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Estimated date of delivery based on LMP. Vaginal ultrasound may be done to establish DOD
Medical & nursing hx including past med health, family hx, social supports, social hx, & review of
systems (to determine risk factors) & past OB hx
Physical assessment: baseline weight, vitals, pelvic exam
Initial lab work:
o Blood type o Urinalysis
o RH factor o Pap
o HIV status o Indirect Coomb’s test will
o Hep B determine if client is sensitized
o VDRL to RH+ blood
o Rubella status
Ongoing Prenatal Visits:
Monitor weight, BP, & urine for glucose, protein, & leukocytes
Present of edema
Fetal development:
o FHR heard by Doppler at 10-12 wks
o Heard with ultrasound stethoscope at 16-20 wks. Listen at the midline, right above the
symphysis pubis, holding stethoscope firmly on abd
o Measure fundal height after 12 wks. Between 18 & 30 weeks, fundal height measured in
cm should equal the week of gestation. Have pt empty bladder & measure from the
level of the symphysis pubis to the upper border of the fundus
o Begin assessing for fetal movement between 16 & 20 weeks gestation
Pap Test Screens for cervical cancer, HSV II, &/or HPV
TORCH (Toxoplasmosis, other infections, rubella, Screening for group of infections capable of crossing
cytomegalovirus, & herpes) when indicated the placenta & adversely affecting fetal
development
Rhogam Administration:
Health Promotion:
Avoid all OTC meds, supplements, & rx meds unless OB who is supervising care has knowledge
of this practice
Alcohol (birth defects) & tobacco (low birth weight) contraindicated during pregnancy
Substance abuse of any kind is to be avoid during pregnancy & lactation
Encourage flu vaccine during the fall months
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Morning sickness: eat cracker or dry toast ½ to 1 hr before rising in the morning to prevent
discomfort. Avoid an empty stomach & drink fluids between meals.
UTIs are common due to renal changes & vaginal flora becoming more alkaline
o Wipe front to back, avoid bubble baths, wear cotton panties, avoid tight-fitting pants, &
consume 8 glasses of water/day
o Urinate as soon as urge occurs
Constipation may occur during 2nd & 3rd trimesters. Drink plenty of fluids, eat a diet high in fiber,
exercise regularly
Leg cramps may occur during 3rd trimester d/c compression of lower extremity nerves & blood
vessels by the enlarging uterus
o Homan’s sign should be checked
o If negative, patient should extend the affected leg, keeping knee straight & dorsiflexing
the foot (toes toward the head)
o Massaging & applying heat over affected muscle or a foot massage while the leg is
extended can help relieve cramping
o Notify PCP if frequent cramping occurs
Varicose veins & extremity edema during 2nd & 3rd trimesters
o Rest w/ legs elevated o Avoid sitting w/ legs crossed at
o Avoid constricting clothing knees
o Wear support hose o Sleep in left lateral position
o Avoid sitting or standing in one
position for long periods of
time
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Gush of fluid from vagina (rupture of amniotic fluid) prior to 37 weeks of gestation
Vaginal bleeding (placental problems such as abruption or previa)
Abd pain (premature labor, abruption placenta, or ectopic pregnancy)
Changes in fetal activity (↓ fetal movement may indicate fetal distress)
Persistent vomiting (hyperemesis gravidarum)
Severe HA (PIH)
Elevated temp (infection)
Dysuria (UTI)
Blurred vision (PIH)
Edema of face & hands (PIH)
Epigastric pain (PIH)
Concurrent occurrence of flushed dry skin, fruity breath, rapid breathing, ↑ thirst & urination, &
HA (hyperglycemia)
Concurrent occurrence of clammy pale skin, weakness, tremors, irritability, & lightheadedness
(hypoglycemia)
Common birthing methods: prepare a pregnant woman for the l&d process & may ↓ anxiety:
Dick-Read method- “childbirth w/out fear”. Uses controlled breathing & conscious & progressive
relaxation of different muscle groups through the entire body. Instructs a woman to relax
completely between contractions & keep all muscles except the uterus relaxed during ctxns
Lamaze- promote a healthy, natural, & safe approach to pregnancy, childbirth, & early parenting
by advocating & working w/ HCP, parents, & prof. childbirth instructors
Leboyer- based on the idea of “birth without violence”. Environmental variables are stressed to
ease the transition of the fetus from the uterus to the external environment (dim lights, soft
voices, warm birthing room). Water births are based on this method.
Bradley- emphasizes partner’s involvement as the birthing coach. Emphasizes increasing self-
awareness & teaching the woman to deal w/ the stress of labor by tuning into her own body.
Mother is encouraged to trust her body & use natural breathing, relaxation, nutrition, exercise,
& education throughout pregnancy
↑ protein intake
↑ foods high in folic acid (leafy vegetables, dried peas & beans, seeds, orange juice. Breads,
cereals, & other grains are fortified with folic acid).
o 600 mcg during pregnancy
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Aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into client’s
uterus & amniotic sac under direct ultrasound guidance locating the placenta & determining
position of fetus. May be performed after 14 weeks
Indications:
o Maternal age >35 years o Prenatal dx of genetic disorder
o Previous birth w/ chromosomal or congenital anomaly of fetus
anomaly o Alpha fetoprotein level for fetal
o Parent who is carrier of abnormalities
chromosomal anomaly o Lung maturity assessment
o Family hx of neural tube defects o Fetal hemolytic disease dx
o Meconium in amniotic fluid
Interpretation of finding:
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o AFP (protein produced by fetus) can be measured from the amniotic fluid between 16-
18 weeks & may be used to assess for neural tube defects in fetus or chromosomal
disorders. May be evaluated to follow up a high level of AFP in maternal serum:
High level: associated w/ neural tube defects such as anencephaly (incomplete
development of fetal skull & brain), spina bifida (open spine), or omphalocele
(abd wall defect). May also be present with normal multifetal pregnancies
Low levels: chromosomal disorders (Down syndrome) or gestational
trophoblastic disease (hydratiform mole)
o Tests for fetal lung maturity may be performed if gestation < 27 weeks in event of
rupture of membranes, preterm labor, or for complication indicating C-section. Amniotic
fluid tested to determine if the fetal lungs are mature enough to adapt to extrauterine
life or if the fetus will likely have respiratory distress. Determination is made whether
the fetus should be removed immediately or if the fetus requires more time in utero w/
the admin of glucocorticoids to promote fetal lung maturity
Fetal lung tests
Lecithin/sphingomyelin (L/S) ratio- a 2:1 indicating fetal lung maturity
(2.5:1 or 3:1 for a client who has DM)
Presence of phosphatidylglycerol (PG)- absence of PG is associated w/
respiratory distress
Preprocedure for Amniocentesis
o Explain procedure & obtain informed consent
o Instruct client to empty bladder to reduce risk of inadvertent puncture
Intraprocedure:
o Assist client in supine position & place a wedge or rolled towel under right hip to
displace uterus off vena cava & place drape over client exposing only abd
o Prepare for ultrasound to locate placenta
o Obtain baseline vitals & FHR & document prior to procedure
o Cleanse abd w/ antiseptic solution prior to administration of a local anesthetic given by
the PCP
o Advise client that she will feel slight pressure as the needle is inserted for aspiration.
However, she should continue breathing because holding her breath will lower the
diaphragm against the uterus & shift intrauterine contents\
Postprocedure:
o Monitor vitals, FHR, & uterine ctxns throughout procedure & 30 mins following
o Have client rest for 30 mins
o Administer Rhogam if Rh (-)
o Advise client to report to PCP if she experiences fever, chills, leakage of fluid/bleeding
from insertion site, ↓d fetal movement, vaginal bleeding, or uterine ctxns after the
procedure
o Drink plenty of fluids & rest for next 24 hours post procedure
Complications:
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Alpha-Fetoprotein Screening
Abnormal finding should be referred for a quad marker screening, genetic counseling,
ultrasound, & an amniocentesis
Indications: all pregnant clients between 16 & 18 weeks
Interpretation of findings:
o High levels: neural tube defect or open abd defect
o Low levels: Down syndrome
Nursing actions:
o Discuss testing w/ client
o Draw blood sample
o Offer support & education as needed
Incompetent cervix
o Painless bleeding w/ cervical dilation leading to fetal expulsion
Preterm Labor
o Pink-stained vaginal discharge, uterine ctxns becoming regular, cervical dilation &
effacement
Spontaneous Abortion
Impaired tolerance to glucose w/ the first onset or recognition during pregnancy. Ideal blood
glucose during pregnancy should be between 70 & 110 mg/dL.
Sx may disappear a few weeks following delivery. Approximately 50% of women will develop
DM w/ in 5 years
GDM causes ↑ risks to fetus including:
o Spontaneous abortion r/t poor glycemic control
o Infections (urinary & vaginal) r/t ↑ glucose in urine & ↓ resistance because of altered
carb metabolism
o Hydramnios, which can cause overdistention of uterus, premature ROM, preterm labor,
hemorrhage
o Ketoacidosis from diabetogenic effect of pregnancy (↑ insulin resistance), untreated
hyperglycemia, or inappropriate insulin dosing
o Hypoglycemia, which Is caused by overdosing in insulin, skipped or late meals, or ↑
exercise
o Hyperglycemia, which can cause excessive fetal growth (macrosomia)
Risk Factors:
o Obesity o Maternal age >35 y.o
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Hypertensive disease in pregnancy is divided into clinical subsets of the disease based on end-
organ effects & progresses along a continuum from mild gestational hypertension, mild &
severe preeclampsia, eclampsia, & HELLP syndrome
Vasospasm contributing to poor tissue perfusion is the underlying mechanism for the s/s of
pregnancy hypertensive disorders
Gestational hypertension (GH), which begins after the 20th week of pregnancy, describes
hypertensive disorders of pregnancy whereby the woman has:
o an elevated BP at 140/90 or greater
o or a systolic ↑ of 30
o or a diastolic ↑ of 15 from the prepregnancy baseline
o no proteinuria or edema
o client’s bp returns to baseline by 12 weeks postpartum
Mild preeclampsia:
o GH w/ addition of proteinuria of 1 to 2+
o Weight gain of more than 2 kg (4.4 lbs) per week in the 2nd & 3rd trimesters
o Mild edema will appear in the upper extremities or face
Severe preeclampsia:
o BP >160/100 o Hyperreflexia w/ possible ankle
o Proteinuria 3 to 4+ clonus
o Oliguria o Pulmonary or cardiac
o Elevated serum creatinine >1.2 involvement
mg/dL o Extensive peripheral edema
o Cerebral or visual disturbances o Hepatic dysfunction
(HA & blurred vision) o Epigastric & RUQ pain
o Thrombocytopenia
Eclampsia is severe preeclampsia symptoms along w/ onset of seizure activity or coma.
o Usually preceded by HA, severe epigastric pain, hyperreflexia, & hemoconcentrations,
which are warning signs of possible convulsions
HELLP syndrome is a variant of GH in which hematologic conditions coexist w/ severe
preeclampsia involving hepatic dysfunction. Diagnosed by lab tests, not clinically:
o H- hemolysis resulting in anemia & jaundice
o EL- elevated liver enzymes resulting in elevated alanine aminotransferase (ALT) or
aspartate transaminase (AST), epigastric pain, n/v
o LP- low platelets (< 100,000), resulting in thrombocytopenia, abn bleeding & clotting
time, bleeding gums, petechiae, & possibly DIC
Gestational hypertensive disease & chronic hypertension may occur simultaneously
Gestational hypertensive diseases are associated w/ placental abruption, acute renal failure,
hepatic rupture, preterm birth, & fetal & maternal death
Risk Factors
o No single profile identifies risks for GH disorders, but some high risks include:
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Nursing Care:
o Assess LOC o Vitals
o Pulse ox o Lateral positioning
o Urine output & obtain clean- o Perform NST & daily kick counts
catch urine sample to assess for as prescribed
proteinuria o Instruct client to monitor I&O
o Daily weights
Meds:
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o Mag Sulfate
Anticonvulsant
Med of choice for prophylaxis or treatment.
Lowers BP & depresses CNS
Use infusion control device to maintain regular flow rate
Inform client she may initially feel flushed, hot, & sedated w/ MgSO4 bolus
Monitor BP, pulse, RR, DTRs, LOC, urinary output (indwelling cath for accuracy),
presence of HA, visual disturbances, epigastric pain, uterine ctxns, & FHR &
activity
Fluid restriction of 100 to 125 ml/hr, maintain urinary output of 30 ml/hr or
greater
Monitor for signs of mag toxicity:
Absence of patellar DTR
Urine output <30 ml/hr
Respirations <12/min
↓ LOC
Cardiac Dysrhythmias
If mag toxicity is suspected:
Immediately d/c infusion
Admin antidote calcium gluconate
Prepare for actions to prevent respiratory or cardiac arrest
o Health Promotion/Disease Prevention
Maintain bed rest & lie in side-lying position
Promote diversional activities
Avoid foods high in Na
Avoid etoh & limit caffeine
↑ fluid intake to 8 glasses/day
Dark quiet environment, avoid stimuli that may precipitate seizure
Patent airway in event of seizure
Admin antihypertensive meds as prescribed
o Client outcomes:
Maintain BP w/in acceptable parameters
Client & fetus will remain free of injury
Preterm Labor
Pain Management
Safety for the mother & fetus must be first consideration of the nurse when providing pain
management measures
Nurse is responsible for helping client maintain the proper position during admin of
pharmacological interventions
Nonpharmacological pain management: seek to reduce anxiety, fear, & tension, which are major
contributing factors of pain in labor
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o Gate-control theory of pain- based on concept that the sensory nerve pathways that
pain sensations use to travel to the brain will only allow a limited number of sensations
to travel at any giving time. By sending alternate signals through these pathways, the
pain signals can be blocked from ascending the neuro pathway & inhibit brain’s
perception & sensation of pain
o Gate-control theory assists in the understanding of how nonpharm pain techniques can
work to relieve pain
o Childbirth prep education, sensory & cutaneous strategies, & frequent position changes
Lamaze, Bradley, Dick-Read methods
Pattern breathing methods: nurse should assess for signs of hyperventilation
(caused by low blood levels of PCO2 from blowing off too much CO2) such as
light-headedness & tingling of the fingers
If hyperventilation occurs, have the client breathe into a paper bag or
cupped hands
o Sensory stimulation strategies:
Aroma therapy Music
Breathing techniques Use of focal points
Imagery
o Cutaneous Strategies:
Back rubs & massage
Effleurage:
Light, gentle circular stroking of client’s abd w/ fingertips in rhythm w/
breathing during ctxns
Sacral counterpressure
Consistent pressure is applied by the support person using the heel of
the hand or fist against client’s sacral area to counteract pain in the
lower back
Heat or cold therapy Transcutaneous
Intradermal water block electrical nerve
Hypnosis stimulation (TENS) unit
Acupressure
Hydrotherapy (whirlpool or shower) ↑s maternal endorphin levels
o Prior to administration, nurse should verify that labor is well established by performing
a vag exam & evaluating uterine ctxn pattern
Adverse effect of opioid analgesics: crosses the placental barrier; if given to the mother too
close to the time of delivery, opioid analgesics can cause respiratory depression in neonate
Epidural & spinal regional analgesia: fentanyl & sufentanil, which are short-acting opioids that
are administered as a motor block into the epidural or intrathecal space w/out anesthesia
o Produce regional analgesia providing rapid pain relief while still allowing client to sense
ctxns & maintain ability to bear down
o Adverse effects:
↓ gastric emptying Bradycardia or
resulting in n/v tachycardia
Inhibition of bowel & Hypotension
bladder elimination Respiratory depression
sensations Allergic rxn & pruritus
Elevated temperature
o Provide client w/ ongoing education r/t expectations for procedure
o Institute safety precautions such as side rails up. Patient may experience dizziness &
sedation, which ↑s maternal risk for injury
o Assess the client for n/v & admin antiemetics as prescribed
o Monitor vitals per hospital protocol
o Monitor for allergic rxn
o Continue FHR pattern monitoring
Epidural Block: local anesthetic bupivacaine along w/ analgesic Morphine or fentanyl injected
into epidural space at 4th or 5th vertebrae. Eliminates all sensation from level of umbilicus to the
thighs, relieving discomfort of perineum.
o Admin when client is in active labor & dilated to at least 4 cm
o Continuous infusion or intermittent injections may be admin through an indwelling
epidural cath
o Patient controlled epidural analgeis is a new technique
o Adverse effects:
Maternal hypotension
Fetal bradycardia
Inability to feel the urge to void
Loss of the bearing down reflex
o Nursing Actions:
Admin bolus of IV fluids to help offset maternal hypotension as prescribed
Help position client into either sitting or side-lying modified Sims’ w/ back
curved to widen intervertebral space for insertion of the epidural cath
Remain in side-lying position after insertion to avoid supine hypotension
syndrome w/ compression of vena cava
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Slowing of FHR after ctxn has started w/ return of FHR to baseline well after ctxn has ended
Causes/Complications:
o Uteroplacental insufficiency causing inadequate fetal oxygenation
o Maternal hypotension, abruption placentae, uterine hyperstimulation w/ oxytocin
(Pitocin)
Nursing interventions:
o Side-lying position o Notify PCP
o Start IV line or ↑ IV rate o Prepare for assisted vag birth or
o D/C oxytocin if being infused C-section
o Admin O2 8-10 L/min per mask
Assessments R/T possible rupture of membranes:
First assess FHR to assure there is no fetal distress from possible umbilical cord prolapse, which
can occur w/ gush of amniotic fluid
Nitrazine paper will turn blue in the presence of alkaline amniotic fluid (pH 6.5-7.5)
Sample of fluid obtained & viewed on a slide under microscope
o Amniotic fluid will exhibit frond-like ferning pattern
Fluid should be a clear straw color & free of odor
Bishop Score
Amniotomy
Artificial rupture of amniotic membranes by PCP using an Amnihook or other sharp instrument
Labor typically begins w/in 12 hrs after rupture
Client is at ↑ risk for cord prolapse or infection
Indications:
o Labor progression too slow & augmentation/induction is indicated
o Amnioinfusion is indicated for cord compression
Outcomes:
o Labor will progress w/out complications
Nursing Actions:
o Assure presenting part of fetus is engaged prior to an amniotomy to prevent cord
prolapse
o Monitor FHR prior to & following AROM to assess for cord prolapse AEB variable/late
decelerations
o Assess & document characteristics of amniotic fluid including color, odor, & consistency
Interventions:
o Document the time of rupture
o Obtain temp q 2 hr
Cesarean Birth
Postpartum Period
Mother’s emotional & physical condition (unwanted pregnancy, adolescent pregnancy, history
of depression, difficult pregnancy & delivery) & infant’s physical condition (prematurity,
congenital anomalies) after birth can affect family’s bonding experience
Culture, age, & socioeconomic level can influence bonding
Bonding can be delayed secondary to maternal or neonatal factors
Psychosocial adaptation & maternal adjustment begin during pregnancy as the client goes
through commitment, attachment, & preparation for the birth of the newborn.
o 1st 2-6 weeks after birth: acquaintance, physical restoration, focus on competently
caring for newborn
o 4 months following birth: achieving maternal identity
o These stages may overlap & are variable based on maternal, infant, & environmental
factors
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Breast care:
o Wear well-fitting bra continuously for 1st 72 hours after birth
o Provide breast care for lactating women
Emphasize importance of hand hygiene prior to breast feeding
Breast engorgement:
Completely empty breasts at each feeding
Allow infant to nurse q 2 hr
Massage breast during feeding
Allow infant to feed 15-20 mins per breast or until breast softens
If 2nd breast doesn’t soften after feeding, it may be emptied w/ pump
Apply cool compresses b/t feedings & warm compresses/warm shower
prior to feeding (↑ milk flow & promotes letdown reflex)
Cold cabbage leaves also ↓ swelling & relieve discomfort
Flat nipples
Suggest client roll nipples between fingers just before breastfeeding
Sore nipples:
Apply small amount of breast milk to nipple & allow to air dry after
feeding
Apply breast creams as prescribed & wear breast shields in bra to soften nipples
Promote adequate fluid intake b/c it’s important to replace fluid lost from
breastfeeding as well as produce an adequate amount of milk
o Non-lactating Women:
Suppression of lactation is necessary for women who are not breastfeeding
Avoid breast stimulation & running warm water over the breast for
prolonged periods until no longer lactating
For breast engorgement, which may occur on 3rd or 5th postpartum day:
Apply cold compresses 15 min on & 45 min off
Fresh cabbage leaves inside bra
Mild analgesics for pain & discomfort
Rest/Sleep
o Plan at least one daily rest period; rest when infant naps
Activity
o Don’t perform housework that requires heavy lifting for at least 3 wks
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Postpartum Hemorrhage
Assessment:
o ↑ vaginal bleeding o Constant oozing, trickling, or
o Uterine atony frank flow of bright red blood
o Blood clots larger than quarter from vag
o Perineal pad saturation in 15 o Tachycardia & hypotension
min or less o Skin that’s pale, cool, & clammy
o Return of lochia rubra once w/ poor turgor & pale mucous
lochia has progressed to serosa membranes
or alba o Oliguria
Nursing Care:
o Monitor vitals
o Assess for source of bleeding
Fundus: height, firmness, & position
Lochia: color, quantity, & clots
Signs of bleeding from lacerations, episiotomy site, hematomas
o Assess bladder for distention
Insert indwelling cath to assess kidney function & obtain accurate measurement
of urinary output
o Maintain/initiate IV fluids w/ isotonic solutions (lactated Ringers or .9% NaCl), colloid
volume expanders (albumin), and blood products
o Provide O2 at 2-3 L per nasal cannula as prescribed to ↑ RBC sat
o Monitor O2 sat
o Elevate legs to 20-30 degree angle to ↑ venous return
Uterine Stimulant Meds:
o Oxytocin
Promotes uterine ctxns
Nurse should assess uterine tone & vag bleeding
Monitor for adverse rxns of H2O intoxication (lightheadedness, n/v, HA,
& malaise). These rxns can progress to cerebral edema w/ seizures,
coma, & death
o Methylergonovine (Methergine)
Controls postpartum hemorrhage
Nurse should assess uterine tone & vag bleeding.
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Dilation & curettage (D&C): performed by PCP to remove retained placental fragments if indicated
Infections
Newborn Assessment
APGAR: done immediately following birth to rule out abn. Completed at 1 & 5 mins of life.
Allows nurse to rapidly assess extrauterine adaptation & intervene w/ appropriate nursing
actions
Score 0 1 2
Heart rate Absent < 100 ≥ 100
Respiratory Rate Absent Slow, weak cry Good Cry
Muscle Tone Flaccid Some flexion Well-flexed
Reflex Irritability None Grimace Cry
Color Blue, pale Pink body, cyanotic hands & feet Completely pink
(acrocyanosis)