring (ways to talk
to the doctor over the phone)
o Category I (the best something going on but its all good)

Baseline FHR in the normal range of 110-160 bpm

Baseline fetal HR variability: moderate
Late or variable decelerations: absent
Early decelerations: may be present or absent
Accelerations either present or absent
o Category II (not the best, but okay)
Abnormal FHR patterns described as non-reassuring
o Category III (Get to the OR now)

Monitoring Techniques
Intermittent auscultation (IA)
o Listening to fetal heart sounds at periodic intervals to
assess FHR
o IA of the fetal heart can be performed with:
Leff scope
DeLee-Hillis fetoscope
Ultrasound device
o Easy to use, inexpensive, less invasive then EFM
o Difficult to perform on women who are obese
o Does not provide a permanent record if needed for a
lawsuit!
Electronic fetal monitoring (EFM) to measure how strong
the contractions are
o External monitoringfirst line! If theres ANY doubt, use an
internal device
FHR: ultrasound transducer
UCs: tocotransducer
o Internal monitoring
Spiral electrode
IUPC
o Display
Monitor paper
Computer screen
Fetal Heart Rate Patterns
Baseline FHR
o Average rate during a 10-minutes segment that excludes:
Periodic or episodic changes
Periods of marked variability
Segments of the baseline that differ by more than 25
bpm
Must be at least 2 minutes of interpretable data
o Variability
Irregular fluctuations in FHR of two cycles per minute
or greater

Care

Sinusoidal pattern is not included in the definition of

variability
o Tachycardia: baseline FHR greater than 160 bpm
o Bradycardia: baseline FHR less than 110 bpm
Changes in FHR
o Periodic changes occur with UCs
o Episodic (non-periodic changes) not associated with UCs
o Accelerations caused by dominance of sympathetic
nervous response
o Decelerations:
Early decelerations in response to fetal head
compression (early isnt a bad thing, benign, no
problem)
Late decelerations due to Uteroplacental
insufficiency (late is not good! You dont want late)
Variable decelerations due to umbilical cord
compression
Prolonged decelerations
Management
EFM pattern recognition and interpretation
o NICHD Workshop 2008 proposed a three-tie system for EFM
interpretation
Category I: normal
Category II: intermediate
Category III: abnormal (Stop the Pitocin, give 7-10L
oxygen on a nonrebreather, .)
o Fetal monitoring standards
o Nursing management of non-reassuring patters
Other methods of assessment and interventions
o FHR response to stimulation
o Fetal oxygen pulse oximetry
o Amnioinfusion: if the baby is showing variations that
usually mean cord compression, this will be done so there
is more fluid and the cord is less likely to get compressed.
o Tocolytic therapy
o Umbilical cord acid-base determination

Key Points
Fetal well-being during labor is gauged by response of the FHR to
UCs
Standardized definitions for common FHR patterns have been
adopted by ACNM, ACOG, AWHONN
Five essential components include baseline FHR, variability,
accelerations, decelerations, and changes in FHR over time

 Monitoring of fetal well-being

FHR assessment
Uterine activity assessment
Assessing maternal vital signs
Nurse must:
Assess FHR patterns
Implement independent nursing interventions
Report abnormal patterns to physician or nurse-midwife
Emotional, informational, and comfort needs must be addressed
when the mother and fetus are being monitored
Documentation is initiated and updated according to institutional
protocol
Chapter 17 Maximizing Comfort for the Laboring Woman
Pain During Labor and Birth
Neurological origins
o Visceral: during the first stage of labor. Uterine
contractions cause cervical dilation and effacement. Pain
impulses are transmitted via T1 to T12 spinal nerve
segment and accessory lower thoracic and upper lumbar
sympathetic nerves, which originate in uterine body and
cervix.
o Referred: occurs when pain that originates in the uterus
radiates to the abdominal wall, lumbosacral area of the
back, iliac crests, gluteal area, thighs, and lower back.
o Somatic: during the second stage of labor and is described
as intense, sharp, burning and well localized. It results from
(1) distention and traction on the peritoneum and
uterocervical supports during contractions (2) pressure
against the bladder and rectum (3) stretching and
distention of perineal tissues and the pelvic floor to allow
passage of the fetus (4) lacerations of soft tissue. Women
report a decrease in pain when they bear down.
Perception of pain: fear and lack of information can increase
pain. Knowledge, a positive attitude, and support result in
decreased pain perception. Pain tolerance is how much pain a
women will endure. Factors that influence her tolerance level
include her desire for a natural, vaginal birth; her preparation for
childbirth; her anxiety level; the nature of her support;
willingness and ability to receive non-pharmacologic measures;
history/experience from other births.
Expression of pain: sympathetic nervous system activity is
stimulated in response to intensifying pain, resulting in increased
catecholamine levels. BP and HR increase, maternal respiratory
pattern changes in response to an increase in oxygen

consumption. Hyperventilation, sometimes accompanied by

respiratory alkalosis, can occur when rapid, shallow breathing
techniques are used. Gastric acidity increases, N&V are common
in first stage, placental perfusion may decrease and uterine
activity may diminish, potentially prolonging labor and affecting
fetal well-being.
Factors influencing pain response:
o Physiologic factorsuterine contractions interval and
duration, cervical dilation, and effacement, fatigue,
anxiety, fetal size and position, and maternal mobility
during labor.
o Culturepg. 383
o Anxietyexcessive anxiety and fear cause more
catecholamine secretion, which increases the stimuli to the
brain from the pelvis because of decreased blood flow and
increased muscle tension. This then magnifies pain
perception.
o Previous experience
o Gate-control theory of painintense pain stimuli can
sometimes be ignored because certain nerve cell
groupings within the spinal cord, brainstem, and cerebral
cortex have the ability to modulate the pain impulse
through a blocking mechanism.
o Comforthaving needs and desires met promote a feeling
of comfort.
o Support
o Environment

Non-pharmacologic Pain Management

Childbirth preparation methods: Dick-Read method, the
Lamaze (psychoprophylaxis) method, and Bradley (husbandcoached childbirth) method.
Relaxing and breathing techniques
o Focusing and relaxationAttention-focusing and distraction
techniques
o Breathing techniques avoid hyperventilation. Shallow
breathing should not be fast! Use a paper bag to rebreathe
some CO2.
Effleurage and counterpressure: Effleurage is light stroking,
usually of the abdomen, in rhythm with breathing during
contractions to distract women from contraction pains. This is
stimulating pleasurable impulses to the brain to compete with
the intense sensation of labor. Counterpressure is steady
pressure applied by a support person to the sacral area with a

firm object or the fist or heel of the hand. Pressure can also be
applied to both hips, or to the knees.
Music
Water therapy (hydrotherapy): with warm water
Transcutaneous electrical nerve stimulation: 2 pairs of flat
electrodes on either side of the womens thoracic and sacral
spine to provide continuous low-intensity electrical
impulses/stimuli.
Acupressure of heat and cold: not acceptable for some
cultures. Acupressure on certain points in the hand and feet can
be used to relieve pain.
Acupuncture: used more in Eastern than Western area.
Touch and massage
o Therapeutic touch
Hypnosis: deep relaxation, similar to daydreaming or
meditation

Non-pharmacologic Management of Discomfort

Biofeedback: based on a theory that if a person can recognize
physical signals, certain internal physiologic events can be
changed.
Aromatherapy
Intradermal water block
Pharmacologic Pain Management
Sedatives: relieve anxiety and induce sleep. Barbiturates,
phenothiazines, benzodiazepines. Epidurals are better than
something systemic because its regional.
Analgesia and anesthesia
o Systemic analgesia: opioids can be administered as
intermittent IV or IM doses by the HCP or PCA pumps.
o Opioid (narcotic) analgesics: (1) opioid agonists (2) opioid
agonist-antagonist (3) opioid antagonists
Nerve block analgesia and anesthesia
o Local perineal infiltration anesthesiamay be used when
an episiotomy is to be performed or when lacerations must
be sutured after birth in a woman who does not have
regional anesthesia.
o Pudendal nerve blockadministered late in the second
stage of labor and is useful if an episiotomy is to be
performed or if forceps or a vacuum extractor is to be
used.
o Spinal anesthesia (block)
Postdural puncture headaches

o
o

Epidural blood patch

Epidural anesthesia/analgesia (block)
Lumbar epidural anesthesia/analgesia
Spinal analgesia
Side effects include (box 17-5): hypotension, local
anesthetic toxicity, fever, urinary retention, pruritus,
limited movement, longer second stage labor,
increased use of oxytocin, increased likelihood of
forceps- or vacuum-assistance
High or total spinal anesthesia
Contraindications to epidural blocks
Active or anticipated serious maternal hemorrhage.
Acute hypovolemia leads to increased sympathetic
tone to maintain BP. Any anesthetic techniques that
block sympathetic fibers can produce significant,
dangerous hypotension.
If a woman is receiving anticoagulant therapy or has
a bleeding disorder, injury to a blood vessel may
cause formation of a hematoma that may compress
the cauda equina or the spinal cord and lead to
serious CNS complications.
Infection at injection site
Increased ICP caused be a mass lesion
Allergy to anesthesia drug
Maternal refusal or inability to cooperate
Some maternal cardiac conditions
Epidural effects on the newborn: there is no evidence of a
lasting effect on the newborn
General anesthesia: rarely used for uncomplicated vaginal
birth and used for only 10% of cesarean births

Care Management
Informed consent for anesthesia: 3 essential components;
(1) the procedure and its advantages and disadvantages must be
thoroughly explained (2) the woman must agree with the plan of
labor pain care as explained to her and (3) her consent must be
given freely without coercion or manipulation from her HCP.
Timing of administration: can be given at any time
Preparation for procedures
Administration of medication
IV route: preferred route because (1) onset of pain relief is
rapid and more predictable, (2) pain relief is obtained with
small doses, and (3) duration of effect is more predictable.
IM route: although it allows quick administration without an
IV site, it is not preferred because (1) onset of pain relief is

delayed, (2) higher doses of medication are required, and

(3) medication is released at an unpredictable rate from
the muscle tissue and is available for transfer across the
placenta to the fetus.
Regional anesthesia
Safety and general care: assess and monitor pain level as well
as physiologic signs of pain, advocate for the patient, education
patient and family when necessary, ensure safety.

Key Points
Nonpharmacologic pain and stress management strategies alone
or in combination with pharmacologic methods help manage
discomfort
The Gate-control theory of pain and the stress response are basis
for many nonpharmacologic methods of pain relief
Type of analgesic or anesthetic is determined in part by the stage
of labor and method of birth
Sedatives may be appropriate for women in prolonged early
labor to decrease anxiety or promote sleep or therapeutic rest
Naloxone (Narcan) is an opioid antagonist that can reverse opioid
effects
Pharmacologic control of discomfort requires collaboration
among health care providers and the laboring woman
Nurse must understand medications, expected effects, potential
adverse reactions, and methods of administration
Maintenance of maternal fluid balance is essential during spinal
and epidural nerve blocks
Maternal analgesia or anesthesia can affect neonatal
neurobehavioral response
Opioid analgesics with preexisting opioid dependence may cause
symptoms of abstinence syndrome
Epidural anesthesia is the most effective pharmacologic pain
relief methods for labor
General anesthesia rarely used for vaginal birth but may be used
for cesarean birth or when rapid anesthesia is needed in an
emergency
Chapter 23 Physiologic and Behavioral Adaptations of the Newborn
Physiologic Adaptations
Cardiovascular system
o Heart rateasleep, awake, and crying
o BP60-80/40-50
o Blood volumearound 80 mL/kg; immediately after birth it
can increase as much as 100 mL or more with delaying
cord clamping.

o Signs of risk for CV problems

Tachycardia: greater than 160 bpm
Bradycardia: less than 110 bpm
Color
o The baby must initiate breathing. The lungs expand as the
baby is born and turns the baby pink during labor (the
baby is blue inside mom). Ductus arteriosus closes off due
to pressure during labor,
o Respirations at birth should be 30-60 bpm

Hematopoietic system
o RBCshigher RBCs and HGB & HCT than in an adult
o Leukocytesinitial increase after birth, then decreases
o Plateletssimilar to adults

Thermogenic system
o Thermoregulationmaintenance of balance between heat
loss and heat production
o Heat loss
Convection: flow of heat from the body surface to
cooler ambient air.
Radiation: the loss of heat from the body surface to a
cooler solid surface not in direct contact but in
relative proximity.
Evaporation: loss of heat that occurs when a liquid is
converted to a vapor. Ensure baby is completely dry
after bathing.
Conduction: the loss of heat from the body surface to
cooler surfaces in direct contact.
o Thermogenesisneonate attempts to generate heat in
response to the cold by increasing muscle activity.
o Cold stressexcessive heat loss that results in increased
respirations and non-shivering thermogenesis to maintain
core body temperature.
o Hyperthermialess frequently occurring than hypothermia,
and can occur due to excess heat production r/t sepsis or a
decrease in heat loss.
o Brown fat helps baby maintain heat

A very sick baby!

An infant should void within the first 24 hours of life
98% of infants void within 30 hours of life
o If a newborn has not voided within 48 hours of life it may
indicate a renal impairment
o Nurses should keep careful I&O records
Gastrointestinal system
o Digestionability to digest depends on certain enzymes,
most of which are functional at birth except for pancreatic
amylase (produced by salivary gland after 3 months) and
lipase (necessary for fat digestion).
o Stools
Meconium: greenish black and viscous and contains
occult blood and should occur in the first 12-24 hours
of life. There is no bacteria in the babys colon which
is why they need a shot of vitamin K to help boost
their immune system.
o Feeding behaviors vary amoung newborns. Caregivers
should watch for signs of hunger.
o Signs of risk for GI problemstime, color, and character of
first stool should be noted. Is the babies tummy distended
and no passage of stool?
o Breast feeding is digested much more quickley so babies are
hungry more often when they are breast fed.

 Hepatic system
o Carbohydrate metabolism-hypoglycemiaafter birth when
the newborn is cut off from maternal glucose supply, the
glucose level can drop between 30 and 90 minutes after
birth then gradualy rise.
o Conjugation of bilirubin
o Physiologic jaundice
Kernicterus: a very serious problem, bilirubin
deposits in the brain. Refers to the irreversible, longterm consequences of bilirubin toxicity such as
hypotonia (aka floppy baby syndrome from reduced
muscle strength), delayed motor skills, hearing loss,
cerebral palsy, and gaze abnormalities.
o Jaundice associated with breatfeeding
o Coagulation deficiencies can be developed by infants, so
circumsized males must be obsereved closely. Hemorrhage
can also be caused be a clotting defect indicated
hemophilia. Babies lack vitamin K which we get from the 3
pounds of bacteria that we carry, so they have a weak ability
to coagulate.
Immune System
o Risk for infection is high within the first months of life.
Lethargy, irritability, poor feeding, vomiting, diarrhea,
decreased reflexes, and pale or mottled skin color are some
s/s that suggest infection. Respiratory symptoms include
apnea, tachypnea, grunting, or retracting can be associated
with infection such as pneumonia.
Integumentary system
o Vernix caseosaa cheeselike, whitish substance that is
fused with the epidermis and serves as a protective covering
after 35 weeks of gestation.
o Sweat glandsinfants dont sweat in the first 24 hours, but
by day 3 sweating begins on the face and progresses to the
palms.
o Desquamation(peeling) of the skin of the term infant does
not occur until a few days after birth.
o Mongolian spotsbluish black areas of pigmentation can
appear over any part of the exterior surface of the body.
They should be documented careful to prevent confusion
with bruises.
o Nevialso known as salmon patches, are the result of
superficial capillary defect and commonly found on upper

eyelids, nose, upper lip, and nape of neck. They have no

clinical significance and require no treatment. Birth marks.
o Erythema toxicuma transient rash that appears within 2472 hours of life and is thought to be an inflammatory
response and has no clinical significance requiring no
treatment. Looks like the baby has acne.
o Signs of risk for integumentary problemscolor, any palor,
plethora (deep purplish color from increased circulating
RBCs), petechiae, central cyanosis, or jaundice.
Reproductive system
o Female usually has slightly swollen genitals from maternal
hormones
o Male can also have swollen genitals
o Both male and female can have a bloody diaper after a few
days
o Swelling of breast tissue for both male and female
o Signs of risk for reproductive system problems
Ambiguous genitalia: chromosome testing necessary
to determine gender of baby
Hypospadias: opening of the penis is opened along
the shaft, not on the tip. May cause infertility later.
Skeletal system
o Signs of risk for skeletal problems:
Molding: cone head
Caput succedaneum: crosses the suture lines, fluid
gets reabsorbed but it gives jelly-like feeling to top of
head
Cephalhematoma: blood filled. Puts baby at greater
risk for jaundice because they have more RBC to
break down
Developmental dysplasia of the hip: RN assess for
hip to click and need to move it back into place
Fractured clavicle: easiest bone to break in the body
and can break during birth, but it heals quickly
Neuromuscular system
o Newborn reflexes: baby should be symmetrically flexed
o Signs of risk for neuromuscular problems
Behavioral Characterists
Sleep-wake states: deep sleep light sleep drowsy quiet
alert active alert crying
Other factors influencing behavior of newborns

o Gestational age: 42 week gestation baby is different than a

39 week baby.
o Time
o Stimuli: baby looks away when the baby has too much
stimuli
o Medication: when the mom takes medication it makes the
baby more irritable and restless
Sensory behaviors
o Vision: they see best 8-12 inches away
o Hearing
o Smell
o Taste
o Touch
Response to environmental stimuli
o Temperant
o Habituation: if you ring a bell in front of the baby it will react
the most the first time, but each time it hears that sound it
will react less and eventually not at all.
o Concolability: some babies calm down when they are picked
up, some do not.
o Cuddliness
o Irritability
o Crying
Key Points
Term infants various anatomic and physiologic systems have
reached a level of development and function that permits
physical existence apart from the mother
Infant has sensory capabilities that indicate readiness for social
interaction
Significant differences exist between respiratory, renal, and
thermogenic systems in the newborn and those of an adult
At any serum bilirubin level, appearance of jaundice during the
first day of life or persistence of jaundice for more than 7 days
usually indicates a pathologic process in term infants
Loss of heat in a newborn may result in acidosis and increase the
level of free fatty acids, leading to cold stress
Some reflex behaviors are important for the newborns survival
Individual personalities and behavioral characteristics of infants
play major roles in their ultimate relationships with their parents
Sleep-wake states and other factors influence the newborns
behavior
Each newborn has a predisposed capacity to handle a multitude
of stimuli in the external world

 Each newborn has a unique personality!

Chapter 20 Postpartum Physiologic Changes
Estimated Date of Delivery
Human gestation lasts 266 days
Conception ocurs approximately 2 weeks after the LMP
Since due dates are based on length since LMP, the length of
pregnancy is counted as 280 days.
Reproductive System and Associated Structures
PP period is the interval between birth and return of the
reproductive organs to their nonpregnant state
Uterus
o Involution process: the uterus gradually shrinks to prepare
for the next pregnancy
o Contractions: happen even after the baby is born
o Afterpains: after multiple babies they become more intense
o Placental site: all the blood vessels that remain in the mom
after the placenta is released and the uterus clamps them
off to stop the placental site from bleeding. If you see
excessive bleeding but she has a strong contracted uterus,
the doctor should assess for a tare.
o Lochia: comes out of uterus, starts out dark red and slowly
lightens to become pale pink, then white.
Rubra: red
Serosa: pink
Alba: white (takes a couple weeks)
Cervix: will contract back and will not be as pinpoint as it was
prior to the baby
Vagina and perineum: go back to normal, may take a couple
weeks if a tare or episiotomy occured
Pelvic muscular support
o Pelvic relaxation
o Kegel exercises
Endocrine System
Placental hormones
o Estrogen and progesterone levels decrease
o Inhibition of milk by estrogen and progesterone levels
Pituitary hormones and ovarian function
o Prolactin remains elevated in women who breastfeed
o Ovulation in 27 days after birth for nonlactating women

o Ovulation in 70 to 75 days in lactating women

Abdomen
Returns to prepregnancy state 6 weeks after birth
o Striae may persist
o Return of muscle tone
Previous tone
Proper exercises
Adipose tissue
o Diastasis recti abdominis
Urinary System
Urine components
o Renal glycosuria disappears by 1 week postpartum
Postpartal diuresis
o Diuresis of extracellular fluid
Urethra and bladder
o Immediately after birth excessive beeding can occur if
bladder becomes distended
Gastrointestinal System
Appetite: they are hungry right away
Bowel evacuation
o Occurs 2 to 3 days after childbirth
o Anal sphincter lacerations are associated with postpartum
incontinence
Breasts
Breastfeeding mothers
o Colostrum: has lots of antibodies for the newborn
o Milk in 72 to 96 hours
Nonbreastfeeding mothers
o Engorgement resolves in 24-36 hours after milk comes in
Cardiovascular System
Blood volume decreases then increases, by elimination of
placental circulation, less vasodilation, and movement of
extrvascular water
Cardiac output back to normal in 6-8 weeks
Vital signs show only minor alterations
Blood components
o Hematocrit and hemoglobin WNL by 8 weeks
o Varicosities

Key Points
Uterus involutes rapidly after birth, returning to true pelvis within
2 weeks
Rapid decrease in estrogen and progesterone levels after
expulsion of the placenta is responsible for triggering anatomic
and physiologic changes in puerperium
Return of ovulation and menses determined in part by whether
the woman breastfeeds her infant
Assessment of lochia and fundal height is essential to monitor
progress of normal involution and to identify potential problems
Under normal circumstances, few alterations in vital signs are
seen after childbirth
Hypercoagulability, vessel damage, and immobility predispose
woman to thromboembolism
Marked diuresis, decreased bladder sensitivity, and
overdistention of bladder can lead to problems with urinary
elimination
Pregnancy physiologic changes allow woman to tolerate
considerable blood loss at birth

Chapter 21 Nursing Care of the Family During the Postpartum Period

Nursing Care of the Postpartum Woman
Nurse provides family-centered care that focuses on assessment
and support of a womans physiologic and emotional adaptation
after birth
Care is wellness oriented
Typical hospital stay is 1 to 2 days after vaginal birth, 2-4 days
after cesarean
Transfer from the Recovery Area
Postanesthesia recovery
o Regardless of obstetric status, no woman should be
discharged from recovery area until completely recovered
from anesthesia
o Women who have received general or regional anesthesia
should be cleared by a member of the anesthesia team
o Transfer from recovery area
o In LDRP settings nurse provides the same level of care
without moving the client
Planning for Discharge

 Laws relating to discharge

o Newborns and Mothers Health Promotion Act of 1966
o Advantages and disadvantages of early postpartum
discharge
Criteria for early discharge
o Mother recovered; able to care for self and baby
o Those at low risk for complications may be discharged as
early as 6 hours from a birth center, 24-36 hours from the
hospital
Care Management
Physical needs
o Couplet care
Routine laboratory tests
Prevention of infection
Prevention of excess bleeding
Maintenance of uterine tone
Prevention of bladder distention
Promotion of comfort, rest, ambulation, exercise
Promotion of nutrition
Promotion of normal bladder and bowel patters
Promotion of breastfeeding and lactation suppression
Health promotion for future pregnancies and children
o Rubella vaccination
o Prevention of Rh isoimmunizationRhogam
Psychosocial needs
o Effect of birth experience
o Maternal self-image
o Adaptation to parenthood and parent-infant interactions
o Family structure and functioning
o Effect of cultural diversity
Discharge Teaching
Self-management; signs of complications
Sexual activity and contraception
Prescribed medications
Routine mother and baby checkups
Follow-up after discharge
o Home visits
o Telephone follow-up
o Warm lines
o Support groups

o Referral to community resources

Key Points
Postpartum care is modeled on the concept of health
Cultural beliefs and practices affect the clients response to the
puerperium
Nursing plan of care includes:
o Assessments to detect deviations from normal
o Comfort measures to relieve discomfort or pain
o Safety measures to prevent injury or infection
Nurse provides teaching and counseling to promote the womans
feelings of competence in self and baby care
Common nursing interventions
o Evaluating and treating the boggy uterus and the full
urinary bladder
o Providing for pharmacologic and nonpharmacologic relief of
pain and discomfort associated with the episiotomy or
lacerations
o Instituting measures to promote or suppress lactation
Meeting psychosocial needs of new mothers involves planning
care that considers the composition and functioning of the entire
family
Early postpartum discharge continues to be the trend as a result
of:
o Consumer demand
o Medical necessity
o Discharge criteria for low risk childbirth
o Cost-containment measures
Effective means to prevent crisis and facilitate physiologic and
psychologic adjustments used in combination include:
o Home visits
o Telephone follow-up
o Warm lines
o Support groups
o Referral to community resources