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OB Maternal Newborn Exam Study Guide
Video #1: Contraception & Infertility
 Diaphragms: client must be refitted for a diaphragm for the following conditions:
1. It’s been 2 years since she has been fitted
2. Gained more than 15 pounds (7kg)
3. Had a full-term pregnancy
4. Had a second term abortion
o When you use a diaphragm, you need to use spermicide with every act of coitus
(withdrawal of penis from vagina prior to ejaculation). Every time you withdrawal, instill
more spermicide.
o Diaphragm must stay inserted for 6hrs after act of coitus.
 Hormonal Contraceptives (Oral)
o Side effects: Chest pain, SOB, Leg pain (from a possible clot), headache or eye problems
(from a stroke or hypertension)
o Contraindications: Women with a history of blood clots, stroke, cardiac problems,
smoker, breast or estrogen related cancers (pill contains estrogen)
 Depo-Provera/Medroxyprogesterone
o Injectable progestin
o Can cause decreased bone mineral density or loss of calcium
 Nursing action: Ensure patient has adequate intake of calcium and vitamin D
 IUD
o Increase risk for PID
o Can cause uterine perforation or ectopic pregnancy (increases risk for ectopic pregnancy)
o Look out for/Notify PCP:
 Change in string length IUD is moving and not in the right place
 Foul smelling vaginal discharge
 Pain with intercourse
 Fever/Chills (infection)
Infertility is defined as an inability to conceive desire engaging in unprotected sexual intercourse for a
prolonged period of time or at least 12 months.
 Common factors associated with infertility include:
o Decreased sperm production (Sperm analysis)
o Endometriosis
o Ovulation disorders
o Tubal occlusions If you test and use DYE (used in the fallopian tubes), make sure the
woman is not allergic to iodine or shellfish/seafood
Video #2: Signs of Pregnancy
Presumptive: Can be defined by things/reasons other than pregnancy
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Amenorrhea  Can be anorexic or exercising too much
Fatigue  Didn’t sleep well
Nausea/Vomiting  Sick
Urinary Frequency  UTI
Quickening/Fluttering in stomach  Gas
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Probable: Changes that make the examiner suspect a woman is pregnant (primarily related to physical
changes of the uterus).
Abdominal enlargement: Related to changes in uterine size, shape, and position
Hegar’s Sign: Softening and compressibility of the lower uterus
Chadwick’s Sign: Deepend violet bluish color of cervix and vaginal mucosa
Goodell’s Sign: Softening of cervical tip
Ballottement: Rebound of unengaged uterus
Braxton Hicks Contractions: False contractions that are painless, irregular, and usually relieved
by walking
Positive Pregnancy Test: Woman’s hormonal level may not be normal
Fetal Outline:
Positive: Very distinct things.
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Fetal Heart Sounds
Fetal Heartbeat can be heard
Can see the baby with ultrasound
Can feel movement in the uterus
Naegele’s Rule: Last menstrual period minus (– ) 3 months + 7 days + 1-year ;Cathy’s Rule: + 9
months + 1 week
Gravidity and Parity:
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Gravida: a woman who is pregnant
Gravidity: number of pregnancies
o Nulligravida: a woman who has never been pregnant
o Primigravida: a woman who is pregnant for the first time
o Multigravida: a woman in at least her second pregnancy.
Parity: the number of births (not the number of fetuses [ex: twins]) carried pat 20 weeks
gestation, whether or not the fetus was born alive.
o Nullipara: a woman who has not had a birth at more than 20 weeks of gestation.
o Primipara: a woman who has had one birth that occurred after 20 weeks of gestation.
o Multipara: a woman who has had two or more pregnancies to the stage of fetal viability.
Know how to find out GTPAL numbers:
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G= Gravidity (# of times a woman has been pregnant PLUS current pregnancy)
T= Term Births (How many babies were delivered at term 38 WEEKS OR MORE)
P= Preterm Births (Below 38 weeks)
A= Abortion (spontaneous or not) or miscarriages L= Living children
Fundal height:
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Measured to evaluate the gestational age of the fetus.
During the second and third trimesters (weeks 18-30), the fundal height in centimeters
approximately equals the fetus’s age in weeks, plus or minus 2 cm.
At 16 weeks, the fundus can be found approximately halfway between the symphysis pubis and
the umbilicus.
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At 20 to 22 weeks, the fundus is
approximately at the location of
the umbilicus.
At 36 weeks, the fundus is at the
xiphoid process.
* When assessing fundal
height, monitor the client
closely for supine
hypotension when place
in the supine position.
Measuring fundal height:
1. Place the client in a supine position
2. Place the end of the tape measure
at the level of symphysis pubis
3. Stretch the tape to the tope of the
uterine fundus
4. Note and record the measurement.
Physiological Maternal Changes:
Cardiovascular system:
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Circulating blood volume increases by approximately 40 – 50%; physiological anemia may occur
as the plasma increase exceeds the increase in the production of red blood cells.
Heart size is increased, and the heart is elevated upward and to the left because of displacement of
the diaphragm as the uterus enlarges.
There is an increase in the body’s demand for iron.
Sodium and water retention may occur, which can lead to weight gain.
Respiratory system:
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Oxygen consumption increases by approximately 15% to 20%
Diaphragm is elevated as a result of the enlarged uterus
Shortness of breath may be experienced.
* During pregnancy, a woman’s pulse rate may increase about 10 to 15 beats/minute, the
blood pressure slightly decreases in the second trimester, then increases in the third
trimester but not above the pregnancy level; and the respiratory rate remains unchanged
or slightly increases.
Gastrointestinal System:
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Nausea and vomiting, which usually subsides by the 3rd month, may occur as a result of the
secretion of human chorionic gonadotropin (hCG); hCG stabilizes or decreases around week 12
Poor appetite may occur because of decreased gastric motility.
Alterations in taste and smell may occur.
Constipation may occur because of an increase in progesterone production or pressure of the
uterus, resulting in decreased GI motility.
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Flatulence and heartburn may occur because of decreased GI motility and slowed emptying of the
stomach cause by an increase in progesterone production.
Gum tissue may become swollen and easily bleed because of increasing levels of estrogen.
Ptyalism (excessive secretion of saliva) may occur because of increasing levels of estrogen.
Renal System:
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Frequency of urination increases in the 1st and 3rd trimesters because of increased bladder
sensitivity and pressure of the enlarging uterus on the bladder,
Decreased bladder tone may occur and is caused by an increase in progesterone and estrogen
levels; bladder capacity increases in response to increasing levels of progesterone.
The renal threshold fir glucose may be reduced.
Reproductive system:
1. Uterus
a) Uterus enlarges, increasing in mass from approximately 60 g to 1000 g as a result of
hyperplasia (influence of estrogen) and hypertrophy.
b) Size and number of blood vessels and lymphatics increase
c) Irregular contractions occur, typically beginning after 16 weeks gestation.
2. Cervix
a) Cervix becomes shorter, more elastic, and larger in diameter.
b) Endocervical glands secrete a thick mucus plug, which is expelled from the canal when
dilation begins.
c) Increased vascularization and an increase in estrogen causes a softening and a violet
discoloration (Chadwick’s sign), which occurs at about week 6.
3. Ovaries
a) Secrete progesterone for first 6 to 7 weeks of pregnancy
b) Block maturation of new follicles
c) Cease ovum production.
4. Vagina
a) Hypertrophy and thickening of the muscle occurs.
b) Increase in vaginal secretions is experienced: secretions are usually, thick, white, and
acidic.
5. Breasts
a) Breast changes occur because of the increasing effects of estrogen and progesterone
b) Breast size increases and breasts may be tender.
c) Nipples become more pronounced and the areolae become darker.
d) Superficial veins become prominent
e) Montgomery’s follicles become hypertrophied
f) Colostrum may leak from the breasts.
Skin:
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Changes in skin occur because of increased levels of melanocyte-stimulating hormone, which
increase secondary ot increases in estrogen and progesterone; these changes include the
following:
a) Increased pigmentation
b) Dark streak down the midline of the abdomen may appear (linea nigra).
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c) Chloasma (mask of pregnancy), a blotchy, brownish hyperpigmentation, may occur over
the forehead, checks, and nose.
d) Reddish-purple stretch marks (striae) may occur over the abdomen, breasts, thighs, and
upper arms
Vascular spider nevi may occur on the neck, chest, face, arms, and legs.
The rate of hair growth may increase.
Musculoskeletal System:
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Changes in center of gravity begin in the second trimester and are caused by the hormones
relaxin and progesterone
The lumbosacral curve increases
Aching, numbness, and weakness may result; walking becomes more difficult, and the woman
develops a waddling gait and is at risk for falls.
Relaxation and increased mobility of pelvic joints occurs, which permit enlargement of pelvic
dimensions.
Abdominal wall stretches with loss of tone throughout pregnancy, regained postpartum.
Umbilicus flattens or protrudes.
* During pregnancy, postural changes occur as the increased weight of the uterus
causes a forward pull of the bony pelvis. It is important for the nurse to encourage
the client to implement measures that maintain safety and correct posture to
prevent a backache.
Discomforts of pregnancy:
 Nausea and Vomiting.
o Interventions: eating dry crackers before rising, avoiding brushing the teeth
immediately after rising, eating small frequent low-fat meals during the day, drinking
liquids between meals rather than at meals, avoiding fried and spicy foods, asking the
primary health care provider about acupressure (some types may require a prescription),
and asking if the PHCP about the use of herbal remedies.
 Syncope.
o Interventions: sitting with the feet elevated and changing positions slowly because of
the risk for falls.
o The nurse needs to inform the pregnant client to avoid lying in the supine position,
particularly in the second and third trimesters. The supine position places the
woman at risk for supine hypotension, which occurs as a result of pressure of the
uterus on the inferior vena cava.
 Urinary urgency and frequency.
o Interventions: drinking no less than 2000 mL of fluid during the day, limiting fluid
intake during the evening, voiding at regular intervals, sleeping on the side at night,
wearing perineal pads if necessary, and performing Kegel exercises.
 Breast tenderness.
o Interventions: encouraging wearing a supportive bra, avoiding the use of soap on the
nipples and areolar area to prevent drying of skin.
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 Increased vaginal discharge:
o Interventions: Using proper cleansing and hygiene techniques, wearing COTTON
underwear, avoiding douching, informing the client of the signs of infection and to
consult the PHCP if an infection is suspected.
 Fatigue.
o Interventions: arranging frequent rest periods throughout the day, using correct posture
and body mechanics, obtaining regular exercise, performing muscle relaxation and
strengthening exercises for the legs and hip joints, and avoiding eating and drinking
foods that contain stimulants throughout the pregnancy.
 Heartburn.
o Interventions: eating small frequent meals and avoid fatty and spicy foods, sitting
upright for 30 minutes after a meal, drinking milk between meals, and consulting with
the PHCP about the use of antacids.
 Ankle Edema:
o Interventions: elevating the legs at least twice a day and when resting, sleeping in a
side-lying position, wearing supportive stockings or supportive hose as prescribed,
avoiding sitting or standing in one position for long periods.
 Varicose veins:
o Interventions: wearing supportive stockings or support hose, elevating the feet when
sitting, lying with the feet and hips elevated, avoiding long periods or standing or sitting,
moving about while standing to improve circulation, avoiding leg crossing, avoiding
constriction articles of clothing such as knee high stockings.
 Thrombophlebitis (is rare but can occur):
o Interventions: teaching leg exercises and avoiding airline travel if possible.
 Headaches:
o Interventions: changing positions slowly, applying a cool cloth to the forehead, eating a
small snack, using acetaminophen only if prescribed by the PHCP
 Hemorrhoids:
o Interventions: soaking in a warm sitz bath, sitting on a soft pillow, eating high fiber
foods, and drinking sufficient fluids to avoid constipation, increasing exercise, such as
walking, and applying ointments, suppositories, or compresses as prescribed by the
PHCP.
 Constipation:
o Interventions: eating high fiber foods such as whole grains, fruits, and vegetables,
drinking no less than 2000 mL per day, exercising regularly, such as a daily 20 minute
walk, and consulting with the PHCP about interventions such as the use of stool
softeners, laxatives, or enemas.
 Backache:
o Interventions: obtaining rest, using correct posture and body mechanics, wearing lowheeled, comfortable, and supportive shoes, performing pelvic tilt (rock) or tailor-sitting
exercises and conscious relaxation exercises, sleeping on a firm mattress.
 Leg cramps:
o Interventions: getting regular exercise, such as walking, dorsiflexing the foot of the
affected leg, and increasing calcium intake.
 Shortness of breath:
o Interventions: taking frequent rest periods and avoiding overexertion, sitting and
sleeping with the head elevated or on the side, avoiding overexertion.
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Maternal Risk Factors
Maternal age: women younger than 20 years and older than 35 years are at risk for advance perinatal
outcomes.
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Adolescent pregnancy.
o Major concerns related to adolescent pregnancy include poor nutritional status,
emotional and behavioral difficulties, lack of support systems, increased risk of stillbirth,
low-birth weight, fetal mortality, cephalopelvic disproportion, and increased risks of
maternal complications such as hypertension, anemia, prolonged labor, and infections.
o The role of the nurse is reducing the risks and consequences of adolescent pregnancy is
twofold: first to encourage early and continued prenatal care, and second, to refer the
adolescent, if necessary, for appropriate assistance, which can help to counter the effects
of a negative socioeconomic environment.
Nutrition: adequate nutrition is necessary for normal fetal growth and development. Nutrition needs are
determined by the stage of the pregnancy and nutrition should support recommended weight gain during
the various stages.
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Women of childbearing age should take folic acid supplements to prevent neural
tube defects and orofacial clefts in the fetus.
Genetic considerations: genetic abnormalities such as defective genes or transmissible inherited
disorders can result in congenital anomalies; the nurse should collect data about genetic risks.
Health care: failure to seek and obtain prenatal care, including dental care, increases the risk of preterm
birth and low birth weight.
Abuse and violence: physical abuse and violence can increase the risk for abruptio placentae, preterm
birth, and infections from unwanted and forced sex.
Medical conditions: concurrent medical conditions, such as, but not limited to, diabetes mellitus,
hypertensive disorder, or cardiac disease, increase the risk during pregnancy.
German measles (rubella): maternal infection during the first 8 weeks of gestation carries the highest rate
of fetal infection.
Sexually Transmitted infections:
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Syphilis.
o Organism may cross the placenta
o Infection usually leads to spontaneous abortions and increases the incidence of mental
sub normality and physical deformities.
Condylomata acuminate (human papillomavirus)
o Transmission may occur during vaginal birth.
o Infection is associated with the development of epithelial tumors of the mucous
membranes if the larynx in children.
Gonorrhea.
o Fetus is contaminated at the time of birth.
o Maternal infection may result in postpartum infection of the neonate.
o Risks to the neonate include ophthalmia neonatorum, pneumonia, and sepsis.
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Chlamydial infection.
o Transmission may occur during vaginal birth and can result in neonatal conjunctivitis or
pneumonitis.
o Infection can cause premature rupture of the membranes, premature labor, and
postpartum endometritis.
Trichomoniasis.
o Associated with premature rupture of the membranes and postpartum endometritis.
Genital herpes simplex virus.
o Characterized by painful lesions, fever, chills, malaise, and severe dysuria and may last 2
to 3 weeks.
o Assessment includes questioning all women about signs/symptoms and inspecting the
vulvar, perineal, and vaginal areas for vesicles or areas of ulceration or crusting; this is
done during pregnancy and at the onset of labor.
o Vaginal birth may be acceptable; cesarean birth is recommended if visible lesions are
present.
o Infants who are born through an infected vagina should be carefully observed, and
samples should be taken for culture.
Human immunodeficiency virus (HIV).
o HIV is transmitted via blood, blood products, and other body fluids such as urine, semen,
and vaginal secretions; the virus is also transmitted through exposure to infected
secretions during birth and via breast milk.
o Repeated exposure to the virus during pregnancy through unsafe sex practices and/or
intravenous drug use can increase the risk of transmission to the fetus.
o Perinatal administration of zidovudine may be recommended to decrease risk of
transmission of HIV from mother to fetus.
Substance abuse.
o Substance abuse threatens normal fetal growth and the successful term completion of the
pregnancy.
o Substance abuse places the pregnancy at risk for fetal growth restriction, abruptio
placentae, and fetal bradycardia.
o Many substances cross the placenta and can be teratogenic; (drugs, tobacco, alcohol,
medications, certain foods such as raw fish); no OTC medications should be taken unless
prescribed.
o Smoking (tobacco) can lead to low birth weight, a higher incidence of birth defects, and
stillbirths.
o Physical signs of drug abuse may include dilated or contracted pupils, fatigue, track
(needle) marks, skin abscesses, inflamed nasal mucosa, and inappropriate behavior by
the mother.
o The consumption of alcohol during pregnancy may lead to fetal alcohol syndrome and
can cause jitteriness, physical abnormalities, congenital anomalies and growth deficits.
Video #3: Weight Gain & Nutrition During Pregnancy AND Diagnostic Tests During Pregnancy
Weight Gain & Nutrition
 Normal weight gain = 25- 35 pounds
 Overweight person weight gain = 15- 25 pounds
 Underweight person weight gain = 28-40 pounds
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The average expected weight gain during pregnancy is 25 to 35 pounds (11-16 kg) for
women with a normal pre pregnancy weight, depending on PHCP preference.
o An increase of about 300 calories per day is needed during pregnancy.
o An increase of about 500 calories per day is needed during lactation.
o A diet high in folic acid and folic acid supplements is necessary for all women of
childbearing age to prevent neural tube defects and orofacial clefts in the fetus.
o Encourage the consumption of at least 8 to 10 ( 8oz) glasses of fluid each day, of which
4 to 6 glasses should be water.
o Sodium is not restricted unless specifically prescribed by the PHCP.
During 1st trimester  A woman should only gain 1-2 kg (2-4 pounds); A woman should not
gain 1 pound per week.
During 2nd trimester  1 pound per week is normal; increase caloric intake by 340 calories per
day
During 3rd trimester  1 pound per week is normal; increase caloric intake by 450 calories per
day
If you are breastfeeding after pregnancy  You still need to eat an extra 300-400 calories per day
Intake of FOLIC ACID Helps prevent Neural Tube Defects (NTD)  Sources: dark green
leafy veggies; orange juice
Women should increase their fluid intake to 2-3L per day
Women should limit their caffeine intake to 300 mg per day
No amount of alcohol is okay
 Pica: is eating nonfood substances such as dirt, clay, starch, and freezer frost. The
cause is unknown. Cultural values, such as beliefs regarding a materials effect on the
mother or fetus, may make pica a common practice. Iron-deficiency anemia may occur
as a result of pica
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Diagnostic Tests During Pregnancy
Noninvasive = Full Bladder
Invasive = Empty Bladder
Ultrasound  Bladder should be full to help sound waves resonate better
Amniocentesis  Bladder should be empty
Biophysical Profile (BPP): Scored from 0-10
 Score between 8-10  Healthy Baby.
 Tests Measures 5 things:
o Reactive HR (0/2)
o Breathing (0/2)
o Body Movement (0/2)
o Fetal Tone (0/2)
o Amniotic Fluid Volume (0/2)
Non-Stress Test (NST)
 Non-invasive
 Measures fetal well-being within the last trimester of pregnancy
 Measures response of FHR to Fetal Movement
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Reactive: FHR accelerates during movement (normal; positive)
Nonreactive: No accelerations during movement (not normal; negative)
 If non-reactive, the DR will perform another test called: Contraction Stress
Test (CST) or a BPP.
Video #4: Diagnostic Tests
Contraction Stress Test (CST)
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Induce contraction with administration of Pitocin/oxytocin or nipple stimulation
During the contraction, monitor FHR for late decelerations
Negative CST Response (no late decelerations, which is what you want)
Positive CST (late decelerations happen, not a good thing)
Risk
o Can send woman into PTL
Amniocentesis.
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Aspiration of amniotic fluid; best performed between 15 and 20 weeks of pregnancy because
amniotic fluid volume is adequate and many viable fetal cells are present in the fluid by this time.
Performed to determine genetic disorders, metabolic defects, and fetal lung maturity
 You want an empty bladder because you will poke into amniotic sac to test for genetic
abnormalities (levels of AFP aka alphafeto-protein)
o Interventions: if less than 20 weeks gestation, the woman should have a full bladder to
support the uterus. If more than 20 weeks gestation, the woman should have an empty
bladder to minimize the chance of puncture. Prepare the client for ultrasonography, which
is performed to locate the placenta and avoid puncture of it. Obtain baseline vital signs
and fetal heart rate. Monitor every 15 minutes. Position the client supine during the
procedure and on the left side after the procedure.
o High AFP = NTD
o Low AFP = Chromosomal disorders such as down syndrome
 LS Ratio (Lecithin Sphingomyelin)  tests for fetal lung maturity
o Ratio of 2:1 = fetal lung maturity
o Ratio of 2.5:1 or 3:1 = fetal lung maturity for client with DM
 Risks/Complications:
o Amniotic Fluid Emboli (AFE)
o Maternal Hemorrhaging
o Infection
o Premature rupture of the membranes
o Rh isoimmunization
o Miscarriage
o Abruptio placentae
Chorionic Villus Sampling (CVS)  Alternative to Amniocentesis:
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Performed for the purpose of detecting genetic abnormalities; the PHCP aspirates a small ample
of chorionic villus tissue at 10 to 13 weeks gestation.
Can be done between 10-12 weeks
Also tests for genetic abnormalities by testing the placenta instead of the amniotic fluid.
Advantage  Can be done earlier
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Interventions: the client may need to drink water to fill the bladder before the procedure
to aid in visualizing the uterus for catheter insertion; obtain baseline vital signs and fetal
heart rate (monitor frequently after the procedure); Rh-negative women may be given Rh
(D) immune globulin, because chorionic villus sampling increases the risk of Rh
sensitization; make sure informed consent is signed.
After chorionic villus sampling and amniocentesis, instruct the client that if chills, fever,
bleeding, leakage of fluid at the needle insertion site, decreased fetal movement, uterine
contractions, or cramping occurs she must notify the PHCP.
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Kick counts (fetal movement counting):
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The client is instructed to sit quietly or lie down on her side and count fetal kicks for a specific
period of time.
Instruct the client to notify the PHCP if there are fewer than 10 kicks in two consecutive 2-hour
periods or as instructed by her PHCP.
Fern Test:
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A microscopic slide test to determine the presence of amniotic fluid leakage.
Using sterile technique, a specimen is obtained form the external os of the cervix and vaginal
pool and examined on a slide under a microscope.
A fern like pattern that results from the salts of the amniotic fluid indicates the presence of
amniotic fluid.
o Interventions: position the client in the dorsal lithotomy position; instruct the client to
cough. This causes the fluid to leak from the uterus of the membranes are ruptured.
Doppler blood flow analysis:
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Noninvasive (ultrasonography) method of studying blood flow in the fetus and placenta
Percutaneous umbilical blood sampling:
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Performed if fetal blood sampling is necessary; involves insertion of needle directly into fetal
umbilical vessel under ultrasound guidance.
Fetal heart rate monitoring is necessary for 1 hour after procedure, and a follow-up ultrasound to
check for bleeding or hematoma formation is done for 1 hour after the procedure.
Alpha-fetoprotein (AFP) screening:
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Assess the quantity of fetal serum proteins; abnormal protein levels are associated with open
neural tube and abdominal wall defects. Can screen for spina bifida and down syndrome; if
abnormal, the test is repeated; a false-positive test result is common.
o Interventions: the AFP level is determined by a maternal blood sample drawn between
16- and 18-weeks’ gestation.
o If the level is abnormal and the gestation is less than 18 weeks, a second sample is drawn
and screened.
o An ultrasound is performed for elevated levels to rule out fetal abnormalities or multiple
gestation.
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Biophysical profile:
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Noninvasive assessment of the fetus that includes fetal breathing movements, fetal movements,
fetal tone, amniotic fluid index, and fetal heart rate patterns via a nonstress test.
Normal fetal biophysical activities indicate that the central nervous system is functional, and the
fetus is not hypoxemic.
Nitrazine test:
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A Nitrazine test strip is used to detect the presence of amniotic fluid in vaginal secretions.
Vaginal secretions have a pH of 4.5 to 5.5 and do not affect the color of the Nitrazine strip or
swab. Amniotic fluid has a pH of 7.0 to 7.5 and turns the Nitrazine strip or swab blue in color.
o Interventions: position the client in the dorsal lithotomy position, touch the test tape to
the fluid, check the test tape for a blue0green, blue-gray, or deep-blue color, which
indicates that the membranes are probably ruptured, causing leakage or amniotic fluid.
Fibronectin Tests:
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Sampling of cervical and vaginal secretions for fetal fibronectin is done (a protein present in fetal
tissues normally found in cervical and vaginal secretions until 16-20 weeks gestation and again
at or near term).
Positive results indicate the onset of labor in 1 to 3 weeks; negative test results are more
predictive that preterm labor will not begin. Test is used if the client is at risk for preterm labor,
before 37 weeks gestation.
o Interventions: client is placed in lithotomy position for a sterile speculum examination,
cervical secretions are obtained with a cotton swab, and laboratory tests are done for the
presence of fibronectin.
Nonstress test:
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Performed to assess placental function and oxygenation; determines fetal well-being; and
evaluates fetal heart rate (FHR) in response to fetal movement.
o Interventions: an external ultrasound transducer and tocodynamometer are applied to
the mother, and a tracing of at least 20 minutes duration is obtained so that the FHR and
the uterine activity van be observed.
o Obtain a baseline blood pressure reading and monitor frequently.
o Position the mother in left lateral position to avoid vena cava compression.
o The mother may be asked to press a button every time she feels fetal movement. The
monitor recorded a mark at each point of fetal movement, and this is used as a reference
point to assess FHR response.
Contraction Stress Test:
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Assesses placental oxygenation and function; determines fetal ability to tolerate labor and
determine fetal well-being. Fetus is exposed to the stress of contraction to assess the adequacy of
placental perfusion under simulated labor conditions. Performed if the nonstress test is abnormal.
o Interventions: the external fetal monitor is applied to the mother, and a 20 to 30-minute
baseline strip is recorded.
o The uterus is stimulated to contract, either by the administration of a dilute doe of
oxytocin or by having the mother use nipple stimulation, until three palpable
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contractions with a duration of 40 seconds or more during a 10 minute period have been
achieved.
Frequent maternal blood pressure readings are obtained and the mother is monitored
closely while increasing doses of oxytocin are given.
Video #5 Bleeding and Complications During Pregnancy
 Ectopic Pregnancy  Ovum is planted outside of the uterus, often in the fallopian tube. Need to
know the symptom of unilateral stabbing pain in the lower abdominal quadrant
o If it burst the fallopian tube, it can be life threatening to the mom
 Gestational Trophoblastic Disease (GTD)  the proliferation and degeneration of trophoblastic
billi in the placenta that becomes swollen, fluid-filled, and takes on the appearance of grape-like
clusters or prune juice.
 Placenta Previa  Placenta previa occurs when the placenta abnormally implants in the lower
segment of the uterus near or over the cervical os instead of attaching to the fundus. PAINLESS
BRIGHT RED VAGINAL BLLEDING during the 2nd or 3rd trimester
o Very dangerous  May hemorrhage and may need to give blood
o Complete or Total: Cervix is completely covered by placental attachment o Incomplete
or Partial: Partially covered by the placental attachment
o Marginal or low-lying
 Abruptio Placenta: the premature separation of the placenta from the uterus, which can be a
partial or complete detachment.
o Sudden onset of intense localized uterine pain with dark, red, vaginal bleeding.
o Clinical Findings: Hypovolemic shock
 Yeast Infections are quite common for pregnant woman
o Signs/Symptoms:
 Cottage cheese discharge
 Vulvar redness
 White patches on vaginal wall
 Incompetent Cervix: Recurrent premature dilation of the dilation of the cervix or cervical
insufficiency (basically the cervix cannot stay closed and will lead to a spontaneous abortion if
not taken care of). If woman has incompetent cervix, she will get a cerclage to help keep cervix
closed and from dilating and is removed at 37 weeks of gestation or when spontaneous labor
occurs.
 Hyperemesis Gravidarum  Nausea and vomiting that goes past 12 weeks. End up having
weight loss & electrolyte imbalances & dehydration.
o Nursing Interventions: IV Fluids, administration of B6, antiemetic medication (Reglan
or Zofran).
Video #6: Medical Conditions
Iron Deficiency Anemia
 Provider will prescribe FE supplements  Take FE Supplement that is rich in Vitamin C (i.e
orange juice)
Gestational Diabetes (GDM)
 If a patient has GDM during pregnancy, it increases her risk of developing DM after her
pregnancy
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 Poses risk to the fetus. Provider may want to do BPP or NST to monitor for complications
 Most oral anti-diabetic meds are contraindicated for pregnancy so woman will have to use insulin
to monitor sugar levels
 When to test: 24 – 28 weeks of gestation
o Start with 1-hour glucose tolerance test
 No fasting required
 Give patient 50g of oral glucose, then 1 hour later, test glucose levels
 Positive screen of 130-140mg/dl or greater indicates need for additional testing
(3 Hr OGTT)
o 3 Hr OGTT
 Requires fasting
 Avoid caffeine and smoking
 Will take fasting glucose level, then will be given 100g of glucose and will test
glucose at 1hr, 2hrs, and 3hrs
Gestational Hypertension (GHTN) Caused by vasospasm contributing to poor tissue perfusion
 Spectrum of GHTN
o GHTN  after 20th week of pregnancy, if a woman has a BP over 140/90 recorded at
least twice, 4-6 hrs apart within a one-week period of time, the patient is POSITIVE for
GHTN. There is NO PROTEIN in urine.
o Mild Preeclampsia
 GHTN (BP 140/90)
 Proteinuria (Level 1+)
 Edema may not be present ATM
o Severe Preeclampsia
 BP >/=160/100 + Proteinuria (Level 3+)
 Creatinine levels will begin to rise and will be >1.2
 May experience headache/blurred vision/hyperreflexia/peripheral
edema/Epigastric pain
o Eclampsia
 Severe Preeclampsia + Seizures
o HELLP
 Hemolysis: resulting in anemia and jaundice
 Elevated Liver Enzymes: ALT & AST Levels will be high
 Manifestations: Epigastric pain, nausea, vomiting
 Low Platelets: Platelet count < 100k
 Manifestations:
o Thrombocytopenia
o Abnormal bleeding and clotting time
o Bleeding gums
o Petechiae
o Possibly disseminated intravascular coagulopathy
Medications:
 Antihypertensives
o Methyldopa
o Nifedipine
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o Hydralazine
o Labetalol
o ** AVOID ACE inhibitors and ARBS
 Anticonvulsants
o Magnesium sulfate:
 Monitor patient for magnesium toxicity!
 Signs & Symptoms No reflexes, reduces DTR, low urine output, RR low, LOC
low, dysrhythmias
 Antidote: Calcium Gluconate
Video #7: Early Onset of Labor
PTL
 Contractions or cervical changes that happen between 20-37 weeks. After 37 weeks, it will be
considered Full Term Labor
 May do a vaginal swab to check the fetal fibronectin to see if she is in PTL
o May administer Nifedipine (Calcium Channel Blocker) Will relax muscles by
suppressing contractions by blocking calcium being transported to smooth muscles
o May administer Magnesium (check for toxicity)  relax smooth muscles of uterus
o May administer Indomethacin  NSAID which inhibits prostaglandins  inhibits
prostaglandins suppresses UCs
o May administer betamethasone  Steroid Help promote fetal lung maturity
PROM
 Major cause of infection (especially if more than 24 hours goes by from when the membrane
ruptured and the time the baby is born)
o If membrane ruptures DR will order a Nitrazine paper test  Paper turns blue (pH 6.57.5)
o Positive ferning test can also indicate rupture of membrane
o If membrane does rupture, patient will be put on an antibiotic, betamethasone (develop
baby’s lungs)
Physiological Changes Preceding Labor:
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Backache
Weight Loss
Lightening (Fetal head drops into the true pelvis)
Contractions (True, not Braxton hicks)
Bloody show
Energy burst right before labor
GI Changes (nausea, vomiting, indigestion)
Rupture of membranes (check with Nitrazine paper)
Tests Done:
 Group B Strep
 Urinalysis (Protein, infection)
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4 Stages of labor:
 1st  Onset of labor until complete dilation of cervix (10 cm)
o Has 3 phases
 Latent
 0-3 cm dilation
o Mother is talkative & eager
 Active
 >3-7cm
o Mother is restless, anxious, and may feel helpless
 Transition
 >7cm-10cm
o Mother is experiencing a lot of pain, has urge to push and may
feel like she is having a bowel movement (increased rectal
pressure)
 2nd  Full dilation of cervix to birth of the baby
 3rd  Birth of baby to delivery of placenta
 4th  Delivery of placenta until mothers’ vitals are stable
Video #8 Pain Management & FHR Monitoring
Non-pharmacological methods
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Aromatherapy
Imagery
Music
Effleurage: light, gentle circular stroking of the client’s abdomen with the fingertips in rhythm
with breathing during contractions
 Sacral Counter-pressure: Consistent pressure is applied by the support person using the heel of
the hand or fist against the client’s sacral area to counteract pain in the lower back
Pharmacological Methods (Sedative & Opioid analgesics)
Sedative  puts baby at risk for respiratory depression
Opioid Analgesic  puts mom at risk for sedation, hypotension, and increased variability in FHR
Epidural Analgesia  Provides lack of sensation at level of the umbilicus to the thighs.
 Needs to be dilated at least 4cm or above
 Side effects include: maternal hypotension and fetal bradycardia.
 Nursing Interventions  Give IV Bolus to counteract hypotension; want to avoid supine
hypotension syndrome (avoid this by placing patient on her side and not on her back).
Spinal Block: provides lack of sensation from the nipples to the feet. Given for C-Sections.
 Side effects include: maternal hypotension and fetal bradycardia, potential headache from
leakage of CSF, and increase incidence of bladder and uterine atony.
 Nursing Interventions  Give IV Bolus to counteract hypotension; want to avoid supine
hypotension syndrome (avoid this by placing patient on her side and not on her back).
FHR Monitoring (VEAL  CHOP)
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 110-160 FHR BPM is normal
 Want variability (moderate), accelerations are okay
 Variable Deceleration  Cord Compression
o Interventions
 Reposition client to side or knee chest position
 Discontinue Pitocin
 Administer O2
 Early decelerations are okay (Compression of fetal head during contraction)
 Late Decelerations  uteroplacental insufficiency (lack of fetal O2)
o Interventions
 Assist mom to side laying position.
 Increase IV Fluids
 Stop Pitocin.
 Administer O2
 Notify PCP
 DO NOT want late and variable decelerations.
 Fetal bradycardia may be related to epidural or placental insufficiency (discontinue oxytocin,
put patient on side and provide more O2 and notify PCP).
 Fetal Tachycardia  may indicate maternal infection. Give antipyretics and O2.
 (Prolapsed) Umbilical Cord Compression  Presenting part of the fetus head is crushing the
umbilical
o Interventions
 Notify PCP and get help
 Use sterile gloved hand, insert 2 fingers into vagina and lift baby head off the
cord to stop compression Reposition client to knee chest, or Trendelenburg
 Use a warm saline soaked sterile towel to ensure cord does not dry up
 Rhogam  administer within 72 hours within giving birth if the mother is Rh- and the baby is
Rh+ to prevent issues with their next pregnancy
 Fundal Height  Immediately after the deliver, the fundus should be firm and midline with the
umbilicus and approximately at the level of the umbilicus. At 12 hours post-partum it may go
1cm above the umbilicus. Every 24 hours after that, it should descend about 1-2cm. By 6th postpartum day, it should be halfway between the umbilicus and the symphysis pubis. By day 10, you
should not be able to palpate uterus.
Video #9: Lochia  Discharge after women gives birth
3 types of Lochia
 Lochia Rubra  bright red bleeding; odor and may have clots (days 1-3 after women gives
birth) fleshy
o Bleeding should not be excessive; 1 saturated pad w/in 15 mins = excessive NOT OK!!
o Should not extend past 3 days. If it does, atony becomes a concern
 Lochia Serosa  Serosanguineous consistency + pinkish brown in color (day 4-10)
 Lochia Alba  Yellowish, white-creamy color with a fleshy odor. (day 11-6 weeks post-partum)
Management After Birth
 Ice baths in the perineum area
 Sitz bath
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 After birth; 2-3 days milk will come in. Before milk comes in, colostrum is what is being
excreted (thicker and yellow consistency. High fat content with antibiotics)
 Average blood loss during vaginal birth = 500ml.
 Average blood loss for a c-section =1000ml.
Uterine Atony  If woman is retaining urine, her bladder will be distended which will displace her
uterus.
 Intervention:
o Have woman empty her bladder
Video #10: Baby Friendly Care
3 phases
 Dependent: Taking in phase:
o First 24-48 hrs after birth
o Mom is eager to talk about birth experience
o Relies on others for assistance
 Dependent-Independent: Taking hold phase:
o Day 2-3 and goes up to a few weeks
o Mother is focused on baby care
o Practicing skills and learning how to take care of baby
 Independent: Letting Go:
o Its not all about how to take care of the baby
o Mother resumes her roles as a partner, individual, returns to work, etc
Discharge Teaching  Breast Engorgement & Post-Partum Disorders
 Milk comes in 2-3 days after giving birth
o Breast Engorgement is common
 Cold compress between feedings, warm shower prior to feeding to help with
circulation
 Cold fresh cabbage leaves on the breast
 Mild analgesics
o If she is not going to breast feed, do not promote milk flow
 Cold compress, and tight bras are the interventions
Post-Partum Disorders
 Higher risk of getting DVT
 Pulmonary Embolism may occur  Signs & Symptoms  Chest pain, difficulty breathing
 PPH  Different types of lochia (COCA)
o Lochia rubra lasting longer
 Culprit = uterine atony or retaining placental fragments
 Make sure bladder is empty
 Monitor pads and saturation
 If she’s losing a lot of blood, she will have tachycardia and hypotension
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 Make sure to massage the fundus
o Medications used for PPH (Post-Partum Hemorrhage)
 Oxytocin/Pitocin (help contract uterus)
 Methylergonovine  Methergine
 Misoprostol  Cytotec
 Mastitis  infection of the breast
o Signs & Symptoms:
 Painful or tender localized hard mass
 Reddened area on one breast
 Flulike symptoms (chills/fatigue)
o Interventions to Prevent Mastitis:
 Wash hands prior to breast feeding
 Keep breast nice and clean
 Allow nipples to air dry
 Make sure baby is taking in the entire nipple and areola into their mouth
 Empty breast with each feeding
Video #11: Post-Partum Depression Vs. Post-Partum Blues & Newborn Assessment
Post-Partum Blues
 Very common, can last up to 10 days (if extends over 10 days or symptoms get more severe,
assess for PPD)
 Signs & Symptoms:
o Tearfulness
o Insomnia
o Lack of appetite
o Feeling of letdown
Post-Partum Depression
 Occurs w/in 6 months of delivery and includes persistent feelings of sadness and intense mood
swings (10% of new moms)
Post-Partum Psychosis
 Common with moms with history of bipolar disease
 Signs & Symptoms:
o Disorientation
o Hallucination
o Obsessive behaviors
o Paranoia
Newborn Assessment (APGAR).
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7-10 = No Distress
4-6 = Moderate Distress
Under 4 = Severe Distress
Score is based on 5 areas
o HR (0/1/2)
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o
o
o
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RR (0/1/2)
Muscle Tone (0/1/2)
Reflex Irritability (0/1/2)
Color (0/1/2)
Video #12: New Ballard Scale
 Neuromuscular Maturity
o Full Term = Well Flexed
 Physical Maturity
o Preterm
 Skin: Thinner/Transparent skin, may be sticky
 Lanugo
 No plantar creases
 No breast tissue/ not well developed
 Boys  Flat/ Smooth scrotum
 Female  prominent clitoris and flat labia
o Full Term.
 Skin: Thicker
 No lanugo
 Plantar creases
 Will have breast tissue (5-10mm in width)
 Boys  Pendulum/Rugae scrotum
 Girls  Labia will be more developed and will encompass clitoris
o Post-mature.
 Skin: Wrinkled, crack, leathery appearance.
 Normal Deviations in Newborns
o Milia = small raised white spots on the nose or chin  will go away w/o treatment
o Mongolian Spots = bluish purple spots on their back or bottom
o Head = 2-3 cm larger than chest circumference; chest should be barreled shaped
 Should have anterior and posterior fontanel; should be soft and flat
 Anterior = diamond shape, 5 cm in size
 Posterior= smaller in size, triangular shape
 If fontanel is bulging, it is NOT NORMAL.
 Sunken is NOT NORMAL.
 Caput Succedaneum “conehead” & Cephalohematoma “bleeding under scalp”
will resolve on their own.
o Eyes = Blue or grey at birth; true eye color established in 3-5 months
o Ears = low set  may indicate down syndrome
o Epstein’s Pearls  small white cysts found at the gums and junctions of the soft and
hard pallets
 Grey white patches on the tongue and gums IS NOT NORMAL. May be
infection!!
Video #13: Reflexes
Sucking & Rooting  Birth to 3-4 months but can last up to a year.
Palmar Grasp  Birth to 6 months
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Plantar Grasp  Birth to 8 months
Moro Reflex  Birth to 6 months
Tonic Neck Reflex  Birth to 3-4 months
Babinski Reflex  Birth to 1 year
Stepping  Birth to 4 weeks
Must keep baby warm. Baby can lose heat in 4 different mechanisms:
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Conduction: Direct contact with a cooler surface
Convection: Lose heat from cooler, environmental air (i.e fan)
Evaporation: Lose surface liquid through vapor
Radiation: Loss of heat from the body surface to another surface that is close by (window or air
conditioner)
Side Notes:
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Meconium should be passed within 24 hours after birth.
Prophylactic eye care  Erythromycin to prevent eye infection from chlamydia or gonorrhea.
Vitamin K  Needed to prevent hemorrhaging given until they can produce their own.
HEPB Vaccine is given at birth (immediately)
Be on lookout for hypoglycemia (S/sx  jitteriness, twitching, high pitched cry, irregular
respirations, lethargy, cyanosis, eye rolling, seizures, blood glucose level will be under 40 mg/dl)
Video #14: Newborn Nutrition
 May lose 5-10% of body weight right after birth but should regain weight within 10-14 days
after they are born
 Breastfeeding is highly advised  reduces risk of infection, helps with brain growth, is
inexpensive and convenient, reduces instances of SIDS
o For the first 6 months of life, babies only need milk
o First food that is introduced (6 months of age) FE fortified cereal (rice)
 Do not introduce solids until 6 months of age
o Breastfeeding is encouraged right after birth to begin breastfeeding
 Can expect uterine cramps while breastfeeding (release of Pitocin; will help
uterus contract and reduce incidences of uterine atony)
 Breastfeed 15-20 mins per breast
 Empty the breast
 Best indicator that baby is eating well
 Voiding 6-8 diapers per day
 How to store breastmilk and formula;
 Breastmilk:
o Stored at Room temp under clean conditions up to 8 hrs
o Refrigerated in sterile bottles for 8 days
o Frozen for up to 6 months
o Deep freezer = 12 months
o Thawing milk  Thaw in fridge for 24 hrs (DO NOT
MICROWAVE OR REFREEZE)
 Use portions of breast milk must be discarded. DO NO
REUSE
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
How to store Formula:
 Can be stored in fridge up to 48 hrs
 Discard any unused portion just like you would breast milk
 Always put baby to sleep on their back to reduce chances of SIDS
 Cord Care & Circumcision Care
o Umbilical Cord:
 Keep dry & above diaper (fold diaper in front so it doesn’t cover cord)
 Sponge baths only until cord falls off (10-14 days after birth)
 Monitor cord and make sure it is not moist, red, or house foul odor or purulent
drainage.
o Circumcision care:
 Clamp procedure
 Apply petroleum jelly with each diaper to prevent diaper from sticking to
penis
 Tub bath is not to be given until circumcision is completely healed
 Yellow film of mucus will form over glands by day 2, DO NOT wash
off.
 May give baby acetaminophen
 Care Safety
o Rear facing car seat, middle seat until age 2!
Video #15: Newborn Complications
Hypoglycemia  Glucose level < 40; GET BABY FOOD.
Preterm Newborn
 At risk for complications:
o Respiratory distress
o Bronchopulmonary dysplasia
o Necrotizing Enterocolitis (inflammatory disease of GI system)
o Hypotonic Muscles
 LGA (Large for Gestational Age):
o Macrosomic (large baby with organs that are not fully developed)
 Born to mothers with diabetes
 Suffer from hypoxia, hypoglycemia, or hypocalcemia (can cause tremors)
 Post-Term:
o Lose subcutaneous fat
o Hair and nails may be long
o May have meconium staining on nails or umbilical cord
 Hyperbilirubinemia  Jaundice
o Physiologic Jaundice = Benign (occurs 24 hrs of age and resolves w/in 7 days)
 Due to immaturity of baby liver
o Pathologic Jaundice = extends over 7 days. Related to blood group incompatibility
related to some kind of infection.
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o
o
o
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Bilirubin Encephalopathy = very dangerous. Related to untreated hyperbilirubinemia.
Levels >25 mg/dl. Associated with cerebral palsy, epilepsy, mental handicap
*Note time that jaundice set in to be able to differentiate types of jaundice
Phototherapy is prescribed if bilirubin is:
 15mg/dl in newborn prior to 48 hrs of age
 18 mg/dl in newborns prior to 72 hrs of age
 >20 mg/dl at anytime then phototherapy is considered
 Interventions:
 Eyes mask over baby
 Keep newborn undressed
 Cover up genitalia on baby
 Avoid applying lotion (absorbs heat and can cause burn)
 Remove baby Q4 hrs, check eyes
 Reposition Q2 hrs
 Effects:
 Bronze discoloration & rash is not serious
 Monitor for dehydration (sunken fontanels, wet diapers)
 Make sure you feed baby frequently or provide formula to help excrete
bilirubin