INTIMATE PARTNER VIOLENCE
Intimate Partner Violence (IPV)
 Domestic Violence – pattern of coercive behaviors and methods to gain and maintain power and control over an
individual in an adult intimate relationship
Intimate Partner
 Emotional connectedness
 Regular contact
 Identify as a couple
 Familiarity of each other’s lives
 Ongoing physical contact and sexual behavior
 Examples: former spouse, boyfriend, girlfriend, sexual partners, dating partners
 Can occur between hetero or homosexual couples and does not require sexual intimacy (emotions, romance,
feelings)
Where did it All Start?
 Women were considered property or “belonging to” their husbands
o 1800s – husbands were allowed to chastise, castigate, or discipline both women and children to keep them
in line
 1800s-1970s – women were blamed for “annoying” their husbands and police would turn a blind
eye to the situation
 New laws were made but only punished men if the wife died by beating or restricted “discipline” to
certain acts (i.e. only using a whip as thick as a thumb or hitting, kicking)
 1950s-1970s – theme of anti-war and civil rights movements laid the groundwork for the feminist movement
o 1960s-1970s – feminist movement began advocating rape is a crime
o Abuse against women became public and the first battered women’s shelter was started in 1973
 If a woman committed adultery or walk outside without her face covered, a law stated the wife can be punished by
death and the wife cannot lay a finger on her husband in return/defense
 Some laws stated for women to be punished publicly (iron muzzles)
Myths and Misconceptions
 Battering occurs in small % of the population
 Domestic violence is a woman’s issue
 Abused women actually provoke their partner to beat them
o Push men beyond their breaking point and incite physical violence
 Alcohol, drugs, mental illness, stress and out of control anger cause battering
 Battered women can easily leave the situation
o Women are weak and have no will power if they stay
 Domestic violence is a low income or minority issue (doesn’t happen to rich white people)
 Battered women will be safer when they are pregnant
 Children are too young to be affected by violence in the home
The Facts
 1 in 3 women will be abused sometime in their lifetime
o Unreported crime
o 24 people/min are victims of rape, stalking, and physical abuse
 Domestic violence is a public health problem
o Health costs (medical, mental, time away from work) exceeds $8.3 billion annually
 Domestic violence doesn’t discriminate
o Highest among females ages 18 to 34
o Rates are higher among (44%) lesbian and (61%) bisexual women compared to (35%) heterosexual
women
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38% of all female murders believed to be by IPV
Can happen to ANYONE
Women from all works of life are affected: all religions, ethnicities, education levels, socioeconomic classes, etc.
Relationship between battering incidence and drug or alcohol use
 Use does not cause abuse
 Shifts the blame from the batterer to “something else”
 Alcohol or drug use can lower the batterer’s inhibitions
 Battered women assume if her partner stops drinking or using drugs abuse will stop, this is not the case
Close to Home
 Texas
o 119 women killed in Texas in 2013
 76% killed in their own home
 56% were shot
 21 were in the process of leaving
 47% were married (wife) and 35% were in a relationship (girlfriends)
 Harris County
o 2014-2015 more than 250,000 women reported in domestic violence situations
o 2014 – Houston police department alone tallied 23,512 domestic violence situations
o 20 women killed in 2013 due to domestic violence
 Most people killed in home
Types of Domestic Violence
 Physical – anything that harms the body
 Sexual
 Psychological – don’t see it, lowering self-esteem
 Stalking – repeated unwanted contact or attention
 Reproductive coercion
 Isolation – controlling where they go/see, jealousy
 Coercion threats – to harm her or friends, commit suicide, buying her gifts
 Intimidation – putting fear into them
 Using others – threaten to take away children
 Male privilege – she should serve him
 Economic abuse – prevent her from getting a job, he makes all financial decisions
Wheel of Abuse
 Physical and sexual assault are the most apparent and are usually the actions for others to become aware of the
problem
 These can only happen occasionally in a relationship or even “threats” for them to happen, however other tactics
are used to maintain power over the individual
 These are not apparent to an outsider at all and might not even be apparent to the woman herself (especially if no
physical or sexual abuse has occurred in the relationship)
 For instance the woman may perceive the threats as “empty threats” or it only happened once
 When in the bigger picture her life is not hers anymore and the abuser has control (she lives in fear)
Batterer Characteristics
 Accept conventional “macho” values (I am the man, I am supposed to be strong)
 Extreme jealousy and possessiveness
o Hallmarks of abusers
 When they are not angry or aggressive they may appear
o Childlike, dependent, seductive, manipulating & in-need of nurturing
 May be well respected in the community (a “nice” guy)
o Important for when women seek help they might not be believed or taken seriously
Cycle of Violence
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Tension-building Phase
o Batterer demonstrates power and control
 Anger, arguing, blaming the partner for external problems
 Minor battering incidents
o Stress builds/communication breaks down
o Sense of growing danger
o Blames self for batterer’s anger
 Believes her own actions can prevent escalation and relationship will somehow change for the
better
o Length: varies from weeks to years
 Acute Battering Incident
o Triggered by either internal or external event
o Acute episodes of violence
 Lack of predictability
 Major destructiveness – pain, bruising, starts breaking things
o Batterer blames woman for the abuse
 Woman accommodates batterer for survival OR escapes but remains when it is over
o Length: few hours to a few days
 Tranquil Phase
o “Honeymoon period”
o Extreme loving, kind, apologetic behaviors
 Woman accepts gifts and apologies with belief it will not happen again
o Relief the “crisis” has passed – thinks it is a one time thing
o Length: without intervention ends at some point
 The cycle will repeat and over time the cycle can increase in frequency and severity
Reproductive Coercion
 Behavior that interferes with contraception use and pregnancy
 Behavior intended to maintain power and control over a woman’s reproductive health
 Strong link between IPV and reproductive health
 Birth Control and Sabotage
o Hiding, holding, destroying OCPs
o Poking holes or removing condoms during intercourse
o Removing vaginal rings, IUDs, the patch
 Pregnancy Pressure
o Pressure a female to become pregnant when she does not wish to become pregnant
 Pregnancy Coercion
o Threats or acts of violence if partner does not comply with batterer’s wish for pregnancy or termination
 Sexual Coercion
o Pressure or coerce a person to have sex or sexual acts without physical force
o Threats to ending the relationship
o Forcing sex without a condom of exposing them to STI
o Happens a lot to teenage girls
IPV and Pregnancy
 IPV affects 1 in 12 women in North America
 Homicide is the leading cause of mortality in pregnancy
o Majority perpetrated by a current or former partner
 Battering may result in adverse pregnancy outcomes
o Psychological distress
o Low birth weight
o Preterm labor
o 2nd and 3rd trimester bleeding
o Poor maternal weight gain
o Risk for STIs
o Anemia
o Tobacco or substance abuse
Impact of Abuse
 Begins slowly and subtly after some form of commitment
o Pregnancy, engagement, marriage, sexual relationship
 Physical consequences
o Bruising
o Broken limbs, ribs, nose, etc.
o Death
 Psychological consequences
o PTSD – future relationships might be affected
o Depression
o Anti-social behaviors
o Suicidal tendencies
o Low self esteem
o Anxiety
o Fear of intimacy
 Social consequences
o Isolation
o Strained relationships
 Healthcare providers and employers
“Why Didn’t You Just Leave?”
 The number 1 question asked is “Why did she stay?” not “Why did he batter?”
 Leaving can be just as harmful as staying
 Some common themes to staying
o Fear, love, family, money, isolation
IPV and Children
 Approximately 15.5 million children in North America were exposed to IPV
o 7 million exposed to severe IPV
o 4.3 million psychological emotional IPV
 1 in 3 (31%) children whom witnessed abuse reported being physically abused themselves
 In 2008, in a single day, 16,485 children were living in abuse shelters
 Close to 50% tried to intervene in some way
o Yelled at the abuser, tried to get away, called for help
 Lasting effects:
o More eating, sleep disturbances, anxiety, PTSD, nightmares, inability to concentrate, unable to be a child
(protector), low self-esteem
o Link between in-home violence and getting into abusive relationships (either perpetrator or victim) as adults
Nursing and IPV
 Screen ALL women
 Healthcare professionals usually the first professional women encounter
 Medical community can play a vital role in identifying and halting the cycle of abuse through:
o Screening, offering ongoing support and reviewing prevention options
 Nurses need advance knowledge in dynamics of battering, assessment, documenting, and appropriate intervention
skills
o Counseling, safety planning, and referring
 Awareness you cannot “save” or “rescue” a woman – it is the woman who has to call the police, you can provide her
with shelters and numbers she can call, make sure you document everything
 Just as important to assess a woman’s strength as it is the abuse
 OBGYNs see women for parental care, WWE, family planning visits
Cues and Screening
 Cues
o Hesitation in providing detailed information about an injury
o “Accident prone”
o Inappropriate affect for situation
o Lack of eye contact
o Vague complaints without accompanying pathology
o Signs of anxiety in presence of batterer
o Bruising on neck, breast, genitals, abdomen
 Environment
o Having a clearly states policy for privacy – see the patient alone, ask violence questions in private
o Safe and Supportive for assessing and responding to IPV
 Ask questions in private
o Having educational materials, hotline numbers, questionnaires in public and private places
Assessment Questions
 Framing Statement
o “We’ve started talking to all of our patients about safe and healthy relationships because it can have a large
impact on your health.”
 Confidentiality Statement
o “Everything here is confidential, meaning I won’t talk to anyone else about what you have said to me unless
(state law) mandates me to report it.”
 Screening Questions
o Within the last year or since you’ve been pregnant:
 Have you been hit, slapped, kicked or otherwise physically hurt by someone?
o Within the last year:
 Has anyone forced you to do sexual activities you do not want to do or force you to have sex when
you did not want to?
o Are you afraid of anyone at home or an ex-partner?
 In Texas healthcare providers are not mandated to report any injuries from domestic abuse. Only are mandated to
report injuries from firearms.
CULTURE AND PREGNANCY
Cultural Sensitivity
 How are decisions made?
o Woman alone, partner, extended family, spiritual leaders
 Do they live for the past, present or future?
o Past – worry about everything leading up to that time where the woman/kid is in the hospital; may start
healthcare visit with lengthy descriptions of past medical treatments, illnesses, family history
o Present – don’t look at past or future, deal with what is happening now; (adolescence) may not engage in
preventative health measures for long-term health, may not realize what happened in the past caused
“present illness”
o Future – worried about if the kid is going to survive and go to college; more concerned with future (i.e.
newborns education or talents) rather than the current illness
 What are their styles of communication?
o Verbal = language barriers, willingness to share, meanings of words
o Non-verbal = different practices of eye contact, personal space, touching, gestures, facial expressions
 What religion do they practice?
o Influence their sexual attributes and behaviors
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How is illness explained?
How is pain interpreted and responded to?
o Some women might be stoic about pain
 How is modesty expressed?
o Interactions between men and women
Culture and Family
 Family roles and decision making is largely influenced by culture
o Culture may determine head of household – primary decision maker
 Matriarchal (mom makes the decisions), Patriarchal (dad makes the decisions), Egalitarian (equal)
 Role may change when it comes to family health
o Extended family, tribal leaders, elderly roles are defined
 Consulting before making decisions about pregnant women or infant
 Grandparents may even be responsible for the care of the sick, children, etc.
o Nurses need to direct their health promotion education and treatment procedures towards the appropriate
individual
Health Beliefs
 Magico-religious belief
o Health and illness are determined by supernatural forces (God, gods, magic, spirits, or fate)
o May gain comfort from prayer, healing rituals and faith healing
o Get chaplain if they think God is punishing them
 Scientific-biomedical belief “Western Medicine”
o Illness caused by virus, bacteria, fungi or damage to the body
o Expect medical intervention (medication, surgery, treatments)
 Holistic Health Belief “balance and harmony”
o Illness is a result of when natural balance or harmony is distributed
o Holistic approaches, CAM, diet, rest
Equilibrium Model of Health
 Balance of:
o Light & Dark
o Hot & Cold
o Ying & Yang
 Manu cultures ascribe to this belief
 Most common is “Hot” and “Cold”
o Latin America, near East and Southeast Asia, African American, Muslim, Caribbean
o Consider illness or pregnancy a “hot” or “cold” state
o Restore imbalances – corrected by the proper foods, herbs, or medications
 Pregnancy is a “hot” state – woman sticks to “cold foods, drinks” to maintain balance
 Ex: Southeast Asia believes it is important to keep women warm after birth, because blood which is
considered “hot” is lost. Therefore they avoid cold drinks and foods following birth
Behavioral Practices
 Prescriptive behaviors – expected behavior of pregnant woman during childbearing period
o Active during pregnancy
o Happy to bring baby joy and fortune
o Craving need to be satisfied or baby will have birth mark – if not and the mother scratches herself, the baby
will have a birthmark in the shape of the food (Isreal)
o After birth, the umbilical cord is cleaned and placed in a keepsake box and kept as a memento to ensure a
positive mother-child relationship (Japan)
 Restrictive behaviors – activities which are limited during childbearing period
o Do not have picture taken with – still birth
o Sitting in a doorway or step will complicate labor
o Arms over head – cord wrap around baby’s neck
o Pregnant women shouldn’t wear leis or necklaces or the baby could become tangled in the umbilical cord
(Hawaii)
o Avoid blowing balloons or bubbles with gum to prevent PROM (Inuit)
 Taboos – restrictions believed to have serious supernatural consequences
o Early baby shower will invite the “evil eye”
o Pining an amulet or spiritual verse to the newborns clothing provides protection (Muslim)
o Avoid naming the baby until after birth – ensure infant survival
o Babies face are covered in mud and called ugly to ward off evil spirits (West Mali)
Differences in Culture
 Malawi, Africa
o Avoid preparing clothes for the infant during prenatal period because they believe this action will lead to
stillbirth
 Polynesia
o Pregnant women are pampered and nurtured by the entire community for the whole 9 months. Midwives
tend to visit regularly and administer massages.
 Hawaii
o Wearing leis or necklaces is avoided as it is believed the loop can cause the child to get tangled in the
umbilical cord
 Mexican American
o Mal Aire – bad air, sometimes related to evil spirits, especially night air. May enter body and cause illness.
Keep windows closed or covering the head.
 Bali
o Eating octopus while pregnant allegedly brings about difficult deliveries
 West Mali
o Babies faces are covered in mud and are called ugly names to ward off evil spirits
Cultural Norms with Infant Feeding Practices
 Hispanic
o Supplement with formula before milk comes in
 Colostrum provides vital antibodies – still many refuse
o Adding food to formula as early as 2 weeks to 3 months
 Rice, beans, cereal, potatoes, yams, and eggs
 “The bigger the baby the better” or healthier
 Belief addition of “traditional” foods – prepare children to accept them
 Sleep better through night
o Overfeeding is very common
 African American
o Adding food to formula as early as 2 weeks to 3 months
 Cereal, sugar/juice, potatoes, and powdered formula
 Child to grow big and healthy
 Thickened formula – more satisfaction and will sleep better
o Overfeeding is very common
 Much of the research on breast/formula feeding has been done on these two cultural groups.
 I bring these up because these are practices you as nurses will most likely run into, I did over 10 years ago in
Indiana and they are still relevant today.
 Overfeeding is very common among both groups – baby isn’t done until he/she spits up
 Interesting fact: Adult Obesity (2013) in United States 35% – Non-Hispanic blacks (48%) and 42% of Hispanics are
obese [followed by White 32% and Asian 11%]
 Childhood 2-19 years: 17% total – Hispanic (22%) and Non-Hispanic Blacks (20%)– followed by 14% white and 7%
Asian
Culturally Competent Nursing
 Examine one’s own culture, religions and beliefs
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o Ethnocentrism – projecting one’s own cultural beliefs onto others with the belief their culture is best and
only acceptable ones
When practices, beliefs, and cultures conflict. Nurses must consider the following questions:
o Is the practice safe?
o Is it feasible?
o Is it important to the woman?
PSYCHO-SOCIAL-CULTURAL ASPECTS OF PREGNANCY
Maternal Adaptation to Pregnancy
 Psychological
 Cultural
 Social
 Physical
 What does it mean to nursing?
o Psychosocial support for the pregnant woman and her family is a distinct and major nursing responsibility
during the antepartum period to help achieve a positive adaptation
 Women’s psychological adaptation to pregnancy is just as profound as her physical adaptation. The woman’s
psychological and development of identity as a mother is crucial aspects of the childbearing cycle.
 * Variables all influence the process
Emotional Rollercoaster
 Many women go through similar psychological and emotional responses through pregnancy
 Intendedness – doesn’t mean it is unwanted
o Many pregnancies are unintended, but not all unintended pregnancies are unwanted. For some women an
unintended pregnancy gives a woman a sense of direction in life or new purpose.
o Although an unintended pregnancy can be a risk factor for depression. Some may perceive life events as
being more stressful – another contributor to depression
o Depression can negatively impact the women’s health choices and behaviors thereby negatively affecting
the pregnancy.
 Ambivalence – might feel like she regretted getting pregnant, is she ready for a baby?
o Even when planned the mother/family may experience a sense of surprise conception actually occurred.
o During the first trimester its very common, thoughts of worry spring up or the timing is somehow “wrong’.
Worries about career, new role, unresolved fears about pregnancy, labor, and birth.
o Some women may consider the possibility of an abortion or tend to focus on the possibility of a
spontaneous “miscarriage”. However, the pregnant woman may feel guilty about having such thoughts and
then may worry the thoughts will harm the baby.
o Strong evidence of ambivalence and possible “warning signs” during the pregnancy can be complaints
about prolonged/frequent depression, considerable physical discomfort, significant dissatisfaction about
body shape, excessive mood swings and difficulty accepting life changes resulting from the pregnancy.
 Introversion – very common, trying to make time for herself
o “Turning in on oneself” is common. May be more concerned with rest and time alone then previous
activities. This can permit the woman to plan, adjust, adapt, build and draw strength in preparation for
childbirth.
o Her partner might take this passivity as exclusionary and may in turn become unable to interact with her
verbally or physically. This can lead to stress for the entire family. It’s essential for the couple to work
together to overcome these blocks to communication.
o One way to help is through a strong supportive partner (or family member/friend) to help the woman have a
more positive attitude.
 Mood swings – crying
o From great joy to deep despair. Some will become tearful with little apparent cause.
o These emotions again can affect the partner, feeling confused or inadequate and many men might unable
to handle the woman's tears and withdrawal or ignore the problem. Leading the woman to feel unloved
(snowball effect).
 Changes in body image – body will get bigger
o How it affects her depends on her personality factors, social network, and attitudes toward pregnancy.
Maternal Tasks of Pregnancy (Rubin’s)
 Reva Rubin identified 4 major tasks that a pregnant woman undertakes to maintain her intactness and that of her
family and at the same time incorporating her new child into the family system
 Ensuring a safe passage for herself and child
o Knowledge seeking - from competent maternity providers (nurses, physicians), literature, through
observation or other pregnant women and new mothers and websites.
o Self care activities - related to diet and exercise, taking vitamins, eliminating alcohol, etc.
 Ensuring social acceptance of the child by significant others (make sure everyone is okay with the baby)
o Partner
o Children
 Attaching or “binding-in” to the child (sing to baby, feel it move and talk to the baby)
o Maternal-Fetal Attachment
o 1st trimester the child is rather abstract concept, as the pregnancy progresses and mom starts to feel the
baby move, the child becomes more real and mom starts to visualize or fantasize her ideal child
o The “binding-in” process is a strong-emotional bond that motivates the women to become competent and
satisfaction in her role as mother.
 Giving oneself to the demands of being a mother
o Personal Sacrifice
 Accomplishment of these tasks helps the expectant woman develop her self-concept of a mother.
 Occasionally a woman never really accepts the mother role but plays the role of babysitter or older sister.
7 Dimensions of Maternal Role Development (Lederman’s)
 Accepting the pregnancy
o Adaptive responses to pregnancy
o Expected feelings: Desires/accepts pregnancy, predominantly happy, high tolerance to discomforts of
pregnancy
 Identification with motherhood role
o How a woman views her mother can affect how she might view herself in the motherhood role. Expected:
vivid dreams of motherhood, seeks company of other pregnant women or women with children, actively
prepares for motherhood role, anticipates changes positively.
 Relationship with own mother (how she might become a mom)
o Expected: mother was and currently available to her during pregnancy, mothers reaction to daughters
pregnancy (positive), mother’s relationship in general to her daughter, relates to her daughter as an adult
vs. a child.
 Reordering relationship with husband or partner
o Love, valued and accepting of the child
o Supportive partner through pregnancy, relationships change and so do the dynamics, partner shows
concern for needs, sexuality, partner involvement in pregnancy
 Preparation for labor
o Classes, reading, fantasizing, dreaming about labor and birth
o The degree of preparation for Labor and birth has an affect on a woman's level of anxiety and fear. More
prepared= less anxiety
 Prenatal fear of loss of control in labor (wants to be in control)
o Loss over body and emotions
o Related to her trust in medical personnel and attitude regarding use of medications. Expected: being
perceived as an adult, questions are answer and properly educated throughout process, compassion &
understanding from partner and nurses, realistic expectations about pain management.
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Prenatal fear of loss of self-esteem in labor
o Fear of “failing” during labor
o “Failing” could mean multiple things - failure to progress turning into a C-section, or “failing” to do it without
medications Expected: Adjust to unexpected, unknown, realistic expectations and awareness of potential
risks, recognize own needs and limitations.
Factors That Influence Maternal Adaptation
 Parity
o Null- or Multi Age
o Adolescents – might not adapt as well
o Older mothers (> 35 years) - might be more accepting but have increased risk for genetic problems,
miscarriage and might have a harder time changing roles or higher ambivalence (hard to adapt the
pregnancy into her career).
 Sexual Orientation
o Lesbian couples - possibly lack of social support particularly from family origins or finding healthcare
providers whom won’t judge them. Many however do plan their pregnancy through donor insemination.
 Single Parenting
o Reports higher degree of stress, anxiety, less tangible support from friends and family, normally live at or
below poverty level and higher risk for depression.
 Psychological
o Depression, anxiety, stress
 Multigestational Pregnancy
o Twins, triplets, etc.
 Socioeconomic Factors
o Food, shelter, healthcare resources
o Can they meet the needs for themselves let alone a new addition? Financial barriers are the most important
factors contributing to maternal inability to receive adequate prenatal care. Immigrant women face
significant economic barriers. Many women might not know about government help for prenatal care
(CHIPS) and newborn care (WIC).
 Abuse
o Beginning or increased
o NOT ALWAYS PHYSICAL
 Military Deployment
o Of the women herself. Woman veterans: pregnancy could exacerbate possible mental health conditions
(i.e. PTSD, depression, anxiety, schizophrenia) and pregnant women might feel fragmented between
Veterans health administration (do not provide prenatal care) and non- VHA providers (this is a very
understudied population)
 Complicated Pregnancies
Nursing Actions
 Know and be aware of community resources for mental health
o Therapist, psychiatrists, support groups, hotlines, pamphlet
 Establish trusting relationship
 Assess mood, emotional states, and anxiety
o Duration, frequency, and intensity
 Assess support system and coping mechanisms
 Discuss expectations about pregnancy, childbirth, and parenting (help bring them back to reality)
 Make referrals to other healthcare professionals as needed
Paternal Adaptation During Pregnancy
 Some men relish the role and look forward to becoming a father or they might detach or even become hostile to the
idea of fatherhood
Effects on Fathers
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Changing relationship with wife and friends
o Sexual responsiveness of wife
 Struggle to feel part of the pregnancy
o Role in Labor and Delivery
 More worry!
o Financial – increased emphasis on role as provider
o Safety about wife and infant
o Ability to be a father
o Disturbed feelings towards the baby (might feel jealousy)
 Abuse may begin
Father’s Participation
 Couvade Syndrome – men experience similar discomforts and symptoms as pregnant partners
 Explorers - Explore all aspects of the pregnancy, childbirth, and parenting (emotional, technical, and physical)
 Managers - Task-oriented (coaches, direct women’s diets/rest) but detached from emotional aspects
 Observers - Sit back and just observe (might be present but prefer not to participate)
 Removers - Remove oneself from whole situation (it’s a woman’s domain) more cultural influence
“Is Intercourse Safe?”
 In a word: YES
o C/I vaginal bleeding, ROM, PRL or history of PTL
o Sex can induce labor
 Depends on other factors
o Physical and emotional, body image changes, trimester (decreases in 3 rd)
o Some women actually feel more attractive and desirable as the pregnancy goes on, other unattractive
Developmental Tasks of Fathers (May)
 Announcement Phase
o May react with joy, distress or combined emotions
o Last for few hours – several weeks
o Common to feel ambivalence
 Moratorium Phase
o Thought of pregnancy put aside temporarily
o Fear of hurting baby with sex
o Feeling of rivalry
o Task = accepting the pregnancy (wife and fetus)
 Focusing Phase
o Last trimester
o Active involvement with preparing for newborn
o Task – role in L&D and parenting
Social Support During Pregnancy
 Material – meals, chores, managing finances
 Emotional – affection, approval, encouragement, and feelings of togetherness
 Informational – sharing information, helping women investigate new sources of information
 Comparison – help given by someone in similar situation
 Nursing Actions:
o Assess social support by someone in similar situation
o Assess barriers to social support (i.e. cultures, immigration status, age, socioeconomic, etc.)
o Explore forms of social support (i.e. church, work, friends, classes, etc.)
 Social Support refers to that support given by someone with whom the expectant mother has a personal
relationship.
 Predominantly: Spouse, partner and mother.
 Research has shown that a strong social support can have a positive impact on pregnancy, including increase in
self-esteem, feelings of being in control, reduced pregnancy complications.
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Barriers: Cultures that value individualism, self-sufficiency, and independence may have difficulty receiving social
support
 Immigration: language barriers, disruption of life-long attachments can cause anxieties and decreased socioeconomic status
 Social support and Professional support are two different things! A nurse can give support but it is not considered
social support. There are programs in place for women that have no one that include home visits from paraprofessionals (i.e. experienced mothers living within that patients community).
Family Centered Care
 Families are guided by common beliefs, cultures, values, religions, and traditions
What Exactly is a “Family”?/What is the Purpose of a “Family”?
 What is the minimum number of people in a family? Can a human and animal be family?
 Is it defined by blood, marriage, birth or adoption and they must live under the same roof? Could be, the US Census
Bureau seems to think so.
 We know there is a more broad definition of family in today’s world: families are individuals who have created
emotional bonds, closeness, support, sharing, caring with others.
 Purpose? Create, promote, and maintain, the social, mental, physical and emotional development of each member.
“Support” “Love” “Enable confidence” “Safety” “Stability”
Family Structure
 Dyad, child-free, nuclear, extended, single parent, three generational, stepparent, blended, cohabiting, gay or
lesbian, adoptive
 The structures of family vary widely among and within cultures. During the course of their lives, children may belong
to several different family groups
Duvall’s Life Cycle of Families
 8 stages
o The Married Couple – establishing marriage, pregnancy
o Childbearing – having and adjusting to an infant: becoming “parents”
o Preschool-aged Children – coping with lack of energy and privacy
o School-aged Children – fitting into the community/encouraging children’s education
o Teenage Children – balancing freedom vs. responsibility; post-parental interest
o Launching the Children – youth to adulthood; maintaining supportive home balance
o Middle-aged Parents – refocusing on marriage/relationship; maintaining kin ties
o Aging Family Members – adjusting to retirement, coping with death, living alone
 Family Developmental Tasks - Framework that categorizes family progression over time.
 Created in the 70s…based on the traditional nuclear family. Changes per type of family “divorced, grandparents”
Needs to be met by few or different individuals.
Family Centered Maternity Care
 Pregnancy not only affects the woman, but family members also experience shifts and changes in feelings,
relationships and lifestyles
 FCMC provides care to both pregnant woman and her family
o Promotes family unity while promoting a healthy pregnancy and postpartum
o Opportunity to gain confidence in new “roles”
o Positive treatment can affect her self-esteem and ability to parent
 To care for a woman without considering her family ignores her most important support system
 A highly functional family increases the overall health of the pregnancy, support system and psychological
adjustment of all members
INTRAPARTUM ASSESSMENT & INTERVENTIONS
Factors Affecting Labor (5 Ps)
 Passage (the pelvis)
 Passenger (the fetus)
 The relationship of the pelvis & passenger
 Powers (the contractions)
 Psyche (the response of woman)
 Position (maternal postures and physical positions to facilitate labor)
Passageway: Bony Pelvis
 Pelvis:
 Measurements
 Parts
 Types:
o Gynecoid
o Android
o Anthropoid
o Platypelloid
The Passenger: Head, Attitude, Lie,
Presentation
Sutures and Fontanelles
The Fetal Head
Fetal Attitude
 The relationship of the body parts of fetus → head flexed with chin on chest → arms and legs tightly flexed
The Passenger: Fetal Lie
 Definition: the relationship of the fetal long axis to the long axis of the mother
 Vertical/Longitudinal (normal)
o Head first
o Spin in alignment
 Vertical/Longitudinal (variation)
o Breech
 Perpendicular (abnormal)
o Transverse
o Oblique – longitudinal position but on one side or another and spine is not aligned
Passenger: Fetal Presentation
 Definition: the leading or most dependent portion of the fetus.
 Cephalic
o Vertex, Brow, Face

Shoulder

Breech
o Frank (feet up), Complete (both feet
+ sacrum), Footling (just a foot/feet)
o Most are born cesarean
Problematic Presentations
Leopold’s, Engagement, Station & Fetal Position
 The relationship of the pelvis to the
presenting part
 The 3rd critical factor
Leopold’s Maneuvers
 4 maneuvers that provide information on fetal lie, presentation, position and engagement
 Abdominal palpation also shows the degree of:
o Uterine irritability, tone, tenderness, current contractility and fetal movement
 Place hands on stomach and determine how the baby is laying in the mother
 Allows you to know where to place the Doppler, what position to place the mother in
Engagement
 Engagement occurs when the biparietal diameter is at or below the inlet of the true pelvis
 Most important part is the inlet because the baby head needs to fit through
 When it goes through it is called engaged (through the hole)
 If a mother has had a broken tailbone then there is a chance that the diameter will be small and it can break again
when the baby comes out
 THE FALSE PELVIS IS THE WIDEST, UPPER PORTION OF THE BODY PELVIS. THE INLET (LINEA
TERMINALIS) IS THE ENTRANCE TO THE TRUE PELVIS.
 THE TRUE PELVIS IS THAT PORTION OF THE PELVIS BELOW THE LINEA TERMINALIS OR THE INLET.
Lightening
 > Frequency of voiding – pushing on bladder
 > Vaginal discharge
 > Lordosis (inward curve of the lumbar spine)
 > Varicosities – increases the pressure on the lower part of the body (can feel ugly, encourage things to make the
mother feel better about herself)
 Shooting pains down legs → pressure sciatic
Station
 Definition: the relationship of the presenting part of the fetus to an imaginary line drawn between the Ischial
spines of the maternal pelvis.
 0 station = level of the Ischial spines
 -1 = 1 cm above the Ischial spines
 +1 = 1 cm below the Ischial spines etc...
 Tells us how the baby is descending and how the pregnancy is progressing
Fetal Position
 Refers to the relationship of the landmark on the presenting fetal part to the anterior, posterior, or sides (right or left)
of the maternal pelvis.
 Where the babies’ head is in relationship to the pelvis
 Want his head to be flexed
Determining Position
 Right (R) or left (L) side of the maternal pelvis
 The landmark of the fetal presenting part: occiput (O), mentum (M), sacrum (S), or acromion (scapula [Sc])
process (A)
 Anterior (A), posterior (P), or transverse (T), depending on whether the landmark is in the front, back, or side of
the pelvis
Contractions: Phases, frequency, duration and intensity
 The powers
 The 4th critical factor
Frequency – start of one contraction to the start of another
Duration – length of the contraction, do not want it to be more than 90 seconds, during contractions the babies blood
supply is starting to cut off and can lead to abnormalities if it lasts too long
 Intensity – forehead (severe), chin (mild), nose (moderate)
Contraction Parameters
 Frequency
o Timed from the START of one contraction to the START of the next
 Duration
o Timed from the START of the contraction to the END of that contraction


o Intensity – mild (nose) → moderate (chin) → strong (forehead)
Physiological Response
 Maternal past experiences – can be traumatic experience, rape
 Preparedness - education classes can help and get them familiar with what is going on with their body
 Support – social workers
 Financial stability – hospitals can be expensive to have babies at
 Impact of another child to care for
 Cultural meaning of children, fertility
Physiological Response
 Losses experienced in Labor:
o Privacy – the bathroom is not private, try to keep the curtains closed
o Control of Situation – the more informed the woman is the more control there will be, can become
hysterical, remind her that if she works with her body she can control how fast her labor can go she will feel
better
o Control over Bodily Functions – pass gas or noises, takes you to primal state, important that people are not
in the room that she does not want to fart in front of, can be nervous and hold it in and can cause problems
o Loss of Current Family Constellation
 Couples become parents, parents of one become parents of two, etc.
 Conflict because mom can feel she is not doing as good as a job ad dad because he is being more
involved
 Siblings – can be very interested but then they do not want them around anymore; other become
enthused and take care of the baby
Psychological Responses
 Support People
o Role of male partner as support person is unique to Western culture
 The decision of whatever the couple decides to do
 Can be relaxing or continuously taking care of the woman
 Realize that the man needs a break every once in a while
o Birthing generally seen as women’s work
o Doula can relieve male partner of need to push the pregnant woman
 Men are acculturated to “fix”; labor usually needs just to be allowed to progress
o “You shouldn’t have people in the labor room that you’d be embarrassed to pass gas in front of.” (MW
direction to primip)
o Any support persons should support MOTHER’S choices
o Helpful to elicit the birth experiences of women in the room
o Also good to find out about MGM’s births as well as prior births for patient
Theories of Labor
 Uterine Stretch theory - stretched to capacity
o Anything that is overstretched is going to empty itself
o Couples of multiples typically are going to deliver early
 Pressure on cervix → Oxytocin from pituitary
o Causes release of natural oxytocin (hormone that causes contractions)
 > Estrogen → irritable uterus
o Towards latter part, things might start breaking down a bit and estrogen is the builder and it is trying to
repair what has tried to degrade and tries to keep things in tact
 Progesterone deprivation → < Quieting
 > Oxytocin & Prostaglandin → > intracellular calcium → contractions
o Calcium causes contractions and magnesium causes relaxation
 Corticotrophin releasing hormone hypothesis
Fetal Factors
 Fetal

o Placental aging → triggers contractions
o Fetal membranes synthesize prostaglandins → contractions
o ↑Fetal cortisol (adrenal glands) → < progesterone → > prostaglandins → contractions
o Prostaglandins are also seen in semen and having sex can increase labor
Triggers
Triggers
Myometrial Activity
 Effacement
o Thinning and shortening of the cervix that occurs during labor
o At 100% effacement, the cervix is paper-thin
 Dilation/Dilatation
o Widening of the cervical external is from less than 1 cm, to full dilatation (approx. 10 cm) to allow birth of a
full term fetus
 Effacement has to occur before dilating
Dilation Occurs Because
 1ST:Contractions > diameter of the cervical canal lumen by pulling the cervix up over the presenting part
 2nd: The fluid filled membranes press against the cervix
Muscular Changes of the Pelvic Floor During Labor
 Levator ani muscle and fascia → rectum & vagina drawn upward & forward with each contraction → perineum <
from 5 to 1 cm thick
Factors and Processes: Matching
Lightening May Occur
 Leg cramps or pains due to pressure on the nerves
 Increased pelvic pressure
 Increased venous stasis, leading to edema in the lower extremities
 Increased urinary frequency
 Increased vaginal secretions resulting from congestion of the vaginal mucous membranes
 Lightening – when the baby is descending
Signs of Impending Labor
 Braxton-Hicks (uterus is “practicing” contractions – no cervical dilation or effacement) vs. true labor contractions
 GI changes (diarrhea, nausea, indigestion)
 Backache – baby coming down and pressing on lower parts of the pelvis
 Sudden burst of maternal energy (>epinephrine)
 Goodell’s sign – softening and ripening of cervix
 Bloody show (brownish or blood tinged)
 Diarrhea, indigestion, or nausea and vomiting just before the onset of labor
 What would you suspect with green or bright red blood discharge? Green (fetal stool, baby gets over excited or
decrease in oxygen and will pass stool)
Spontaneous Rupture of Membranes (BOW)
 ROM/BOW
o Immediately assess FHT
 Cord prolapse
o Trendelenburg position & lift presenting part off cord (cannot take out hand until the baby is born)
 Only 5 minutes of cord compression can lead to CNS damage or death
o Cord falls out – baby can lay on it and cut off blood supply
True vs. False
Physiology of Labor
 Pulse = > 10 – 18 beats/m
 > Cardiac output & BP
 Fluid & electrolytes altered by diaphoresis
 Renal → polyuria R/T > cardiac output
 GI = < motility, absorption and gastric emptying
 > WBC → > neutrophils in response to stress
 < Blood glucose as used for energy during uterine contractions → < need for insulin
Maternal Positions
 POSITION as to comfort– not on back
 Worst one is being in bed
Pain of Labor
 Hypoxia of contracted muscles
 Distension of vagina & perineum
 Pressure on adjacent structures
 Dilation and stretching of cervix
 Pain pathway from uterus to spinal cord. Nerve impulses travel through the uterine plexus; pelvic plexus; lower,
middle, and superior hypogastric plexuses; and lumbar sympathetic chain. They enter the neuroaxis through the
10th, 11th, and 12th thoracic and 1st lumbar spinal segments
Pain in Transition Phase and Second Stage of Labor
 The perineal component is the primary cause of discomfort. Uterine contractions contribute much less.
 Feels like her bottom is on fire because of stretching
Fetal Responses to Labor: Heart Rate, Acid Base, Hemodynamics, and Behavioral States
Changes in Heart Rate #1
 EFM reveals FHT 140 - 150, with sporadic sharp decelerations to 120 that last for 45 – 65 seconds during
contractions. You note three accelerations in 20 minutes. Contractions (ctx) are q 4-4.5 minutes, last 50-60 seconds
and palpate as moderate.

What is your assessment of this strip?
o Early deceleration, as contraction goes up the HR goes down
o Good because it means the labor is continuing and travelling down the birth canal
o Due to head compression
 What interventions are essential at this time?
o Just keep caring for the mother, this is normal
o Normal HR is 110-160
Change in Heart Rate #2

What is the interpretation of this strip? Why does it occur?
o Fetal HR coming down only at the TOP of the contraction
o Everything is contracted and no blood supply is getting to the baby
o LATE deceleration
 What actions need to be done?
o Give oxygen to the mom
 How might the epidural help with this event?
o Improve because mother will not have the resistance and the baby will get more oxygen because the mom
is not tensing up as much
Change in Heart Rate #3


Interpret the meaning of the d’ cells:
Why occur?
o Cord compression
o Amniotic fluid has decreased
 Response and interventions?
o Put mom in another position, side or knee-chest
Fetal Response in Labor
 Acid base status = < pH & O2; > fetal base deficit and in PaCO2
 Hemodynamic changes fetal and placental reserve → pull the fetus through anoxic periods unharmed.
 Behavioral states quiet and active
 Fetal sensation to light & pressure
Labor
 Labor is the process in which the fetus, placenta, and membranes are expelled spontaneously.
 Stages of Labor
Mechanism of Labor
 Engagement – head needs to go in the inlet
 Descent
 Flexion
 Internal rotation – get shoulders into the inlet
 Extension
 External rotation
 Expulsion
The Cardinal Mechanisms of Labor: Matching
The Third Stage of Labor
 A globular-shaped uterus
 A rise of the fundus in the abdomen
 A sudden gush or trickle of blood
 Lengthening of umbilical cord out of the vagina -> baby then comes out all the way
Fourth Stage
 Blood loss (350 – 500 cc) + < pressure post birth → redistribution of blood into vascular beds
 → > pulse pressure, <BP, & tachycardia
 Physiologic response soon after that slows the heart (Physiologic Bradycardia of Postpartum)
 Heart needs to become a better pump (slow down) or they will have pulmonary edema due to decreased CO
 Pulse pressure is the difference between the systolic and diastolic pressure readings. It is measured in
millimeters of mercury (mmHg). It represents the force that the heart generates each time it contracts. If resting
blood pressure is (systolic/diastolic) 120/80 millimeters of mercury (mmHg), pulse pressure is 40.
Checking Fundal Height
 Want the uterus to feel firm and contracted, otherwise she will bleed; need to massage if it is soft
NURSING CARE – CARE OF THE FAMILY DURING LABOR AND BIRTH
Indicators of Normal Labor Process on Admission
Nursing Care During The First Stage
Nursing Care Second Stage
 Nursing Assessments in the Second Stage of Labor
o Mother – blood pressure, pulse, respiratory every 5-15 minutes; uterine contraction palpated continuously
o Fetus – FHR every 5 minutes
Positions for Giving Birth
 Sitting on ball
 Hands & knees
 On knees leaning over chair or bar
 Sitting
 Leaning on support person
 Lithotomy – mostly seen (on back with her legs up)
 Birthing chairs no longer used due to tearing
Lacerations
 Tear in the fascia heals much better on its own than with stiches
 2nd degree – stiches will be needed
 Blow out – pieces of skin everywhere, need to cut if that is going to happen
The Newborn
 Obtain Apgar scores at 1 min and 5 min
 Newborn ID
o Mom and baby will have matching armbands with same number
 Medication administration
o Vitamin K because they have a sterile duct and not producing blood factors
o Eye medications – preventing gonorrhea
Apgar Scoring @ 1 and 5 Minutes
Newborn Care
 Dry thoroughly and place cap on head
 Warm, dry, stimulate – first thing you do
 For persistent cyanosis of the trunk, administer blow-by O2
 PPV (positive pressure ventilation) for infants not breathing OR HR < 100
 Chest compressions if HR < 60
 Deep suction after 5 minutes done for persistent rales or rhonchi
 Gross physical assessment for abnormalities – thorough exam will happen within the 1st hour
Newborn Care: Suctioning
 Current guidelines state there is no evidence to support the value of the practice of routine bulb suctioning of the
newborn.
 Current Neonatal Resuscitation Program (NRP) guidelines no longer include bulb sx in the initial resuscitation of the
normal term newborn.
 NRP guidelines no longer (2006) recommend mechanical sx of the mouth and nasopharynx on perineum with
meconium present in amniotic fluid.
 Babies can be on their side; mouth can be wiped PRN
 Studies of catheter deep suctioning fail to show a benefit in oxygenation
 Studies recommended that the routine and indiscriminate use of or nasopharyngeal catheter suctioning at birth be
curtailed.
Newborn Care
 Label baby with identification bands (per hospital protocol) before it leaves the delivery room
 Baby footprints and mother’s fingerprint
 Obtain cord blood samples if required (Rh negative or Group O)
 Obtain cord gases if indicated (i.e., low Apgar)
Continued Care
 Monitor temperature, heart rate, respiratory rate, skin color, level of consciousness, tone, activity
Initial Newborn Evaluation
High Risk Factors/Hints
 Apgar less than 8 at 1 minute and less than 9 at 5 minutes or baby requires resuscitation measures (other than
whiffs of oxygen)
 Respirations below 30 or above 60, with retractions and/or grunting
 Apical pulse below 110 or above 160 with marked irregularities Skin temperature below 36.5°C (97.8°F)
 Skin color pale blue or circumoral pallor
 Baby less than 38 or more than 42 weeks' gestation
 Baby very small or very large for gestational age
 Congenital anomalies involving open areas in the skin (meningomyelocele)
Management of Pain
Counterpressure
 Comfort measures: Counter pressure
 Direct pressure to the sacrum or hips to counteract stretching of ligaments – makes the baby move away from the
sacrum
 Anterior – feel discomfort in abdomen
 Posterior – feel discomfort in the back
Pain Management in Labor
 Shower
 Warm bath (Intermittent FHT by Doppler, usually q 15 or 30 minutes per protocol)
 Whirlpool bath (Jacuzzi)
 Warm water causes oxytocin production, which will then cause labor to come sooner
Pain Management in Labor
 Breathing
 Important because there is a natural tendency to hold the breath with pain
 In general, as labor becomes active and contractions get stronger, deeper breathing is difficult/impossible
 Patterned breathing also acts as distraction
 Panic can lead to hyperventilation
o Tingling hands, lips
o Breathe into cupped hands or surgical mask
Tapping at Meridian Accupressure Points
 Create phrase: “Even though I (name problem or issue), I accept myself.
 Using the first and middle fingers, tap 5–7 times on each point
o Eyebrow point → side of eye → under eye → under nose → under lip
(@chin point) → Collarbone → under arm → top of head in this
Support People
 Familiar voice and touch is generally helpful


Provide specific suggestions, techniques
Monitor rest, food, fluids for them as well
o Take things away during active labor incase an emergency occurs
 Help them to help the mother
Analgesic Medication in Labor
 Want the smallest amount for the best effect
 Stadol = do not give to drug dependent women = risk precipitation of sudden withdrawal response in mom & baby
 Fentanyl crosses placenta rapidly- may be used with regional anesthesia
 Agonist = In pharmacology the term agonist–antagonist is used to refer to a drug which exhibits some properties of
an agonist (a substance that fully activates the neuronal receptor that it attaches to) and some properties of an
antagonist (a substance that attaches to a receptor but does not activate it or if it displaces an agonist at that
receptor it seemingly deactivates it thereby reversing the effect of the agonist).
Inhalation Anesthesia
 Nitrous oxide
o 50% oxygen and 50% nitrous oxide
o Reduces pain - Not complete relief
o Laughing gas
o Hard to work with some women during labor
 Halothane
o Inhalation (breathing the gas into the lungs) by trained anesthesia

60% of laboring women in the United Kingdom,2 50% of laboring women in Australia,3 and almost 50% of women
who deliver in Finland and Canada, 1% of women reported the use of nitrous oxide for labor analgesia in the United
States
 The efficacy and safety of nitrous oxide for labor analgesia has not been recently evaluated. The most recent
review,1 in 2002, summarized the results of 11 randomized controlled trials, of which only one was published after
1996. The peak analgesic effect of nitrous oxide lags the start of its administration by 50 seconds; however, uterine
contractions typically peak 30 seconds after they start and stop 30 seconds later, out of phase with the analgesic
effects of nitrous oxide administered beginning at the start of a contraction
Anesthesia in Labor & Birth
 Local anesthetic toxicity= accelerated systematic absorption = uritarcia to anaphylaxis- Cardiovascular effects are
primarily those of direct myocardial depression and bradycardia, which may lead to cardiovascular collapse.[1] At
extremely high levels, cardiac arrhythmia or hypotension and cardiovascular collapse occur
Epidural Block
 Consent forms after full explanation
 Establish IV and administer fluid bolus
 Ready equipment: O2, fetal monitor, epidural equipment, IV fluids (500 – 1,000 cc)
 Placement takes time
 Systemic toxicity
 Large placental transfer
 > Incidence of inadequate block
 Maternal hypotension
 Fetal bradycardia
 Help position patient in side-lying or sitting position – attach BP cuff
 Assist anesthesiologist with procedure
Spinal Anesthesia
 Drug into the subarachnoid cerebrospinal fluid space (CFS). The injection is usually made in the lumbar region at
the L2/3 or L3/4 space – punctures dura
 Immediate action -shorter procedures
Spinal
 Possible medications: bupivacaine hydrochloride, ropivacaine hydrochloride and lignocaine hydrochloride
 Complications are related to the techniques, resulting in systemic toxicity, or to the effects of the block, rather than
to the drugs used.
Complications Spinal
 Cardiovascular: seizures or convulsions, arrhythmias, cardiac arrest
 High Block = nasal stuffiness, respiratory distress or arrest
 Total spinal = which occurs when the injection has been given unintentionally at the wrong site, is a rare but serious
complication. TSA is characterized by sudden hypotension, rapidly increasing motor block, temporarily loss of
breathing, loss of consciousness, dilated pupils, and is preceded by respiratory distress due to the blockade of
some nerve cells` Treatment: Maintain airway and ensure oxygenation and position the patient on the side to
prevent aspiration of secretions.
 Post-dural Puncture Headache
o Blood patch (10 – 15 ml blood injected into dural space)
 Ventilation with a bag or mask.
 Protect the airway from aspiration by placing a tube in the airway tract.
 Treat hypotension with appropriate medications such as ephedrine.
 Treat slowing of the heart with appropriate medications.
 Loss of consciousness and dilated pupils should resolve once the respiratory and cardiovascular systems are
supported.

In the pregnant women, the fetus should be monitored closely and urgent delivery may be required if the fetal
distress is severe and/or resuscitation in difficult.
Spinal Anesthesia
 Adverse reactions:
o <BP, allergic or toxic reactions, respiratory paralysis, partial or total anesthetic failure
 Nursing responsibilities:
o Assist anesthesiologist
o Maintain IV site
o Be prepared for emergency situations if occur
CHILDBIRTH AT RISK – PRELABOR AND INTRAPARTUM
Preterm Labor & Delivery
Definitions of Gestation
 Early Term Birth: 37 and 38 weeks + 6 days
 Full Term Birth: 39 – 40 weeks + 6 days
 Late Term Birth: 39 – 40 weeks
 Post Term Birth: Birth after 42 weeks
 Preterm Birth (PTB): 20 – 37 weeks
o 2012 = 11.54% births prior to 37 weeks
o Cost = $26 billion / year
o ACOG – > 2X’s African American have PTB & low birth weight C/T Caucasian women
Premature Delivery
 ≥ 20 weeks but< 37 weeks
 Weight depends on gestation
 Responsible for 2/3 of neonatal deaths
 Girls are much healthier than boys
Preterm Birth
 Incidence – 1 in 9 of all births in 2013 (CDC)
o 40% due to spontaneous PTL
o 40% due to PPROM
 1:8 babies were born preterm in Texas in 2008 (13.3%) compared to 12.1% nationally.
 Accounts for 50 to 70% of neonatal deaths
 Doubled for low socioeconomic status
Patients at Risk of Preterm Labor
 Unplanned pregnancy
 Weight at time of pregnancy
 General health status
 Uterine fibroids
 GU infections
 Periodontal disease
 Intimate partner violence
 Employment
 Cigarette smoking
 Substance abuse
 Stress
 Low SES/poor PNC
 Age
 Previous PTL
 Incompetent cervix
 Multiple gestation
 History of cone biopsy
 Abdominal sx during pregnancy
 Cervical shortening
 DES exposure – drug that was used for morning sickness, causes problems with offspring female anatomy
Factors in Current Pregnancy Indicating High Risk
 Placenta Previa
 Polyhydramnios & Multiple gestation – cause uterus to think it is overstretched
 Abdominal surgery
 Maternal infection, diabetes, preeclampsia
 Uterine irritability
 Premature rupture of membranes (PROM)
 Vaginal Infection - bacterial vaginosis
Risks of Complications & Gestation
Preterm Labor: Symptoms
 Symptoms of PTL are often subtle
o Pain: abdomen, back & pelvis
o Uterine contractions (often painless)
o Menstrual-like cramps
o Constant backache
o Pelvic pressure
o Increased vaginal discharge
o Blood-stained vaginal discharge
o Urinary frequency & diarrhea
Predicting Preterm Birth: Biochemical Markers
 Fetal Fibronectin if test is positive = inconclusive result
 Negative Test = 95% likelihood of not giving birth within the next 7 – 10 days
Interventions < PTB: Primary
 DIAGNOSIS
o Tip: Care with measuring cervical length by endovaginal US (ultrasound)
o → pressure of probe or full bladder → falsely long measurements
 TREATMENT
o Infections: bacterial, BV, UTI
o Cervical cerclage – sew up incompetent cervix
o Progesterone administration – keep it nice and quiet
Interventions < PTB: Secondary
 Antibiotic treatment
 Tocolysis
Table 24-3. Criteria for Diagnosis of Preterm Labor in Gestations of 20 to 37 Weeks
Methods of Tocolysis
 Initial Steps – in patients with minimal to no cervical dilation:
o IV hydration – causes the body to produce oxytocin
o Rest
o Subcutaneous Terbutaline
 Once cervical change is documented more aggressive treatment begins.
 Goal of tocolysis is to delay labor for 24 to 48 hours so that IM steroid injections can be given to promote fetal lung
maturity.
Home Management
 Tocolytics
 Uterine Monitoring
 Activity restrictions
Common Tocolytic Drugs
Tocolytics
 Terbutaline Sulfate (Brethine)
o Beta-adrenergic agonist that inhibits contractile response of uterus
o Given IV, subcutaneous, and orally for <48-72 hrs
o Side effects
 Inc HR, nervousness, & tremors
 N&V, cardiac arrhythmias, and elevation of glucose levels
 New FDA Black Box Warning
Steroid Administration
 Glucocorticoids accelerate fetal lung maturity.
 May be used from 26 to 34 weeks
 Birth must be delayed 24-48 hours
 Betamethasone or dexamethasone can be given (Matteson, p771-772)
o Betamethasone dosage: 12mg IM q 24 hrs x 2 doses
o Dexamethasone dosage: 6mg IM q 12 hrs x 4 doses
 Nursing assessment of patient with DM or GDM
Preventative Interventions
 Patient Education
o Behavior change
o Signs of PTL
 Nursing Support
 Pharmacologic intervention
 When PTL has been diagnosed:
o GBS Prophylaxis
o Antenatal corticosteroids
No Attempt to Stop PTL if ? Exists
 Fetal demise
 Lethal fetal anomaly
 Severe PE or Eclampsia
 Hemorrhage/abruption placentae
 Chorioamnionitis
 Severe fetal growth restriction
 Fetal maturity
 Acute non-reassuring fetal status
 Gestational age < 24 wks
 Oligohydramnios
 Nonreactive non-stress T +CST
 < Diastolic flow upon Doppler umbilical blood
 > Variable decelerations
 > Vaginal bleeding →abruption, unless patient is stable and fetal well-being is established
Nursing Diagnoses
 Knowledge, Readiness for Enhanced, related to an expressed desire to understand the causes, identification, and
treatment of PTL and its implications
 Fear, related to early labor and birth
 Coping, Ineffective, related to need for constant attention to pregnancy
 Anxiety, related to the possibility of a preterm birth (PTB)
Risk Because of Premature Rupture of Membranes
Premature Rupture Of Membranes (PROM)
 Spontaneous rupture of the membranes prior to the onset of labor.
 Causes
o Infection
o Polyhydramnios
o Trauma
o Multiple gestation
 Incidence 3-18% of all births
 Maternal Risks
o Infection (Chorioamnionitis & endometritis)
 Neonatal Risks
o Sepsis
o Prolapse of cord
o Prematurity
PROM
 Treatment at term is induction
 Preterm Premature Rupture of Membranes (PPROM)
o Observation
o Determination of fetal pulmonary status
o Determination of risk of infection (C-reactive protein, ultrasound)
o Omit vaginal exams
o Administer corticosteroids and tocolytics
o If Group B Strep positive - treat with antibiotics
Risk Because of Placental Problems
Placenta Previa
 Implantation of the placenta in the lower uterine segment
o Low implantation
o Partial placenta previa (partially covers cervix)
o Total placenta previa (completely covers cervix)
 Placenta separates as uterus contracts

Amount of bleeding depends on the amount of
separation
 Signs & Symptoms
o Painless vaginal bleeding
o Bleeding is bright red blood
o No uterine tenderness
o Normal uterine tone
o FHT’s present
o Engagement absent
o Presentation may be abnormal
 Treatment
o No Vaginal exams
o Bed rest
o Monitor blood loss
o Laboratory test- Hgb, Hct
o I.V. fluids
o Type and Cross Match for blood
o Tocolyis if pre-viable fetus
o C-section for delivery
Abruptio Placentae
 Premature separation of the normally implanted placenta from the uterine wall
o Marginal - separation begins at the edge of placenta (vaginal bleeding present)
o Central - separation occurs
centrally and blood trapped
between placenta and uterine
wall (concealed or occult
hemorrhage)
o Complete - Massive vaginal
bleeding evident from vaginal
tone with placental separation
 Risk Factors
o Polyhydramnios
o Multiple Pregnancy
o Cocaine Use
o Smoking
o Alcohol Ingestion
o Increased Maternal Age
o Trauma
o Increased Blood Pressure
 Etiology - Unknown
 Theories
o Decreased blood flow to placenta
o Extensive intrauterine pressure
Abruption
 S&S
o Sudden onset
o Bleeding external or concealed
o Color of blood is dark venous
o Shock
o Severe pain
o Uterus tender and board-like pain
o >FHT
 Neonatal Risks
o Mortality is about 15% overall
o With complete abruption- 100%
o Prematurity
o Anemia
o Hypoxia (brain damage)
 Treatment
o Emergent C-Section
Placenta Previa vs. Abruption
 Previa
o Repeated bleeding episodes
o No abdominal pain
o Normal uterine tone
o No uterine tenderness
o Bleeding bright red
o FHT usually heard
o Low implantation
 Abruption
o Single, sudden bleeding episode
o Severe abdominal pain
o Tenderness & rigid
o Dark venous blood
o FHT difficult/absent
o Normal implantation
Risk Because of Cervical Insufficiency
Incompetent Cervix
 Premature dilation of cervix
 Usually occurs about 4-5th month
 History of repeated painless abortions
 Incidence of 0.1% to 1.0 %
Causes of Incompetent Cervix
 Cervical structural defects
 Uterine anomalies
 DES exposure
 Previous traumatic birth
 Previous trauma to cervix
 Cervical conization
 Cervical cauterization
Treatment for Incompetent Cervix
 Bed rest (Trendelenburg)
 Cerclage (Modified Shirodkar, McDonald, or abdominal)
o Reinforces a weak cervix using a suture
o May be released at term
o Educate women to call if any signs of labor
o Success rate is 80-90%
Risk because of Multiple Gestation
Risks with Multiple Gestations
 Spontaneous abortion
 Gestational diabetes: > risk 6% twins & 22-39% triplets
 Preeclampsia & HELLP: >risk 2.6 X’s with twins
 Acute Fatty liver
 Pulmonary embolism or edema
 Maternal anemia, > discomforts of pregnancy
 PROM
 L & D: PTL, dystocia (> stretch), presentation, instrumental/c section, PP hemorrhage
 Newborn: < birth wt., NICU, 26% deaths
Nursing Diagnoses
 Fear, related to unknown outcome of the birth process
 Coping, Ineffective, related to uncertainty about the labor and birth plan
 Knowledge, Deficient, R/T lack of information about the associated problems
 Gas Exchange, Impaired, (fetuses) related to decreased oxygenation secondary to cord compression
Risk because of Amniotic Fluid Complications
Hydramnios or Polyhydramnios
 Occurs when there is more than 2000 mL of amniotic fluid contained within the amniotic membranes
o Birth defects (anencephaly), GI or GU or CNS
o Rh disease
o Diabetes in the mother
o Identical twins (twin-to-twin transfusion)
o Fetal anemia
Treatment
 If maternal dyspnea and pain hospitalization for removal of the excessive fluid AROM or needle amniotomy by
amniocentesis
 Prostaglandin synthesis inhibitor (indomethacin) < amniotic fluid volume by < fetal urine output
Oligohydramnios
 Oligohydramnios occurs when there is a severely reduced volume of amniotic fluid.
 Intrauterine growth restriction (IUGR), post maturity, and fetal renal and urinary malformations.
 Risk: variable decelerations because the amniotic fluid is insufficient to keep pressure off the umbilical cord.
LABOR RELATED COMPLICATIONS
Dystocia R/T Dysfunctional Contractions
 Dystocia – labor pattern in which abnormalities occur
o Power (uterine contractions or maternal expulsion forces)
o Passenger (size, position or presentation)
o Passage (soft tissue or pelvis)
 Dystocia – Cervical dilatation
o < 0.5 cm/hr over 4 hrs during active phase of 1st stage OR < 1 cm/hr of fetal descent during the 2nd stage
 *Most common = dysfunctional (or uncoordinated) uterine contractions -> prolonged labor
Risk Factors for Dystocia
 > Maternal age
 Maternal obesity
 Nulliparity
 < Maternal height
 Post term or LGA
 Labor induction
 Mal presentation
 Premature rupture of membranes
 Prolonged latent phase
 Epidural anesthesia
 Chorioamnionitis
Figure 25-1 F = Frequency & D = Duration
 A - Expected: F= Q3min; D = 60 seconds. BRT = <10 mmHg.
 B - Tachysystole: F =1.5 min, D 90 s BRT=10 mmHg.
 C - Hypotonic: F = 7 min, D = 50 s, seconds, and 25 mmHg during contractions.
Nursing Diagnoses for Tachysystole
 Pain, Acute, related to the woman's inability to relax secondary to tachysystole uterine contractions
 Coping, Ineffective, related to ineffectiveness of breathing techniques to relieve discomfort
 Anxiety, related to frequency of contractions and lack of an adequate uterine relaxation period
Nursing Evaluation for Tachysystole
 The woman's labor pattern expected with contractions of frequency, duration, and intensity.
 The woman and her partner are able to cope with the abnormal labor pattern and interventions.
 The woman's level of pain becomes more tolerable.
Hypotonic Contractions
 Usually occurs during the active phase of labor -> inadequate contractions < intensity, frequency and durations -> <
cervical dilation, effacement or fetal descent


Related to: overdistension, fetal macrosomia or LGA, or grand multiparity
Treatment: if - engaged -> amniotomy vs. not R/O CPD
o Pitocin
AMNIOTOMY – Artificial Rupture of the Membranes
 Advantages of doing this before Pitocin
o Contractions are more similar to those of spontaneous labor
o Usually no risk of rupture of the uterus
o Does not require as close surveillance
 Disadvantages of an Amniotomy
o Delivery must occur
o Increase danger of prolapse of umbilical cord
o Compression and molding of the fetal head (Caput)
 Nursing Care: check fetal heart tones; assess color, odor, amount; provide with perineal care; monitor contractions;
check temperature every 2 hours
Dangers of Inadequate Progress
 Constriction ring
o Develops around a depression in the fetus
o Related to hyperstimulation of the uterus
o Keeps the fetus from descending
 Ring may be felt abdominally & doesn’t move
 Uterus below the ring is often loose and floppy
 Head does not move down at all with contractions
o Uterus becomes tender but will not rupture
o Labor does not progress
o May occur in any stage of labor
Dangers of Inadequate Progress
 Bandl’s retraction ring
 Develops after excessive retraction of the upper segment
 “Hallmark of neglected labor”
 Above the ring is THICK; lower segment below is paper-thin and can rupture
 As the lower segment thins the ring rises
 Generally occurs late in the second stage
Post Term Pregnancy and Predisposition
 Is one that extends more than 294 days or 42 completed weeks past the first day of the last menstrual period.
 Associated with: primiparity, previous postterm pregnancy, placental sulfatase deficiency, fetal anencephaly, male
fetus, maternal obesity, and genetic predisposition
 Sulfatase is a key enzyme of estrogen biosynthesis in the human placenta
Post Term Risks
 Maternal
o Discomforts of pregnancy
o Anxiety & insomnia
o C/S or instrument
o Perineal trauma
o Hemorrhage
 Fetal
o IUGR, SGA, LGA
o Oligohydramnios
o Birth trauma
o CPD
o Meconium aspiration
o Hypoglycemia
Fetal Malpresentation - Face, Brow, Breech & Shoulder; Mal-presentations of the fetus
Mal-Presentations of the Fetus
Persistent Occiput Posterior Position
 The occiput posterior -> > length of labor > back discomforts predisposes
 Vaginal and perineal trauma and lacerations
Malpresentation
A = Flexed (9.5cm)
B = Military (sinciput) (12.5cm)
C. Brow (13.5cm)
D. Face (9.5cm)
Breech
A = Frank breech
B = Incomplete (footling)
C = Complete
D = on vaginal exam may feel anal sphincter
Transverse Lie
Shoulder - Feel the acromion process
Precipitous Labor
 Labor that last less than 3 hours = Unexpected fast delivery
 Etiology
o Lack of resistance of maternal tissue to passage of fetus
o Intense uterine contractions
o Small baby in a favorable position
 Complications: Cervical lacerations
o Uterine rupture
o Fetal hypoxia and intracranial hemorrhage
Precipitous Birth Outside Normal Setting
 Mom is frightened, angry, feels cheated
 Nursing Care:
o Do NOT leave the mother alone
o Try to make the place clean, (don’t break down table)
o Try to get the mother in control -- Have mom pant < push
o Apply gentle pressure to the fetal head as it crowns to prevent rapid change in pressure in the fetal head,
which can cause subdural hemorrhage or dural tears.
o Deliver the baby BETWEEN contractions to control delivery
o Suction or hold baby’s head low place on mom/s abdomen, tie off cord & Allow to breast feed, Document!
Risk Because of Macrosomia
 Maternal Obesity – 2X’s more likely
 > Pregnancy weight gain
 Type 1 or 2 or gestational diabetes → > glucose
 Post term pregnancy, Multiparity or grand multiparity
 Previous macrosomic infant, shoulder dystocia
 Male sex
 Birth: dysfunctional labor patterns, CPD, lacerations, operative birth
 Post partum: hemorrhage & infection
Birth Risks
 Maternal
o CPD
o Dysfunctional labor pattern
o Perineal lacerations
o Extension of episiotomy
o C section or operative birth
 Infant
o Shoulder dystocia: nerve & brachial plexus,
o Erb’s fractured clavicles
o Meconium aspiration
o Asphyxia
o Hypoglycemia
o Polycythemia
o Hyperbilirubinemia
o Obesity (child or later)
Shoulder Dystocia
 Flexing of thighs to abdomen
Management of Nonreassuring Fetal Status
 Recognize pattern changes
o Deep, repetitive variable decelerations
o Prolonged decelerations
o Ongoing late decelerations
o Begin intrauterine resuscitation measures:
o Change maternal position.
o Correct maternal hypotension.
o Discontinue Pitocin.
o Administer medications, i.e. terbutaline to < Uterine activity
 Increase IV fluid rate or begin IV immediately if not already established.
o Assess for prolapsed cord via vaginal exam
o If abnormal patterns resolve, continue with EFM
o If patterns do not resolve and vaginal birth is imminent, proceed as quickly as possible.
o If birth not imminent and bradycardia persists, or if a scalp pH level is < 7.20, perform a C Section
Prolapse of Umbilical Cord
 Umbilical cord passes through the cervical canal ahead or along side of the presenting part
 Etiology: inlet is not occluded, Fetus is not engaged
 Goal: Relieve pressure off the cord– NEVER REPLACE CORD
 TRX: elevate part with sterile gloved hand, trendelenberg or knee chest position
o Give oxygen per mask at 10 Liters
o Have someone else cover exposed cord with sterile wet gauze
o Stay with the patient and offer support
Amniotic Fluid Embolism
 Bolus of amniotic fluid, fetal cells, hair, or other debris → enters maternal circulation → lungs
 80% mortality rate, 1 / 30,000 pregnancies
 Symptoms: shortness of breath, hypoxia, cyanosis, and cardiovascular and respiratory collapse
 Diagnosis is made by symptomology
 TRX: stabilize mom and immediate c section
Uterine Rupture
 Complete separation of the: endometrium, myometrium, and serosa
 Incomplete or partial not all layers, but some, have been disrupted
 Early: initial tearing along previous car
 Late: blood flowing out into the endometrium
Cephalopelvic Disproportion
 Factors
o Fetal size, presentation, and position
o Size and shape of the maternal pelvis
o Quality of the uterine contractions
 Factors prevent fetal descent through the maternal pelvis
 Results: C section
Clues to Contractures of Maternal Pelvis
 Diagonal conjugate inlet <11.5 cm (contracture of inlet); outlet less than 8 cm (contracture of outlet)
 Unengaged fetal head in early labor in primigravidas (?? inlet, malpresentation, or malposition)
 < Uterine contraction pattern (? contracted pelvis)
 Deflexion of fetal head (not flexed on chest;? OCP)
 > Urge push prior complete dilatation of cervix (? OCP)
 < Descent (? contracture of inlet, midpelvis, or outlet)
 Edema of anterior portion (lip) of cervix (obstructed labor at the inlet)
Complications of Third & Fourth Stages of Labor: Retained Placenta, Lacerations
Retained placenta
 Retention of the placenta beyond 30 minutes after birth
 TRX: manual removal of the placenta
 May be r/t attachment of the placenta:
 Plancenta acreta- placental villi extend beyond the endometrium and attach to the superficial aspect of the
myometrium
 Placenta Increta: chorionic villi invade well into the myometrium but not through the entire wall
 Placenta Percreta: villi invade through the myometrium into the serosa
Lacerations
 1ST: laceration: fourchette, perineal skin, and vaginal mucous membrane
 2nd laceration: perineal skin, vaginal mucous membrane, underlying fascia, and muscles of the perineal body;
 3rd: Extends through the perineal skin, vaginal mucous membranes, and perineal body and involves the anal
sphincter & anterior wall rectum
 4th: Similar to the third degree but extends through the rectal mucosa to the lumen of the rectum; it may be called a
third-degree laceration with a rectal wall extension
Welcome to our World
 Non-reassuring fetal status is indicated by persistent late decelerations, persistent severe variable deceleration, and
prolonged decelerations. If fetal stress is recognized and treated appropriately, the fetus may be spared any
permanent damage.
BIRTH RELATED PROCEDURES
Obstetric procedures are sometimes necessary to maintain the safety of the woman and the fetus
External or Cephalic Version
 Pressure applied to head or buttocks → fetus flips backward or rolls forward change from breech, oblique or
transverse to cephalic presentation
Criteria for External Version
 Criteria for
o A single fetus (singleton)
o Fetal breech not engaged
o An adequate amount of amniotic fluid
o Has a reactive NST
o Gestational age = 36 – 37 weeks
 Criteria against
o Suspected IUGR
o Fetal anomalies
o Multiple gestation
o Nuchal cord
o Abnormal FHT
o ROM or oligohydramnios
o Cesarean birth indicated anyway
Podalic or Internal Version
 2nd twin is not in cephalic position -> doctor reaches hand in uterus and turns fetus to a breech position and assists
with birth
Induction and Augmentation of Labor
 Induction of labor is the process of deliberate starting labor artificially
 Augmentation of labor is artificial stimulation of labor that began spontaneously but has progressed abnormally
Complementary Therapies to Stimulate Labor
 Further research is needed to determine the effectiveness of these therapies
o Acupuncture
o Bowel stimulation—castor oil or enema
o Herbal preparations—Black Cohosh, Blue Cohosh, Evening primrose oil, raspberry leaves
o Sexual intercourse
Induction of Labor: Criteria
 Engaged presenting part
 No previous classical C/S incision
 No CPD disproportion
 Reassuring FHR pattern
 No placenta Previa
 No major bleeding from abruptio placentae
Cervical Ripening
 “Ripening”: is the process of physical softening and opening of the cervix in preparation for labor and birth.
o Mechanical cervical ripening
o Prostaglandins PgE2 (Cervidil)
 10 mg embedded in plastic held in mesh & placed in the posterior fornix of the vagina for 12 hours
o Misoprostol (Cytotec) a tablet inserted vaginally
o Luminaria inserted into the cervix
o Foley Bulb: 24-26Fr 30cc balloon (60cc H2O)
 Pharmacological: Exogenous & synthetic oxytocin
 With Cervidil, cytotec, laminaria bedrest X 30 m minutes, then may use BR
 Continuous FHR monitoring for two hours after insertion
 With Foley bulb, catheter is pulled taut and taped to the leg, then OOB is encouraged.
o May intermittently monitor per risk status
 Laminaria and Foley will often fall into the vagina (or out of the body) once cervix effaces/dilates
 Pitocin commonly used the following morning for induction of labor
Interventions: Fetal Distress
 Reposition in lateral recumbent
 Increase IV mainline fluid (LR)
 Apply FSE and assess cervix and station
 Assess for S & S of placental abruption
 Turn Pitocin off
 Administer O2 @ 8-10 L/min via NRB
 Call physician
 Be prepared to administer Brethine
 Prepare for C-S if FHR still no better.
Care of the Woman with Amniotomy
 Advantages
o The contractions elicited are mid
o Free of risk hypertonus or rupture (Pitocin)
o < Intensive monitoring as with Pitocin
o Allows other monitoring (FHT, pressure catheter, enable pH sampling)
o See color & composition of amino fluid
o < $ c/t other methods induction
 Disadvantages
o Risk of infection
o Danger prolapsed cord
o Compression and molding of head
o Fetal injury with amniotic hook
o Bleeding with comps (vasa previa)
o Severe variable d-cels
o May > mom’s pain
Prolapse of Umbilical Cord
 Umbilical cord passes through the cervical canal ahead or along side of the presenting part
 Etiology: inlet is not occluded, Fetus is not engaged
 Goal: Relieve pressure off the cord– NEVER REPLACE CORD
 TRX: elevate part with sterile gloved hand, Trendelenburg or knee chest position
o Give oxygen per mask at 10 Liters
o Have someone else cover exposed cord with sterile wet gauze
o Stay with the patient and offer support
Amnioinfusion
 A technique by which 250 – 500 cc’s of warmed, sterile, normal saline or Ringer's lactate solution is introduced into
the uterus by intrauterine pressure catheter
o > Amniotic fluid to < variable decelerations
o Meconium dilution
Epsiotomy
 Surgical incision of the perineal body
 Better to support the perineum and allow natural healing
Risk for Episiotomy
 Primigravid status
 Large or macrosomic fetus
 Occiput-posterior position
 Use of forceps or vacuum extractor
 Shoulder dystocia
 White race
 Lithotomy Position
 Sustained breath holding during pushing → > stretching → altered blood flow → < responsiveness to own urges
 Arbitrary time limit placed by provider on length of pushing
Forceps Delivery
 Forceps assist the birth of a fetus by providing traction or a means o rotate the fetal head to an acciput-anterior
position
 Full dilation
 Engaged head
 No CPD
 Types: Outlet, Low
o Mid-forceps (rarely used)
 Outlet Forceps
o Fetal skull has reached the perineum. Scalp is visible between contractions
 Low Forceps
o Fetal skull is at +2 station or more
Forceps Delivery: Risks
 Neonate
o Cephalohematoma
o Transient facial paralysis and bruising
o Facial edema
o Cerebral edema
 Mother
o Perineal swelling
o Bruising
o Hematoma
o Hemorrhage
o Postpartum infection
Capput Succadaneum
Trial of Labor or Vaginal Birth after CS
 One previous cesarean birth and a low transverse uterine incision
 An adequate pelvis
 No other uterine scars or previous uterine rupture
 A physician who is able to do a cesarean needs to be available throughout active labor
 In-house anesthesia personnel available for emergency cesarean births if warranted
Risks with Repeat Cesarean Delivery
 Blood loss
 Abnormal placentation
 Surgical injury to bowel or bladder
 Adhesions
 Postsurgical complications
 Longer hospitalization
 Increased cost
 Hysterectomy
FETAL MONITORING
Electronic Fetal Monitoring
 External Contraction Assessment:
 Tocodynamometer (toco for short) placed at the top of the fundus (measures uterine contractions)
 Uterus rises and moves forward during the increment, then reverses with decrement
 Creates typical “hills” on monitor screen and/or paper
 Appearance of the tracing depends on maternal position, weight, parity
Electronic Fetal Monitoring
 External Fetal Assessment:
 Ultrasound transducer detects sound waves
 Prefers the loudest sound
 Affected by position of the fetal heart in relation to the transducer (position the fetal heart monitor by Leopold's
maneuver)
 Also by thickness of maternal abdomen
 Internal Contraction Assessment
 Intra-Uterine Pressure Catheter (IUPC)
 Directly measure pressure exerted by uterus in mmHg
 Can be used for amnioinfusion in removal of thick meconium (not supported in large RCT in 2005) – when baby is
stressed, will pass meconium and to decrease chance of fetal stress we can insert sterile fluid to have the baby
float upon)
 Used for correction of deep variables (not well-supported w/ research)




Internal Fetal Assessment – screw attached to catheter
Fetal scalp Electrode (FSE)
Directly measure fetal heart rate
Used if the mom has too much adipose in her abdomen
Fetal Heart Rate Monitoring
 NST (Non-stress test)
o Fetal monitoring done to identify fetal well-being
o Used anytime fetal movement is decreased
o Used at the end of pregnancy, usually 2-3x per week to monitor reactivity
o Reactive NST: Two accelerations, 15 bpm x 15 seconds in a 20 minute period.
 Prolonged decelerations
 FHR decreases from the baseline for 2-10 minutes
 Can be caused by cord prolapse or maternal hypotension (with regional anesthesia)
 If baseline becomes tachycardic, indicates hypoxia and stress
 Bradycardia: Below 110 bpm
 Moderate bradycardia from 81-110 bpm
 Severe bradycardia less than 80 bpm for 2-3 minutes
 Causes to consider
o Maternal hypotension (common with epidural)
o Late (profound) fetal asphyxia
o Prolonged umbilical cord compression (if laying on the cord you need to change positions to get them off)
o Fetal arrhythmia
 Tachycardia: above 160 bpm
 Mild: 161-180 bpm
 Severe: 181 bpm or greater
 Causes to consider:
o Maternal fever
o Dehydration
o Betasympathomimetic drugs (e.g. terbutaline)
o Early fetal hypoxia
o Maternal hyperthyroidism
o Fetal arrhythmia
o Fetal anemia
 Variability
o Measure of the interplay of the sympathetic and parasympathetic nervous systems
o Assessed as a sign of fetal well-being
o Larger rhythmic fluctuations of FHR (jiggly line)
o Occur 3-5 times per minute
o Normal range of 6-10 bpm
o Increases w/movement; decreases with sleep
 Classifications
o Decreased 0-5 bpm
o Average/moderate 6-25 bpm
o Marked/saltatory 25 bpm+
How Often To Monitor?
 Maternal Temperature, RR
 Intact/not ruptured: q4h
 Ruptured: q2h
 Maternal BP, P
 Early labor low risk: q1h; active/transition: q30”; pushing: q15”; epidural q15” for the first hour
How Often To Monitor? Fetal Heart Tones & Contractions
 Low Risk
o Early labor q60”
o Active & transition q30”
o Pushing q15”
 High Risk
o Early labor q30”
o Active & transition q15”
o Pushing q5”
LABOR AN DELIVERY VARIATIONS - CESAREAN BIRTH
Preparation
 Basically, 3 types of C/S situations:
 Scheduled (previous cesarean or scheduled – pelvis disproportion)
o Come in 2 hours early for admission
o Time at home to emotionally begin to grieve, adjust
o May also be desired, planned repeat or primary C/S
o Listen to assess mother’s emotional state
o If prior C/S was stressful, she may need to talk about it; let her do so
 Unscheduled, non-emergent

o Already admitted; 30 minutes to prepare further
o Usually FTD/FTP without any non-reassuring fetal heart tones; SROM but no labor
o Many mothers are exhausted and relieved birth will occur
o Some grief may be felt or expressed over loss of vaginal birth
o Lots of praise for her efforts; acknowledgment of grief & loss helps
Unscheduled, emergency
o Uterine rupture, abruption, severe fetal distress (brady or tachycardia); previa w/ labor & bleeding
o Any free staff rush in
o Preparation ASAP!
o Keep woman and partner apprised of what you do, but really no time to explain why
o Goal is often <5 minutes from decision to cut
Mrs. M
 Mrs. M. is a 27-y/o gravida 3, para 2, who was admitted at term at 6:30 p.m. She stated that she had been having
contractions at 7 to 10 minute intervals since 4 p.m. They lasted 30 seconds. She also stated that she had been
having "a lot of false labor" and hoped that this was "the real thing". Her membranes were intact. Mrs. M.'s
temperature was 99.1, pulse 90, respirations 22bpm and her blood pressure was 124/80. The fetal heart tones were
134 and regular. The nurse examined Mrs. M. and found that the baby's head was at -3 station, and the cervix was
3 cm. dilated and 80 percent effaced. Upon assessment it was recognize that Baby M was in a transverse
presentation.
 Mrs. M is anxious about her baby
o What effect can the psyche have on labor? Can cause stress hormones to be formed and can impede labor
itself
o Attempted version of the fetus and change of maternal positioning to assist with realignment of the fetus.
The attempts appeared to be making a difference
 1 hour later
o One hour later the pattern below was apparent on the FHR monitor.
o What your interpretation of this strip? Variability is very marked, distressed
o What is indicated? Support baby, change moms position, late decelerations – give oxygen
o Soon thereafter the FHR decreased to 100 bpm

Emergency
o It was determined that baby M was in severe distress and stat c section procedure was instituted.
Preparation
 Informed consent signed
 Call anesthesia and any consults
 Start 18 gauge IV and draw labs, type and hold/screen or cross-match 2 units of blood if ordered
 Monitor FHR for > 20 mins for reactivity
 Prehydrate with 1,000 mL LR (lactated ringers)
 Use clippers to remove hair at top of the pubic hair line as necessary – decreases risk of infection
 Administer antacid (Bicitra 30 ml PO) and Reglan IV or as ordered – alter pH so it does not cause damage in
esophagus if she aspirates
 Get scrubs for support person
 Walk patient or transfer to OR
 Position on table sitting for spinal or tilted if epidural in place and level being raised – spinal is quicker than
epidermal COULD go up to lungs and cause respiratory distress and a spinal headache after deliver (give blood
patch)
 Insert Foley once patient is numb
 Cautery grounding pad to thigh, wire unrolled and off OR table
 Arms on boards; may cover with drape and secure with wide tape PRN
 Count instruments with scrub nurse/tech
Types of Incisions
 Pfannenstiel (skin) - the skin and subcutaneous tissue are incised using a lower transverse, slightly curvilinear
incision.
 Kerr (uterine) - lower segment transverse
o Area less likely to rupture – if vaginal birth is after
o Least morbid & most common
o 1% risk of rupture with VBAC
 Selheim (uterine) - vertical incision in lower uterine segment
o Can VBAC - vaginal birth after cesarean
 Classical (uterine) - vertical through fundus
o Cannot VBAC (6% risk of rupture)
o Skin scar does NOT = uterine incision type
Cesarean section
 Benefits for mom:
o Ability to plan day and time of delivery
o For mothers unable to tolerate stress of labor, safer delivery (i.e. congenital heart disease)
o For mothers who want a PPTL, a single surgery
 Risks for mom:
o Hemorrhage
o Blood clots
o Bowel obstruction
o Longer-lasting and more severe pain
o Infection
o Internal scars / adhesions
 Increase risk for ongoing pelvic pain and for twisted bowel.
o Longer initial hospital stay
o Higher risk for re-hospitalization – heavier weight can have risk of dehiscence of the incision
o Injury to bowels, bladder, other structures
o Less early contact with her baby
o Future babies more likely to be stillborn
 Future reproductive risks for mom:
o Ectopic pregnancy
o Reduced fertility – manipulated inside of uterus and may not attach as well
o Placenta previa
o Placenta accreta
o Placental abruption
o Rupture of the uterus
 Benefits for baby:
o More rapid and controlled delivery for babies stressed or at risk
o For sick or high-risk deliveries, ability to plan for presence of NICU or other support staff
 Risks for baby:
o Baby may be cut during the surgery (usually minor)
o Baby may have breathing difficulties around the time of birth – chest squeezed when going through birth
canal and secretions are pushed out
o More likely to experience asthma in childhood and in adulthood.
o Babies who were born by cesarean are less likely to be breastfed
ANTEPARTAL SCREENING AND DIAGNOSTIC TESTS
Common Maternal Conditions Indicating Need For Antepartal Tests
 Preexisting Medical Conditions
o HTN
o Renal Disease
o Pulmonary or Cardiac Disease
o Autoimmune Disease
o Type 1 Diabetes
 Pregnancy Related
o PIH – pregnancy induced hypertension (Can cause preeclampsia)
o Decreased Fetal Movement
o Hydramnios, oligohydramnios, polyhydramnios
 Fetal Conditions
o IUGR
o Multiple gestations
o Post-term Pregnancy
o Previous unexplained fetal demise
o Rh Isoimmunization
o Fetal Anomalies
 In General antepartum fetal surveillance has been used in pregnancies in which the risk of antepartum fetal demies
is increased.
Nurses’ Role in Antepartal Tests
 Assessing Risk Factors
 Knowledge and understanding the test(s) and why they are conducted
 Provide information regarding the test(s)
 Provide comfort, reassurance and psychological support to woman and her partner – no false hope
 Document woman’s response and results of test(s)
 Perform certain test(s)
o Non-stress test (NST) and Limited Ultrasound (extra training)
 Many women who have these test(s) are at high risk for maternal/fetal complications, so one can assume that most
women and their partners are anxious and vulnerable. So the nurse can play a key role in alleviating these feelings
by everything we talked about.
o If you explain the test and why its done can help many women be at ease along with using compassion,
reassurance (do not give false hope) and just support her feelings (if she's crying, let her cry, listen!).
Assessment of Risk Factors
 Biophysical factors – arising from the mom
o Genetic, nutritional, medical (diabetes, PIH) & OB
o Originate from mother/fetus and impact developmental function of mother/fetus
 Psychosocial factors
o Maternal behaviors and lifestyle
 Smoking, caffeine (max 200 mg a day), alcohol, depression (might not bond with the baby)
 Socio-demographic factors
o Access to care, age, parity, marital/support, ethnicity (African American woman are at risk for sickle cell and
other hemoglobin problems), financial status
 Environmental factors
o Workplace, chemicals, pollutants, radiation
Biophysical Assessments – Ultrasound, Doppler Velocimetry, Magnetic Resonance Imaging (MRI)

Meaning of the fetus…tie this category together of thinking “how can I see/assess the fetus or physical aspects of
the fetus”
Ultrasonography (US)
 Screening or Diagnostic
 High frequency sound waves produce an image of tissue, organ, bone, air (based on density).
 Methods: Most Common test done in pregnancy
o Transvaginal (1st trimester)
 Lithotomy position and a sterile covered probed is inserted through the vagina. Since the uterus is
not above the pubic bone at this point, this type of ultrasound gives a better visualization of the
early gestational sac/fetus along with cervix, uterus and ovaries.
o Transabdominal – later in pregnancy
 Supine Position: Best with a full bladder due to it pushes the uterus more towards the abdomen.
Uses gel with a transducer on top of the abdomen.
 Indications: Varies per trimester
 Advantages:
o Non-invasive
o 3D/4D allow for complex visualization of fetal movements, facial features, and placenta vessels
 Indication: Fetal malformations (brain, skeletal, facial).
 Risks: None
US Measurements during Pregnancy
 1st Trimester Milestones (most accurate dating)
o Yolk sac (5-6 wks.)
o Cardiac Activity (6-7 wks.)
o Fetal Breathing (11 wks.)
o Best for gestational dating (with error of +/- 3-5 days) after 12 weeks
gestation the Accuracy decreases
 Dating Terms
o CRL (crown-rump length)(<12 wks.) - used for gestational
age/dating (up to 12 weeks then accuracy decreases) and why that
is, is because baby starts outgrowing its surrounding and starts to
curve or go into “fetal position”
o BPD (biparietal diameter)(12-30 wks.) - dating after 12 weeks is
about +/- 7-10 days accuracy
o FL (Femur Length) (12-30 wks.) - if the BPD is hard to obtain
 OTHER:
o Cervical Length (Normal 3-5 cm) - important in situations that a
physician could predict the need for a cerclage or know to monitor.
3cm-5 cm in length is normal… < 2.5 cm = monitoring
o AFI (Amniotic Fluid Index)
o NT (Nucchal Translucency)
Umbilical Artery Doppler Flow (Doppler Velocimetry)
 Screening
o Rate and volume of blood flow between the placenta and
umbilical vessels
o Used in Adjunct to US
 Indication:
o IUGR, HTN/Pre-eclampsia, Fetal cardiac anomaly
 Advantages:
o Non-invasive
 Risks: None
 Looks at blood flow changes in maternal-fetal circulation in order to
assess placental function.
 US beam is directed at the umbilical artery and the signal is reflected off the RBCs moving within the vessels,
thereby enabling a “waveform-like picture”.
 Highest peak is systolic and lowest is diastolic
 S/D ratio (decreases near term fetus) - this phenomenon reflects the decreasing resistance of placental and
umbilical vasculature to allow for greater umbilical flow to meet the needs of the growing fetus.
 What does it mean: Looks at both Systolic and Diastolic flow through the umbilical artery. If there is a decrease in
cardiac activity or increase in placental resistance it decreases the actual amount of blood getting to the fetus.
Magnetic Resonance Imaging (MRI)
 Diagnostic
o Detailed radiological evaluation maternal/fetal tissues, organs, and placenta when abnormalities are
suspected.
o Interpretation done by radiologist
 Indications:
o Abnormal US of suspected anatomical malformations or placental accreta
 Advantages:
o Non-invasive
o More detailed evaluation of fetal brain, GI, GU systems and placenta
 Risks: None
Maternal Assays - Triple Marker Screen, Quad Screen
Maternal Serum Alpha-Fetoprotein (MSAFP)
 Screening
o Alpha-fetoprotein (AFP)- fetal glycoprotein secreted from fetal yolk sac, GI and liver
 Procedure: blood test drawn @ 15-20 wks. Gestation detects neural tube defects (NTD) and abdominal wall
defects.
 Indications: Recommended routine screening (Due to 95% of NTDs occur in the absence of risk factors)
 Interpretation:
o Increased Levels: NTDs, anencephaly, omphalocele, gastroschesis
o Decreased Levels: Trisomy 21
 Advantages: 80-85% NTD or abdominal defect & 90% anencephalies can be detected in early pregnancy.
 Risks: High false positive rate -> anxiety
 QUESTION: HOW DO WE PREVENT NTD during pregnancy? FOLIC ACID (0.4 mg) at least.
 Positive: Additional testing is required (CVS and Amniocentesis).
Multiple Marker Screening
 Screening
o Blood test that combines multiple hormones and proteins along with maternal age & ethnicity to detect
Trisomy 13, 18, 21, and NTDs
 Triple Marker
o Alpha-fetoprotein (AFP)
o Human chorionic gonadotropin (hCG)
o Estriol levels
 Quad Screen
o Alpha-fetoprotein (AFP)
o Human chorionic gonadotropin (hCG)
o Estriol levels
o Inhibin-A (increases detection of Trisomy 21 to 80%)
 Procedure: blood test drawn @ 15-22 wks. (15-16 wks. Most accurate)
 Indication: offered to all pregnant women
 Interpretation:
o Increased hCG and inhibin-A = levels 2x as high in Trisomy 21
o Increased AFP Levels = NTDs, anencephaly, omphalocele, gastroschesis
 Advantages: 60-80% Trisomy 21 identified (after a diagnostic test); 85-90% open NTDs detected
 Risks: None (high false positive rate, anxiety)
 Next Step: Amniocentesis
Nuchal Translucency (“First Trimester Screening”)
 Assess the accumulation of fluid between spine and neck
 Procedure: Combination US and maternal serum test @ 10wks. - 13wks.
o Pregnancy associated plasma protein –a (PAPP-A)
o Free beta-hCG
 Indication: Offered to all pregnant women
 Interpretation:
o Increased amt. of fluid = risk abnormalities, genetic
syndromes, birth defects, poor pregnancy outcomes.
o > 3mm fold = increased risk of Trisomy 21
 Advantage:
o Earlier than maternal assays.
o 82-87% accuracy detecting Trisomy 21
 Risk: None
 Next Step: CVS or Amniocentesis
Biochemical Assessments - Chorionic villus sampling (CVS), Amniocentesis, Percutaneous Umbilical Blood Sampling
(PUBS)
 Involves biological examination and chemical determination
 Conditions that can be diagnosed prenatally include Trisomy 21 (Down Syndrome), 18 & 13 (not compatible with life),
spina bifida and anencephaly, cystic fibrosis and some familial conditions.
Chorionic Villus Sampling (CVS)
 Diagnostic
 Procedure: US and Transcervical or Transabdominal
 Aspiration small amt. of placental tissue (chorion) for chromosomal,
metabolic and DNA testing between 10-13 weeks.
 Indication:
o Detects Fetal Abnormalities
o (DOES NOT DETECT NEURO TUBE DEFECTS)
 High risk mothers (i.e. > 35 yrs., HX: familial or
previous fetus w/ genetic disorders, positive/? 1st
trimester screen)
 Advantages:
o > 99% accuracy
 Risks:
o 7% chance of fetal loss due to bleeding, infection or rupture of membranes (ROM)
o 32% % chance of vaginal bleeding or spotting
Amniocentesis
 Diagnostic
o Used to obtain amniotic fluid and fetal cells for genetic testing, fetal lung maturity (FLM), assessment of
hemolytic disease in fetus or intrauterine infection
 Procedure:
o Adjunct with US
o Needle through abdominal wall -> uterine cavity ->
obtain amniotic fluid
 Indication:
o Maternal age > 35 yrs., hx: familial or previous fetus w/
genetic disorder, positive maternal assay test,
o > 20 weeks (FLM)
 Advantages:
o > 99% accuracy
 Risks:
o <1% fetal loss after 15 wks. (2-5% risk before 15 wks.)
o Placental or Fetal Trauma
o Bleeding
o Maternal Infection
o PTL/ROM
Percutaneous Umbilical Blood Sampling (PUBS)
 Diagnostic
o Fetal blood tested for metabolic, hematologic disorders, fetal infection, & DNA > 20 Weeks
 Procedure:
o Adjunct with US
o Needle inserted into umbilical vein or near placental origin -> small fetal blood sample obtained
 Indication:
o Rarely needed but may be useful after (+) CVS/Amniocentesis
o Fetal transfusion (additional use)
 Advantages:
o Results within 18-24 hours
 Risks:
o 1.4 % fetal loss
o Cord vessel bleeding or hematomas
o Maternal-fetal hemorrhage
o Infection
Screening Tests for Fetal Well-Being - Fetal Kick Count, Non-Stress Test (NST), Vibroacustic, Stimulation (VAS),
Contraction Stress Test (CST), Amniotic Fluid Index (AFI), Biophysical Profile (BPP)
 GOAL: reduce the number of preventable stillbirths
 In most pregnancies these tests start around 32 weeks gestation
 What do they mean/say about fetal well-being is: FETAL DEATH is HIGHLY unlikely in the next 7 days/week.
Fetal Kick Counts
 Procedure: maternal feeling of fetal movements (internal/palpate abdomen) @ roughly same time daily after 28
wks.
o No “set” protocols in place
 Indication: suggested to all pregnant women > 28 wks.
 Interpretation: Normal
o 10 distinct movements in 2 hours
 Decrease or No Movement:
o Lie on left side, eat, drink & try again
o No movement in 24 hours = OB office or L&D

Some controversy over if this causes more anxiety in pregnant women and if it is really effective at screening for
fetal hypoxia and/or preventing stillbirth
Non-Stress Test (NST) - Monitors fetal heart rate in response to fetal activity.
 Procedure:
o Semi-fowler or side-lying position, w/ 1 transducer at fundus (Contractions) and 1 over fetus (FHR). Mother
given “clicker” to note fetal movements for 20 mins (up to 40 mins).
o Done once to 3 times/week
 Indication:
o Decreased fetal movement, HTN, Diabetes (type I, II, gestational), postdates, bleeding, multiple gestations,
etc.
 Interpretation:
o Reactive: (> 32 wks.) FHR increases 15 bpm for 15 sec x2 in 20 min.
 < 32 wks. FHR increases 10 bpm for 10 sec x2 in 20 min.
o Non-reactive: Lack of significant elevation over 40 min.
 Expected is FHR to increase with fetal activity
 It is assessing mainly for fetal oxygenation status or hypoxia. The normal HR of a fetus with adequate oxygenation
and intact autonomic nervous system accelerates in response to movement.
 These conditions can lead to a decline in uteroplacental functioning which decreases O2 to the fetus thereby
leading to fetal hypoxia/still birth.
Vibroacoustic Stimulation (VAS)
 Procedure: use of an auditory stimulator to startle the fetus when NST not-reactive after 20 mins
o Applied for 1-2 sec, may be repeated up to 3 times at 1 min intervals for 3 sec.
 Indications: Non-reactive NST after 20 min.
 Interpretation: Same as NST
Contraction Stress Test (CST) - Monitors FHR in response to spontaneous or stimulated uterine contractions and if the fetus
can withstand the stress of labor.
 Procedure:
o Induce contractions w/ nipple stimulation or
IV oxytocin (Pitocin) while on EFM over 10
mins.
o Adequate contractions: at least 3, lasting 40
sec in 10 min.
 Indications: IUGR, Diabetes, Post-Dates (> 42 wks.),
abnormal BPP, Non-reactive NST.
 Interpretation:
o Negative: No late or significant decelerations
o Positive: Late Decelerations noted 50% or
more w/ contractions
o Equivocal-Suspicious: variable or intermittent
decelerations
 During contractions, intrauterine pressure increases, blood flow is then reduced temporarily thereby reducing the
O2 to the fetus. A healthy fetus tolerates this well. If insufficient O2 or fetus is sub optimally oxygenated, fetal
hypoxia occurs during contractions and decreases fetal
heartrate (Late Deceleleration)
Amniotic Fluid Index (AFI) - Measures the volume of amniotic fluid
with US to assess fetal well being & placental function.
 Procedure: US measures 4 fluid-filled quadrants of uterus
 Indication: SGA, HTN, PIH, Diabetes, Placental insufficiency
 Interpretation:
o Average: 8-24 cm
o Oligohydramnios: AFI < 5 cm
 Placental insufficiency, poor maternal diet & dehydration
o Polyhydramnios: AFI > 24 cm
 Diabetes, NTD, fetal malformations including:
 GI (< swallowing), Hydrops, Renal (< process)
 Amniotic fluid is based on fetal urine production that is dependent on fetal renal profusion. If prolonged fetal
hypoxemia has occurred, blood is shunted away from the fetal kidneys thereby decreases urine production =
decrease in amniotic fluid
Biophysical Profile - Evaluation of fetal status through US observation of
various fetal reflex activities.
 Procedure: Combines NST and US exam
o Scoring:
o 2 pts: Reactive NST
o 2 pts Each:
 Fetal breathing
 Fetal Movement
 Fetal Tone
 AFI
 Indication: Diabetes, HTN, Decreased FM, IUGR, postdates,
PROM, pre-term labor (PTL)
MATERNAL PHYSIOLOGY
Pregnancy: System by System
Hormones of Pregnancy
 Estrogen
o Secreted: Ovaries -> Corpus Luteum -> Placenta
o Stimulates suitable uterine environment
o Develops mammary, ductal tissue and increase prolactin
o Estrogen increases rapidly early in pregnancy, slow between 24 and 32 weeks, and then increases until
term.
o Increases blood flow to the uterus through vasodilatation
o Changes the sensitivity of the respiratory system to carbon dioxide
o Softens the cervix, initiating uterine activity and maintaining labor
o Breasts development (hyperplasia and hypertrophy)
 Progesterone
o Secreted: Corpus Luteum (first 5 weeks) -> Placenta
o Maintains uterine environment
o Relaxes smooth muscle (GI, Uterine, Urinary – enlarges ureters and increases bladder capacity)
o Breast – Lobules and acini (prepares breast for lactaction)
 Human Chorionic Gonadotropin (hCG)
o Secreted: Produced 1st by trophoblast (surrounding the tissue)/then chorionic villi (Placenta)
o Pregnancy hormone
o Detectable approx. 7 days in maternal serum/10 days in urine
o Maintains corpus luteum
o It maintains the function of the corpus luteum until the placenta takes over
o The main function of HCG is to maintain the corpus luteum in early pregnancy by producing progesterone.
It doubles every 2 days.
 Human Placental Lactogen (hPL)
o Secreted: Placenta
o
o
o
o
o
o
o

Decrease maternal glucose metabolism
Increase maternal circulating free fatty acids
Insulin antagonist
More for metabolic/glucose needs for the mom
Begins soon after implantation; levels gradually rise and peak at 36 weeks.
Involved in the process of making adequate glucose available for the fetus.
HPL lowers the sensitivity of maternal cells to the action of insulin and improves the ability of the body to
metabolize and use fatty acids for energy. Needed for fetal development
Relaxin
o Secreted: Placenta
o Inhibits uterine activity, diminishes contraction strength
o Softens cervix
o Aids in remodeling collagen (pelvic structure)
o Helps widen our pelvic girdle
 Prolactin
o Secreted: Anterior pituitary
o Lactation Hormone
Endocrine System
 Female Pituitary:
o Decreased LH and FSH (don’t need anymore eggs so our period stops
 Thyroid:
o Thyroid hypertrophy & Increased BMR
 Pancreas
o Increased need for glucose and insulin
o Decreased tissue sensitivity to insulin
 Due to: human Placental Lactogen (hPL)
 Adrenal glands
o Increased aldosterone
 Decrease sodium excretion
Metabolism
 Basal Metabolic Rate increases 10-20%
o Kcal (77,000 kcal/pregnancy)
 Approx. 90 kcal - 1st, 250 kcal – 2nd, 475 – 3rd
 Water
o Increase in water retention (6.5L)
o Not getting rid sodium
 Carbohydrates
o Diabetogenic effect
 Reduced tissue response to insulin, hyperinsulinemia and hyperglycemia
 Maternal response to glucose load is blunted -> postprandial hyperglycemia
 Fetus -> constant drain of glucose -> maternal hypoglycemia (fasting)
 Fats
o Lipolysis = Increase in cholesterol, lipids, triglycerides
Immune System
 Myth: Pregnant woman are immunocompromised
o Mor & Cardenas (2010) believe that is the growing fetuses active immune system modifies the way a
mother responds to environmental factors. In turn this modulation leads to different responses depending
microorganisms and stage of pregnancy.
 Fact:
o Maternal immune system not altered
o Key to successful fetal allograft seems to be the placenta
o Not fully understood
Neurological System
 Compression of nerves
o Muscle Cramps, Restless Legs
 Sensory Changes
o Paresthesia of extremities, Bell’s Palsy
 Carpal tunnel syndrome
 Tension headaches
 Ophthalmic
o Increase in cornea thickness r/t fluid retention
o Decrease in intraocular pressure
 Blurred Vision
Headaches
 Causes
o May be due to changes in:
 Blood volume
 Hormones
 Vascular tone
 Emotions
 Lack of Sleep
 Bad headache in 3rd trimester that does not go away it can be an indicator of hypertension
 Relief Measures
o Change posture slowly
o Darkened room
o Rest/Relax
o Eating a small snack
o Medication: Avoid ASA/NSAIDS; acetaminophen is recommended
Sleeplessness
 Causes
o May be due to:
 Hormones
 Worry/Anxiety
 Discomforts = going to the bathroom all the time, heartburn, restless legs
o Leads to:
 Maternal exhaustion
 Mood changes
 Inability for body to recover from daily stressors.
 Relief Measures
o Warm milk
o Yoga, Tai Chi
o Relaxation tapes.
o Sleep hygiene: regular time, breathing exercises, low-key activities such as reading.
o Keep away from phones or tablets
 Avoid OTC drugs, alcohol, etc.
Fatigue
 Causes
o Usually starts very early in pregnancy.
o Unrelieved by rest
o May be due to hormonal changes.
o Most women are “Wonder Woman”. (try to do everything they can, go to work, school, take care of the
family)

Relief Measures
o Frequent rest periods
o Exercise regularly (walking, swimming, etc.)
o Usually corrects itself during 2nd trimester.
o Check blood count (risk for anemia), eat healthy foods
Integumentary System
 Striae Gravidarum (stretch marks)
o “Silvery” or reddish – slightly depressed streaks
o Relief Measures
 Maintain skin comfort: lotions, oatmeal baths, non-bonding clothes
 Encourage good weight control
o Can also be found of breast and thighs
 Hyperpigmentation:
o Chloasma
o Darkening of areola, vulva, & linea nigra
o Make sure to still use sunscreen
 Increased:
o “Spider” Angioma (Nevi) – popped blood vessels, nothing
to be concerned of, they go away
o Facial flushing/hot flashes
o Sweating
o Oily skin & Acne
o Nice hair – pregnancy hormones stop the hair cycles so
the hair stops falling out
 Softening of fingernails
 Hair follicles – anagen phase vs. telogen phase.
Cardiovascular System
 Circulatory
o Body water increases 6-8 liters
o Blood volume increases by 1600 mL
o RBCs increase 20% - increased need for iron
o Plasma volume increases 45-50%
 3x greater then RBCs (dilution) = low Hgb
 Physiologic anemia of pregnancy (RBCs cannot keep up with the amount of plasma)
 Hematologic
o Decrease:
 Hemoglobin (<11 mg/dl – anemia)
 Hematocrit (normal for pregnant women - 31.9 to 36.5%)
 Fibrinolysis (prone to clots)
o Increase:
 Fibrinogen (30-50%)
 Coagulation Factors (VII-X)
 WBC (<15,000) – normal for pregnancy
Iron Deficiency Anemia
 Iron requirements increase
o Blood expansion, RBC mass, fetus, placenta & anticipated blood loss
 Iron = Hgb formation = O2 binding
 Poor maternal diet in iron rich foods & iron absorption enhancers.
 Lab values
o Hgb: <10.5
o Hct: < 32%
o Severe: Hbg < 6
o Average hemoglobin is 12 mg/dl with a mean hematocrit of 33.8%. Anything below 10.5 mg/dl is a sign of
iron deficient anemia (2nd trimester).
 S/S
o Fatigue
o Pale
o headaches
 Relief Measures:
o Prenatal Vitamins
o Iron Rich Foods: spinach, red meat, kale, liver, leafy vegetables
o Iron Supplements (TID) w/ Vitamin C
Cardiovascular System
 Heart
o Heart pushed left and upward
 PMI @ 4 ICS
 Systolic ejection murmur (90% of pregnant women)
o Stroke volume increases 20-30%
o Cardiac output increases 40-50%
 Cardiac output: 6-7 liters/min vs. 3-5 l/m
o Heart Rate increases 15-20 bpm
 Vascular
o Systemic Vascular Resistance
 Decreases 20%
o Pulmonary vascular Resistance
 Down 34%
o Arterial blood pressure:
 Decreased 1st-2nd trimesters
 Back to normal by term
o Femoral Venous pressure:
 Slowly rises
 Increases tendency for blood stasis causing, edema, varicose veins of legs, vulva, rectum and
postural hypotension (feel faint when going from squatting to standing position)
 90% of women have a systolic heart murmur at 20 weeks. Disappears after delivery. Diastolic murmurs are rare.
 Increase in cardiac output and the slight decrease in mean arterial pressure results in a decrease in the systemic
vascular resistance or total circulatory resistance. Hormones cause smooth muscle to relax, vessels to dilate,
allowing the body to accommodate the increased blood volume without pressure changes.
Common Discomfort: Hypotension
 Postural Hypotension (Faintness)
o Symptoms of Faintness: hypotension, fainting, dizziness, pallor
o Rise slowly from supine/sitting
o Avoid locking knees & standing still
o Lie on left side
 Vena Cava Syndrome
o Uterus puts pressure on the VC when supine – due to woman lying on her back
o Decreases blood return to the heart
o Results in:
 Hypotension
 Fainting
 Dizziness
 Pallor
o Keep woman on her side or upright
Common Discomfort: Edema
 Dependent Edema and Varicosities
o Wear loose clothing
o Maternity girdle: decrease venous pressure and increase circulation
o Dorsiflexion of feet when prolonged sitting/standing
 Contracts muscles and squeezes fluid back into circulation
o Avoid crossing legs
o Wear support hose (prescription)
o Elevate legs at least 3x daily
Respiratory System
 Diaphragm elevates 4 cm – harder for them to catch their breath
 Transverse & AP diameter increases 2 cm
 Oxygen consumption increases 15-25%
 Tidal volume increases 50%
 Respiratory rate increases slightly
 Increased vascularity entire upper tract
o Nasal stuffiness (due to vascular changes), congestion
o Increase Epistaxis
Respiratory
 Dysnpea (common in pregnancy)
o Encourage good posture
o Instruct to stand and stretch, taking a deep breath during day and night
o Sleep in semi-sitting position with additional aids for support
o Warning Signs:
 Flu-like symptoms – fever, N/V, coughing up mucous, night sweats
 Productive cough
 Chest pain, SOB, diaphoresis, palpitations
 Anxiety
o Can still be a sign of respiratory or cardiac illness, should be assessed
 Nasal Congestion and Epistaxis
o Cool mist humidifier
o Saline nasal spray
Breasts
 Increased Size (hypertrophy (increase in size)/hyperplasia (changes in cells))
 Increased Fat deposits (lactation)
 Increased Vascularity (veins)
 Increased Pigmentation areola/striae
 Increased Montgomery’s tubercles – sebaceous glands that keep the nipple supple (without them they would look

like “cow nipples”
Increased Colostrum from 16th wk. - most fats, nutrients, first milk before the actual bulk milk is made, good
moisturizer for the nipples
Breast
 Breast enlargement
o Upper back pain
 Tenderness, nipple sensitivity
o Loose clothing, avoid contact with nipple
 Relief measures:
o Well fitting supportive bra
o Massage, Heat
o Good body mechanics & exercises to improve posture
o 3rd trimester leaking = soft cotton breast pads
Gastrointestinal System
 Mouth:
o Ptyalism: Salivary glands more active – swallowing more, have them suck on hard candy or chew gum)
o Increased vascularity of gums and mucus membranes
o Can also get gingivitis
 Hepatic:
o Function of gallbladder and liver slower
 Increased risk of gallstones
 Generalized pruritus (hands & feet most common)
 Increased serum bile and cholestasis
Gastrointestinal System
 Stomach – Intestines:
 Delayed gastric emptying
 Decreased motility and tone in stomach and intestines
o Due to: Progesterone
o Constipation & hemorrhoids
 Relaxation of cardiac sphincter
o Contributes to reflux and heartburn
 Altered tastes & cravings
o PICA – eating food with no nutritional value (ice, clay, dirt)
 Increased appetite (esp. 2nd trimester)
Common Discomfort: “Morning Sickness”
 Can occur anytime during the day
o Begins 4 to 8 wks. – Ends 14-16 wks. gestation
o Consist of nausea, vomiting or both
o Occurs in 70-85% pregnant women
 Theories:
o Due to increased: hCG (best theory, introducing brand new hormones, stabilizes during 2 nd trimester) and
progesterone (things are slower and they overeat).
o Functional changes in GI, emotional, & carbohydrate metabolism.
 Hyperemesis gravidarum
o Excessive N/V (after 1st trimester)
o Leads dehydration, weight loss, impaired electrolytes and nutrition status
o May require hospitalization (need IV fluids)
Relief Measures
 Medications
o Pyridoxine and Doxylamine (Diclegis – safest to give)
o Ondansetron (Zofran)
o Promethazine (Phenergan)
 Lifestyle Changes
o Eat crackers or dry toast before arising
o Avoid strong smells/odors
o Eat small frequent meals
o Drink liquids between meals
 Alternative Therapies
o Acupressure to wrist
o Ginger (ginger ale, tea, lollipops)
o Pyridoxine (Vitamin B6) Alone
Common Discomfort: Heartburn
 Causes
o Backflow of stomach contents in esophagus
 Effects 70% of pregnant women
 Relief Measures
o Medications:
 Antacids
o Lifestyle Changes
 Papaya (enzyme helps with digestive issues) or pineapple
 Ginger
 Peppermint (tea) – calming to the stomach
 Small frequent meals
 Elevate HOB
 Avoid eating fatty, spicy foods and prior to sleep
Common Discomfort: Constipation
 Causes
o Increase transit time
o Increase water absorption
o Decreased bulk
o Prevention
 Increase in fiber
 Prunes, dried fruits, raw vegetables, whole grains, bran cereals.
 Increase fluid intake
 Warm liquids in AM
 Exercise
 Medications
o Fiber Therapy
 Metemucil
o Stool Softeners
 Docusate sodium
o Stimulants
 Senokot
 Milk of Magnesia
Common Discomfort: Hemorrhoids
 Aggravating Factors
 Dilated veins in the lower rectum
 Increase venous pressure
 Straining
 Low fiber diet
 Medications: Iron supplements, Stool Softeners, Enemas
o S/S: itching, burning, pain & bleeding

Relief Measures
o Warm Sitz Baths
o Increase fiber in diet
o Avoid straining and prolong sitting on the toilet.
o Medications:
 Witch Hazel Pads (Tucks)
 Preparation H
Ovaries
 Ovum Production Ceases
o Decrease of FSH & LH
 Corpus Luteum
o Developed inside ovary
o Maintained by: hCG
o Secretes Progesterone - maintain uterine lining
 Increase Estrogen & progesterone
o Produced by the ovaries for 8 to 10 wks until placenta takes over.
 30% have spotting first trimester – implantation bleed
 Bleeding during pregnancy is never normal except for implantation spotting. Some women will have spotting
associated with implantation and mistake it for a period.
Uterus
 Enlargement (hypertrophy & hyperplasia)
o 2 oz. (pear-shaped) to 2 lbs. (size of a watermelon).
o Starts out the size of a fist. Enlarges to a size capable of holding a volume of 5 to 10 liters.
o Thinning of muscle wall after 3 months (reason you can palpate fetal parts closer to term)
o Alters placement of lungs, GI system and ribcage.
o Initially, the myometrial cells enlarge (hypertrophy)
o Then hyperplasia occurs - increase in the number of cells.
o Due to hormonal influences seen even in ectopic pregnancies, the uterus enlarges during the first 8 weeks.
 Development of decidua (endometrium lining where the placenta is)
o Estrogen & Progesterone influenced
 Changes in consistency
o Goodell’s Sign – cervix is softer (spongy)
o Hegar’s Sign – softening of the cervical isthmus
o Ballotment – hit the baby and feel it go up then come back down (probable sign of pregnancy)
Common Discomforts: Braxton-Hicks
 Begin around 4 months - birth
o Irregular, inconsistent, painless contractions
 Instruct to call provider if contractions become regular, painful and persist prior to 37 weeks
 Relief Measures
o Ensure at least 1000 – 2000 cc’s fluid q day
o Pregnancy Girdle
o Multipara will feel more due to uterus being stretched more often
Cervix
 Physical Exam changes:
o Goodell’s Sign – softening of the cervix (feels like an earlobe)
o Chadwick’s Sign – cervix turns blue, increase of vascularity of vagina and cervix (and edema)
 Hyperactive mucus
o Mucus plug - the cork at the opening of a bottle and obstructs the cervical canal due to proliferation of the
mucus glands. Mucus forms within the cervix and serves to protect the fetus from ascending infectious
bacteria
o As labor becomes imminent, the plug is expelled.



Long, thick and posterior
o ≥ 2 inches in length
Strong muscle to hold pregnancy in
Incompetent cervix - painless dilation of the cervix prior to full term usually in the 2nd trimester after 12 weeks.
o Cerclage needed
o Open and not as strong
Vagina
 Increase in vascularity
o Chadwick’s sign
 Increase leukorrhea
 Loosening of connective tissues
 Varicosities
 Vagina becomes more acidic (lactic acid)
o More bacteriostatic
o Favors the growth of yeast
o More sugar going through the body and yeast loves sugar
Common Discomfort: Leukorrhea
 White Mucous-like discharge that occurs daily
 Warning signs:
o Odor – dead fish
o Colored (White Clumpy, Green, Yellow, Gray)
o Itching/Burning
o Bloody
o Constant Trickle “think amniotic fluid”
 Relief Measures
o Reassurance of Normalcy
o Daily bathing (Soaps can change pH = vaginitis)
o Cotton Underwear
o Wipe Front to back
o No Douching
Renal System
 Kidneys:
o Renal plasma blood flow increases 50%
o GFR increases
o Increased excretion:
 Bicarbonate
 Creatinine
o Dilation of renal pelvis and ureters
o If glucose >160 – may spill in urine.
o Protein in urine may indicate preeclampsia
 Bladder:
o Relaxation of bladder smooth muscle (stasis)
o Due to: Progesterone
o Increased risk of UTI
Common Discomforts: Urinary Frequency
 Frequency, urgency, and Nocturia
o Most common 1st and 3rd trimesters with uterine compression
 Education: UTI Prevention
o Empty her bladder frequently
o Wipe front to back
o > Fluids 1,000-2,000 cc daily
o Urinate after sex
o Notify provider if pain or blood in urine
o Kegel exercises
Musculoskeletal System
 Posture changes:
o Center of gravity shift
 Kyphosis - humpback
 Lordosis – curvature of the lower back
 Low back pain
 Diastasis recti - separation of rectus abdominis muscle – more common in the small tiny women
 Altered gait “pregnant waddle”
 Joint Discomfort
o Widening of pelvic girdle
 28-30 wks. gestation
o Relaxin
 Leg cramps – dorsiflex the foot (relaxes calf muscle)
 Round Ligament Pain
o Groin/Side Pain
Common Discomforts: Backache
 Other causes must be ruled out:
o UTI, Pyelonephritis (ask if they have a fever or if they are peeing), Preterm labor, renal calculi or
liver/gallbladder
 Relief measures:
o Maternity Girdle
o Warm compress/baths
o Massage, Posture, Low-heeled shoes, Exercises
o Pillow between knees, Firm mattress
 Medications:
o Acetaminophen
Common Discomforts: Round Ligament Pain
 Almost all pregnant women experience
o Occurs between 16 to 20 weeks
o Sharp “knife-like”, “stabbing” pain to dull intermittent pain in lower abdominal & inguinal regions.
 Relief measures:
o Maternity Girdle
o Warm compress/baths
o Side-lying position w/ knees to abdomen
 Medications:
o Acetaminophen
PRENATAL HEALTH ASSESSMENT & CARE
Preconception Health Care
 CDC (2013): Show your love: is a national campaign designed to improve the health of women and babies by
promoting preconception health and healthcare.
 Goal: to increase the number of not only planned pregnancies but to also encourage healthy behaviors before
becoming pregnant or for those women who don’t want a family/baby in the near future at all, just to encourage
healthy behaviors in general.
Preconception Counseling: Women
 Set of interventions that aimed at identifying medical, behavioral and social risks to a woman’s health or pregnancy.

Consist of:
o Health promotion
 Folic Acid 0.4 mg daily, Weight, Vaccinations
o Risks screening
 Medical conditions, smoking, substance abuse, alcohol, mental & IVP
o Implementing interventions
 Smoking cessation, exercise & nutrition, self-care, education
Preconception Health Care: Men
 CDC recommends preconception health care for a male planning pregnancy with partner should consist of:
o Comprehensive physical evaluation
o Prevent and Treat STIs
o Managing high-risk behaviors
 Alcohol Abuse, Substance Abuse, Violence, Mental Health
 Obesity
o Preconception education
 Partner support, healthy weight, fatherhood, etc.
Evidence-Based Practice Improving Health in the U.S.
 Many preconception interventions reduce risks of adverse pregnancy outcomes
o Birth defects, Miscarriage, Low birth weight, Preterm delivery
 Not limited to just 1 visit
 Tailored to meet individuals’ needs
 Timing is key!
o Fetus is vulnerable for certain problems 17-56 days after conception.
o Prenatal care usually starts around 11 or 12 weeks
Preconception Education: What Nurses Can Do
 Provide a woman with information to enhance her health before becoming pregnant
 Nutrition & Weight
o Encourage nutritious foods & appropriate serving sizes
o Achieving and maintaining a healthy weight before pregnancy
o Regular exercise program
 Prenatal Vitamins
 Self-Care
o Decrease risk behaviors (i.e. smoking, avoid second-hand smoking, alcohol use, excessive caffeine use)
 Medication use
 Timing of conception
Diagnosing pregnancy
Presumptive Signs of Pregnancy
 Physiological changes perceived by the woman
 Subjective signs can be caused by causes outside of pregnancy (not diagnostic)
o Amenorrhea
o Breast changes and tenderness
o Nausea and Vomiting
o Urinary Frequency
o Quickening
o Fatigue
Probable Signs
 Objective signs which can be perceived by health care providers
 Could have other causes outside of pregnancy
Pregnancy Tests
 Urine
o Convenient, affordable
o Positive approx. 4 wks. of LMP
o Best performed w/ first am void
 Highest concentration hCG
 Serum – more sensitive and specific
o Detects β-subunit hCG in maternal serum 6- 8 days after ovulation
o hCG should DOUBLE (53%) in 1.5 to 2 days for normal intrauterine pregnancy
o After miscarriage levels should decline 21% to 35% in 2 days
o 1500-2000 mIU/ml = should see an intrauterine pregnancy
Positive Signs
 The objective signs of pregnancy that can only be attributed to the fetus
PRENATAL CARE
Planning for Birth
 Choosing a Provider
o Physicians
o Midwives
 Choosing a Place of Birth
o Hospital
o Birth Centers
o Home Births
 Birth Plans
 Childbirth Education
o Lamaze Method (psychoprophylaxis method), Bradley Method (husband coached childbirth), Dick-Read
Method (natural childbirth methods)
o Sibling Classes
o Adolescent Pregnancy classes
Centering Pregnancy
 Developed by a CNM
 Model of prenatal care that emphasizes health assessment, education and support within a group setting
 Group sessions:
o 90 minutes each
o 10 sessions
o Start at 12-16 weeks
o Monthly meeting x 4 months, then biweekly
o End with early Postpartum meeting
 The patients are responsible for their own b/p, weight, and checking urine samples and documenting them in their
medical records
 A NP/CNM then reviews their information and does the prenatal assessment and any follow up assessment (heart
tones).
 Baylor Teen Clinic does Centering Pregnancy in combination with solo-prenatal visits
Visits: Course of Prenatal Care
 1st day of the last normal menstrual period (LMP) to onset of labor
o 280 Days
o 9 Calendar months
o 40 weeks
 Trimesters: 3
o 1st trimester: weeks 1- 13
o 2nd trimester: weeks 14- 26
o 3rd trimester: weeks 27-40
 Office Visits
o Every 4 weeks until 28 weeks
o Every 2 weeks until 36 weeks
o Every week until delivery
Initial Prenatal Visit
Initial Prenatal Assessment
 Demographics
 Health Status
o Pregnancy Status
 LMP
 EDD
o Medications/Allergies
 History
o Current Pregnancy
o Past medical
o Family
o Reproductive
o Social
 Complete head to toe exam
o Pelvic Exam
o Breast Exam
o Pregnancy Exam
 Uterine Growth
 Fetal Heart Tones
 Weight: BMI
 Blood pressure to establish baseline
 Urinalysis/Urine dipstick
 Laboratory and Diagnostic Studies
o Ultrasound
o OB Labs
 Prenatal Education
o Warning signs
o Common conditions
o Foods to avoid
o What to expect
Current Health Status
 Demographics
o Age
o Race, Ethnicity, Religion
o Marital/Family status
o Occupation
o Education
 Health Status
o Pregnancy Status
 LMP (calculate EDD)
 Complaints/Concerns
o Prior and Present Health Status
 Current Health Conditions (thyroid, autoimmune, diabetes, obesity, asthma, mental health)
o Medications/Allergies
 Vitamins, RX, OTC, Complementary
o Immunizations
Estimated Gestational Age
 Estimated Due Date (EDD)
 Purpose:
o Decreases morbidity and mortality
o Decreases number of diagnostic procedures and cost of care
o Allows for appropriate prenatal management
 Nagele’s Rule
 Fundal Height
 Ultrasound
 Pregnancy Wheel
Nagele’s Rule
 First day of LMP (last menstrual period)
 Add 7 days
 Subtract 3 months
 Example: LMP Nov 21
o Add 7 days: November 28
o Subtract 3 months: August 28
 Be careful of the end of the month, and the length of the month when you add the 7 days
 LMP: 6-29-2015
 EDD: April 6, 2016
Nagele’s Rule: Alternative Method
 Add 7 days
 Add 9 months
 Example: LMP September 1st
o Add 7 days: September 8th
o Add 9 months: June 8th
 LMP: April 8, 2015
 EDD: January 15, 2016
Health History
 Past Medical History
o Hx: Surgeries & Blood transfusions
o Hx: Hospitalizations
o Hx: Past medical conditions (i.e. childhood asthma, DVT, STIs, etc.)
o Hx: Physical or Sexual Abuse
 Family History
o Family medical hx.
 Current
 Genetic – we need to screen for them
 Medical conditions
 Living/deceased
Reproductive History
 Menstrual
o Last menstrual period (LMP)
 Obstetrical
o Gravida/Para
o Types of Deliveries
o Complications
 Gynecological
o Cancers
o Surgeries
o STIs
 Contraception
o Past/Current
 Sexual History
o # of partners in past 3-6-12 months
Gravida & Parity
 Gravida = total # of times a woman has been pregnant
o Without regard to # fetuses, including a current pregnancy
 Example: If a woman is pregnant with triplets, her pregnancy only counts as 1, not 3.
 Para = # of births after 20 weeks whether alive or still birth
o < 20 wks = abortion (spontaneous or elective) not counted
o More than 1 fetus = one birth
 Example: our lady with triplets delivered 3 girls. It still counts only as 1 birth episode.
Calculating G’s & P’s
 What is a woman’s G & P?
o Is at her 1st prenatal visit at 12 weeks, and has two children age 2 and 4 years
 G3 P2
o Has 1 child age 5 yrs, a set of twins & had two spontaneous abortions (at 18 weeks) and confirmation of
pregnancy today?
 G5 P2
GTPAL System
 Expanded System to Include Specific Information about past pregnancies, deliveries & current number children
 G = Number of pregnancies (gravidity)
 T = Term (>37 weeks)
o Regardless of living or stillbirth
o Multiples count as 1
 P = Preterm (<37 weeks)
o Regardless of living or stillbirth
o Multiples count as 1
 A = Abortions (spontaneous or therapeutic @ <20 weeks)
 L = Living Children
 Has 1 child age 5 yrs at 38 weeks, a set of twins at 34 weeks & had two spontaneous abortions (at 18 weeks) and
confirmation of pregnancy today?
o G5 T1 P1 A2 L3
Social History: Self-Care/Lifestyle/Safety
 BMI class (kg/m2)
o Underweight: < 18.5
o Normal: 18.5 – 24.9
o Overweight: 25-29.9
o Obese: ≥ 30.0
o Morbidly Obese: ≥ 40.0
 Nutrition & Exercise
 Patterns of sleep & stress management
 Substance Use: Tobacco, alcohol, recreational, caffeine
 Use of CAMS
 Safety Practices: seat belts, sunscreen, etc.…
Exercise & Pregnancy
 BENEFITS:
o Maintain maternal fitness
o Muscle Tone
o Improved Self-Image
o Relieves tension
o Increases Energy
o Improved Sleep
o Weight-gain control
o Promotes Bowel functions
o Associated w/ Improved Postpartum recovery
o Role in Prevention of complications (i.e. GDM, PIH)
Exercise & Pregnancy
 Avoid
o Physical contact sports/ High risk of falling
o Starting new vigorous program
o Supine exercises after 1st trimester
o Hot tub/sauna – can cause the baby to increase the temperature and damage the baby
 C/I (Aerobic)
o Heart Disease
o Incompetent cervix
o Placenta Previa after 26 wks.
o ROM
o Preeclampsia
o Premature Labor
o Persistent 2nd or 3rd trimester bleeding
Nutritional Assessment & Education
 Drink 8-10 glasses of water/daily
 Limit caffeine to 200 mg/day
 Limit processed foods
o High in carbs, sugars and sodium
 Avoid certain fishes
o Shark, swordfish, tile fish, king mackerel
o Smoked or raw seafood
 Avoid certain foods
o Soft cheeses (brie or feta)
o Unpasteurized dairy products
o Unheated hotdogs or deli meat
o Raw sprouts of any kind
 Encourage variety of foods
Social History Continued…
 Psychosocial
o Mental Health
 Ascertain past and present psychological & emotional support
 Identify social patterns & sources of support
 Accepting the pregnancy
 Cultural
o Beliefs
 Impact on health & pregnancy
o Practices
 Incorporate knowledge in care
o Primary language
 Need for translator?
 Educational materials in primary language
 Environmental
o Home
 Abuse Assessment
 Cats, raw meat, paint in older homes, pesticides, household chemicals
o Workplace
 Past & current exposure to hazards/toxins
 Financial
o Basic needs related to food & housing
o Resources
o Health insurance
 Determine resources for meeting need
 Refer for social services, OR $ support PRN
Intimate Partner Violence (IPV)
 Consist of either physical, sexual or emotional abuse

Abuse Assessment Screen
o 16% or 1 in 6 pregnant women report physical or sexual abuse
o 1 in 3 women will be abused
 Homicide is the most likely cause or death in a pregnant or recently pregnant woman.
 Pregnancy is often the only time, women come in contact w/ healthcare provider frequently
 ALL (PREGNANT) WOMEN SHOULD BE SCREENED!!
Abuse Assessment
 Three simple screening tools can reliably identify abused women:
o Within the last year or since you’ve been pregnant:
 Have you been hit, slapped, kicked or otherwise physically hurt by someone?
o Within the last year:
 Has anyone forced you to do sexual activities you did not want to do or force you to have sex when
you did not want to?
o Are you afraid of anyone at home or an ex-partner?
 Nursing Actions:
o Assessment, education, advocacy and referral to community resources.
FIRST TRIMESTER: WEEKS 1- 14 (Every 4 Weeks)
Baseline Weight & Vitals
 BMI class (kg/m2)
o Normal Weight Gain:
 25-35 lbs. total
 1st Trimester 2-5 lbs.
 2nd/3rd Trimesters 1lb./wk.
o Need to educate how much weight they should be gaining
 Vitals: HR 60-90 bmp, RR: 16-20, Temp: 97-100
 Baseline B/P
o Close to “normal” 120/80
 Decrease in 1st trimester
 Return to baseline by end of 2nd
o Gestational Hypertension > 20 weeks
 Systolic: increase 30 mmHG (above baseline)
 Diastolic: increased 15 mmHG (above baseline)
 ≥140 systolic or ≥ 90
Recommended Weight Gain
Distribution of Weight Gain
1st Trimester Labs
 ABO typing and Rh Factor
o Concern: Negative RH
 Antibody Screen
 CBC:
o Hgb
o Hct
o RBC
o WBC
o Platelet count
 STI Panel:
o RPR, VDRL
o HIV
o Hepatitis B (surface antigen)
o GC/CT
 Rubella
 Genetic Screening - offered or based on hx.
o Hgb Electrophoresis
o Cystic Fibrosis
o NT Screen
o CVS
 Urinalysis
 Urine Culture and Sensitivity
 Pap smear (@21 yrs.)
 *Dating US
 *HgbA1c, TSH, b-hCG, progesterone, PPD, Drug Screen
Cystic Fibrosis Screening
 Life-threatening genetic disease that causes persistent lung infections and progressively limits the ability to breathe.
 Carrier of CF recessive gene


Can be done before pregnancy
Only needs to be done once
o If mother is positive, father is tested
 25% chance for baby to be born with CF if both parents are carriers
Ultrasonography (US) Indications
 Varies by trimester:
o 1st Trimester:
 Confirmation of intrauterine pregnancy (FHR 4.5-5 wks.)
 # 0f fetus
 Gestational age
o 2nd-3rd Trimesters:
 Placental placement
 Amniotic Fluid Index (AFI)
 Uterine Abnormalities
o Other:
 Pelvic pain or vaginal bleeding in 1st trimester
 Hx repeated pregnancy loss or ectopic
 Cervical length
 Discrepancy between dates and size of pregnancy based on HX
First Trimester Warning
 Vaginal Bleeding/Spotting
o Miscarriage; Vaginal infection
 Pelvic/Abdominal Pain
o Ectopic, Appendicitis, UTI
 Absent FHT
o Molar Pregnancy (big sack of grapes?), Missed abortion
 Fever
o Infection
 Dysuria, Urinary Urgency
o UTI
Subsequent Visits
Follow up Visits
 ALWAYS Assess:
o Blood Pressure
o Weight Gain
o Fetal Heart Tones
o Fundal Height
o Urinalysis
 Warning signs:
o Vaginal bleeding
o Fluid leakage
o Contractions
o Fetal Movement
Fetal Heart Rate (FHR)
 Detect baseline rhythm and increase or decrease in FHR
 Use of a Doppler after 11 weeks
o 110-160 bpm
Fundal Height (FH)
 Top of the symphysis pubis to top of the uterine fundus
o Tape measure (cm)
o Approx. = # weeks pregnant (+/- 1-2 cm)

Findings may differ
o Obesity
o Uterine fibroids
o Poly- or oligo- hydramnios (too much or too little fluid)
o IUGR, multiples, fetal demise
Fundal Height “Milestones”
 12 Wks. just above symphysis pubis
 16 Wks. Halfway to umbilicus
 20 Wks. @ umbilicus
 28 Wks. Halfway to Xiphoid
 32 Wks. @ Xiphoid
 38 Wks. – 40 Wks. Lightening can occur
o Fundal Height Decreases
Second Trimester: Weeks 15-27 (Every 4 Weeks)
2nd Trimester Labs
 Additional Genetic Screening Tests
o Maternal Serum Alpha-feta protein (MSAFP)
o Triple Marker Screen
o Quad Screen
 Diagnostic Tests
o Amniocentesis
2nd Trimester Warning Signs
 Vaginal Bleeding/Spotting/Fluid
o Placenta Previa, Vaginal infection, PTL
 Pelvic/Abdominal Pain
o PTL, Appendicitis, UTI
 Absent FHT
o Fetal Death or distress
 Dysuria, Urinary Urgency
o UTI
 Prolonged Nausea & Vomiting
o Hyperemesis gravidarium
 Severe Back pain
o PTL, pyelonephritis
Third Trimester 28-42 weeks (delivery) (@ 28 weeks Every 2 weeks; @ 36 weeks weekly visits)
3rd Trimester Labs
 Repeat CBC, HIV, RPR
 Rho-Gam
o Given to Rh negative mothers @ 28 wks., postpartum & after any invasive procedure
o Protects fetus from Rh (–) mother’s immune system
 1H Glucose Tolerance Test (GTT)
o @24-28 weeks
o 50 gm glucose drink w/ one hour lab draw post drink
 > 140 requires 3H GTT
 > 200 diagnostic for Gestational Diabetes (GDM)
 3 H GTT
o Must Be Fasting
o 100 gm glucose drink w/ fasting, 1h, 2h, 3h lab draws
 2 of 4 lab values must be elevated for GDM diagnosis
rd
Late 3 Trimester Labs
 Group Beta-Strep (GBS)

Swab from perineum to rectum @ 35-37 weeks
o Maternal Effects: Asymptomatic, UTIs, vaginal discharge, chorioamnionitis, postpartum endometritis
o Fetal Effects: meningitis, sepsis, pneumonia
 Treatment indicated:
o Positive
o Unknown Status
 PTL (< 37 weeks)
 PROM (< 37 weeks)
 ROM > 18 hours
 Maternal fever during labor (100.4F/38C)
 When: Onset of Labor or ROM
 DOC: Penicillin G
 Goal: Prevent transmission to fetus
 *Transmission Rates approx 1-2 % but can result in an invasive GBS infection in the infant could lead to permanent
neurological sequel (deafness or learning disabilities)
 Transmission: when fetus passes through birth canal or ROM > 18 hours
 When would treatment not be indicated? Think how it is transmitted (through the birth canal or ROM) so 1) negative
culture 2) Planned C-section w/o ROM
Leopold’s Maneuver
 4 maneuvers which provide information on fetal lie, presentation, position (attitude) and engagement
o Maneuver A: Top of Fundus (fetal lie & presenting part)
o Maneuver B: Palpating back (fetal presentation)
o Maneuver C: Pelvic inlet (fetal engagement)
o Maneuver D: Pelvic Inlet (fetal position/attitude)
 Abdominal palpation also shows the degree of:
o Uterine irritability, tone, tenderness, current contractility and fetal movement
 Fetal Lie – Transverse or Vertical position
 Fetal Presentation- which way the baby is facing & What is the presenting part to be born (breech or cephalic)
 Fetal Attitude- locating the brow to determine the attitude of the head (extended, neutral or flexed)
3rd Trimester Warning Signs
 Vaginal Bleeding/Spotting
o Placental abruption vaginal infection, PTL
 Pelvic/Abdominal Pain
o PTL, Placental Abruption, Appendicitis, UTI,
 Absent FHT
o Fetal distress or death
 Dysuria, Urinary Urgency
o UTI
 Severe Back pain
o PTL, Pyelonephritis
 Severe Headache

o Gestational HTN
Edema (Hands & Face)
o Gestational HTN