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Obstetrics
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Prenatal Period
A time of physical and psychological preparation for birth and parenthood
Duration of pregnancy: Gestation
Time of fertilization of ovum until the estimated date of birth
Spans 40 weeks or 280 days after the last menstrual period or 266 days after conception
Separated into 3 trimesters
o First: Weeks 1-13
o Second: Weeks 14-26
o Third: Weeks 27-40
Diagnosis of Pregnancy
 Presumptive indicators:
o Reported by the pregnant person (usually subjective)
o Amenorrhea, nausea and vomiting, breast tenderness, urinary frequency, fatigue
o Quickening- feeling baby move
 Probable indicators:
o Detected by examiner (usually objective)
o Uterine enlargement
o Braxton Hicks contractions
o Placental souffle- soft, blowing sound heard on auscultation produced by fetal
circulation at the placenta
o Ballottement- examiner taps the wall of the uterus and feels the fetus rebound
o Goodell sign- softening of cervix around 6-8 weeks gestation
o Positive pregnancy test
 Positive indicators:
o Attributed to the fetus
o Distinct fetal heartbeat (doppler or fetoscope)
o Fetal movement felt by someone other than the pregnant person
o Visualization of the fetus (ultrasound)
Gravidity and Parity
 Gravidity – refers to the number of times pregnant
o Nulligravida = never been pregnant
o Primigravida = pregnant for the first time
o Multigravida = at least their second pregnancy
 Parity – refers to the number of births after 20 weeks gestation
o Nullipara = has not had birth at more than 20 weeks of gestation
o Primipara = has had 1 birth that occurred after the 20th week of gestation
o Multipara = has had 2 or more pregnancies to the stage of fetal viability
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Pregnancy Outcomes: GTPAL
 G = Gravidity - # of times the person has been pregnant (includes current pregnancy,
miscarriages, and abortions)
o Only time you count the current pregnancy
o Person pregnant with twins/triplets would still be G=1
 T = Term births - # born (alive or stillborn) passed 37 weeks gestation
o Count the pregnancy only
o Person pregnant with twins/triplets would still be T=1
 P = Preterm births - # born 20-36 weeks 6 days (alive or stillborn)
o Count the pregnancy only
o Person pregnant with twins/triplets would still be P=1
 A = Abortions (or miscarriages) - pregnancy losses before 20 weeks (counts toward
gravidity as well)
o Preterm or term is not an abortion
o Count only pregnancy (not individual fetuses for multiple pregnancies)
 L = # of current Living children
o Only time multiples are counted separately
GTPAL Tips:
 ALL pregnancies counted with gravidity, including current pregnancy
 Twins/triplets, etc. count as 1 for G, T, P, A
o Count each LIVE child individually for L
 A termination of the pregnancy after 20 weeks is referred to as a “therapeutic
termination”
o The death of a fetus after 20 weeks for any reason is counted towards
term/preterm births (not abortion)
Example: Olivia is pregnant for the fourth time. Her first pregnancy she carried to term, and the child
is still living. Her second pregnancy ended in miscarriage at 10 weeks. During her 3rd pregnancy, she
gave birth at 36 weeks to twins (both currently living)  G=4 T=1 P=1 A=1 L=3
Pregnancy Appointments
Initial Visit
 Prenatal interview (most extensive interview)
 Gynecological history - GTPAL
 History or risk of intimate partner violence (risk increases with pregnancy)
 Review of systems
 Gestational age- may be calculated using Naegele’s rule or other methods
Naegele’s Rule
 Start with first day of LMP
 Subtract 3 months
 Add 7 days
 Add 1 year if applicable
*Assumes 28-day cycle
ex. October 15 th 2022
July 15th 2022
July 22nd 2022
July 22nd 2023
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Physical examination
Supine hypotension (baby compresses inferior vena cava/abdominal aorta)
o Advise to sleep on left lateral side
 Laboratory tests
o Urine, cervical, and blood samples
 HGB and HCT decrease in pregnancy d/t hemodilution (circulating blood
volume expands so much there is a relative lowering of blood values)
o Screening and diagnostic tests for infectious diseases and metabolic conditions
 Nausea and vomiting during pregnancy
o Typically lasts through the first semester
o Health teaching: vitamin B6, ginger, simple carbohydrates (pasta, crackers), salt,
antiemetics, avoid spicy/fatty foods, smaller meals more frequently, drink liquids
between meals rather than at meals, eat crackers in bed before getting up, avoid
triggers
 When to worry – Hyperemesis Gravidarum
o Persistent nausea and vomiting during pregnancy in the first trimester that
causes disturbances in nutrition and fluid and electrolyte balance
o Interventions: antiemetics, fluid replacement therapy, monitor FHR, drink
between meals rather than at meals to avoid stomach distension, sit upright
after meals, monitor for signs of dehydration, ketones, and electrolyte imbalance
Follow-up Visits
 Frequency:
o First 28 weeks: q4weeks
o 28-36 weeks: q2weeks
o 36-40 weeks: q1week
* More often for high-risk pregnancies
 Interview (how are things going?)
 Physical examination:
o Fetal assessment
o Fetal heart tones
o Fundal height
 Gestational age
 Health status
 Additional blood tests
 Group B strep:
o Should be tested between 35 & 37 weeks
o All women should be tested regardless of birth plan
o Studies show that within 5 weeks of delivery is most accurate (don’t want to test
too early- status can change)
 Gestational Diabetes Mellitus (GDM)
o Should be tested between 24 & 28 weeks*
o Earlier if high risk
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Reminders
 There is an increased incidence of physical, mental, and verbal abuse during pregnancyimportant to assess
 Teach to avoid supine lying in 2nd and 3rd trimester
o Hypotension from pressure on inferior vena cava
o Remain mindful when completing abdominal exams
 Culture, age, parity, and multifetal pregnancy can have a significant effect on the course
and outcome of the pregnancy
 Nurses must ask patients and their families about preferences, practices, and customs
related to childbearing to provide culturally sensitive care
Risk Conditions Related to Pregnancy
Hemorrhagic Disorders (Medical Emergencies)
 Bleeding in pregnancy jeopardizes pregnant parent and fetal well-being
 Blood loss decreases oxygen-carrying capacity and increases risk for the following
conditions:
o Hypovolemia
o Anemia
o Infection
o Preterm labour
o Impaired oxygen delivery to the fetus
o Hemorrhagic disorders in pregnancy are medical emergencies
 Early bleeding Miscarriage (spontaneous abortion)
o A pregnancy that ends as a result of a natural cause before 20 weeks of gestation
o Approximately 10-15% of pregnancies end in miscarriage
o Nursing Care:
 Depends on the classification of the miscarriage and S & S
 Expectant management
 Medical management- Misoprostol (Cytotec)
 Surgical management- Dilation and curettage (D&C)
 Follow-up care - phone calls; support groups
 Loss at any stage should be treated as profound
 Late bleeding Placenta Previa
o Placenta implanted in lower uterine segment near or over internal
cervical os
o Degree to which the internal cervical os is covered by placenta has
been used to classify three types:
 Total (complete) placenta previa
 Partial placenta previa
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 Marginal (Low-lying) placenta
o Clinical manifestations:
 Sudden onset of painless, bright red vaginal bleeding
 Uterus is soft, relaxed, and nontender
 Fundal height may be more than expected for gestational age
o Interventions
 Monitor maternal and fetal VS and fetal activity
 Initiate patient bed rest or limited activity
 Monitor bleeding
 If bleeding is heavy, caesarean delivery may be warranted
 Vaginal exams used to be the standard- no longer recommended (could
result in fetal loss)
 May correct itself as the pregnancy progresses
Late bleeding Abruptio Placentae
o Premature separation of placenta from uterine wall after the 20 th week of
gestation before the fetus is delivered
o Clinical manifestations:
 Dark red vaginal bleeding
 Uterine pain or tenderness
 Severe abdominal pain
 Fetal distress
o Interventions:
 Monitor maternal and fetal VS and fetal activity
 Assess for excessive vaginal bleeding, abdominal pain and increase in
fundal height
 Initiate patient bed rest, administer O2 and fluids
 Place patient in Trendelenburg’s
 Prepare for immediate delivery
 Monitor for DIC postpartum
Reminder: Hemorrhagic Disorders
o Blood loss during pregnancy = warning sign until the cause is determined
o Some miscarriages occur for unknown reasons, but fetal or placental
maldevelopment and maternal factors account for many others
o A pregnancy that ends before 20 weeks’ gestation (whether spontaneous or
elective) is termed an abortion
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o Placenta previa and placental abruption are differentiated by type of bleeding,
uterine tonicity, and presence or absence of pain
Gestational Diabetes (GD)
 Elevated glucose levels that are first recognized during pregnancy
 Most return to a euglycemic state after birth
 In Canada, affects 3.8 - 6.5%
 Considered high risk
 Characterized by hyperglycemia resulting from defects in insulin secretion, insulin
action, or both
 Clinical manifestations:
 Excessive thirst
 Hunger
 Weight loss
 Frequent urination
 Blurred vision
 Glycosuria and ketones
 Large for gestational age fetus
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Fetal risks:
Caesarean birth more likely
Macrosomia (high birth weight)
Shoulder dystocia
Hypoglycemia within 2 hours of birth (r/t withdrawal of glucose supply)
Risk factors:
Age over 35
Obesity
Indigenous persons
Multiple gestations
Polycystic ovarian syndrome (PCOS)
Previous delivery of child weighing over 9lb (4kg)
Previous pregnancy with GD
Hypertension in pregnancy
Interventions:
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Antepartum care:
 Diet & Exercise
 Monitor patient’s weight
 Assess for maternal complications
 Self-monitoring of blood glucose
 Pharmacologic therapy
 Fetal surveillance
 Intrapartum:
 Blood glucose monitored hourly in labor
 Administer insulin as needed
 Postpartum:
 Likely normal glucose levels after birth
 Need to be re-tested 6 weeks - 6 months
 Likely to recur in future pregnancies
 Risk for Type 2 (40% increased risk)– baby too!
Hypertensive Disorders of Pregnancy
 Major cause of perinatal morbidity and mortality due to:
 Uteroplacental insufficiency (placenta not working properly)
 Premature birth
 Of maternal* deaths worldwide, 10-15% can be attributed to preeclampsia and
eclampsia
 Preeclampsia accounts for more than 50,000 maternal* deaths each year
 4 major categories:
1. Preeclampsia
2. Chronic/pre-existing HTN
3. Chronic HTN with superimposed preeclampsia
4. Gestational HTN
 Onset of hypertension without proteinuria or other systemic findings
diagnostic for preeclampsia after week 20 of pregnancy
 Systolic BP >140, diastolic BP >90
Preeclampsia:
 Pregnancy-specific condition in which hypertension and proteinuria develop after 20
weeks of gestation in a previously normotensive woman
o When it occurs before 32 weeks, it’s referred to as early onset pre-eclampsia
 Patients often experience headache, proteinuria* and blurred vision
o Proteinuria is not a reliable indicator because kidney and liver dysfunction can
occur without signs of protein; amount of protein does not predict severe
disease progression
 If unmanaged, can lead to eclampsia and seizures
 In the absence of proteinuria, preeclampsia may be diagnosed if hypertension exists
with any of the following:
o Thrombocytopenia
o Impaired liver function
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o New development of renal insufficiency
o Pulmonary edema
o New-onset cerebral or visual disturbances
Risk factors:
o Previous preeclampsia or gestational HTN
o Previous placental abruption or fetal demise
o Primigravida (first pregnancy)
o Family hx of first-degree relative with preeclampsia
o Age 40 years or older
o Black ethnicity
o Multifetal pregnancy
o Hx of chronic HTN and/or kidney disease
o BMI greater than 26
o Metabolic syndrome
o Medical conditions (DM, lupus, thrombophilia, etc.)
o Multiple gestation
o Used IVF to conceive
Important lab values:
o CBC
o Serum creatinine
o Liver chemistries
o Urinary protein (not a reliable diagnostic sign)
o Coagulation measures* indicated in pts with placenta previa and placentae
abruptio (risk for DIC)
Clinical manifestations:
o Persistent HTN
o Swelling of face or hands
o Headache; visual changes such as blurred vision
o Pain in upper abdomen or shoulder (liver)
o Nausea & vomiting (2nd half of pregnancy)
o Sudden weight gain
o Difficulty breathing
o *Monitor neurological status
*Signs of eclampsia
o *Monitor deep tendon reflexes for presence of hyperreflexia or clonus
HELLP Syndrome (medical emergency)
o Severe pre-eclampsia can result in HELLP syndrome
o Complication of HTN and gestational HTN disorders
o May represent a severe form of preeclampsia or may be a separate disorder
o Characterized by Hemolysis, Elevated Liver Enzymes, and Low Platelet Count
o Clinical manifestations:
 Pain in RUQ
 Headache
 Blurred vision
 HTN
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 Proteinuria
 Edema
o Management:
 Bed rest
 Transfusions for severe anemia
 Monitor for seizures
 Anti-hypertensives
 Fetal monitoring
Chronic (pre-existing) Hypertension:
 HTN present before pregnancy or diagnosed before week 20 of gestation
Preeclampsia Superimposed on Chronic Hypertension
 Chronic hypertension with new proteinuria or exacerbation of previously well-controlled
hypertension or proteinuria, thrombocytopenia, or increases in hepatocellular enzymes
 Already had hypertension pregnancy made it worse
Complications of Gestational HTN
Eclampsia
 Onset of seizure activity or coma in a woman with preeclampsia
 No history of pre-existing pathology
 Condition can develop while pregnant or in the immediate postpartum period
 Emergency interventions:
o Stay with the patient, prevent self-injury, enhance oxygenation, reduce
aspiration risk, establish control with magnesium sulfate and prepare for delivery
o Magnesium sulfate- anticonvulsant of choice for preventing or controlling
eclamptic seizures, requires careful monitoring of reflexes, respirations, and
renal function
 Toxicity starts with loss of reflexes and progresses to respiratory
paralysis and cardiac arrest
 Antidote: calcium gluconate
Care Management for Hypertensive Disorders
 Monitor BP closely- Instruct patient on how to accurately monitor BP at home
 Monitor fetal activity and fetal growth
 Encourage frequent rest periods/best rest depending on severity
 Ensure compliance with antihypertensives
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o Recommended for severe hypertension (BP > 160/110) with the goal to maintain
BP around 140/90
o Ex. hydralazine, labetalol, nifedipine
Ensure adequate hydration (avoid diuretics)
Monitor urine output and neurological status
o Assess deep tendon reflexes for hyperreflexia or clonus (absence of reflexes)
Monitor for HELLP syndrome
Corticosteroids may be administered for fetal lung maturity
Delivery will be considered for patients over 34 weeks of gestation
o Delivery is the cornerstone of treatment
o Only curative treatment
o Prompt delivery is indicated after maternal stabilization
Coordinating Care for a Patient with a Complex Medical Condition
 Identify the needs of the patient
 Engage the patient in care coordination
 Determine which organizations/disciplines should be a part of the patient’s team
 Create a coordinated care plan
 Reassess the patient based off desired care needs
Labour
Factors Affecting Labour
Powers
 Uterine contractions forces (powers) acting to expel the fetus
 Primary powers:
o Body’s physiologic mechanism
o Frequency, duration, intensity
o Effacement- shortening and thinning of the cervix
o Dilation- enlargement of the cervical os and canal
 Cervix dilates to 10cm during the first stage of labour
 Secondary powers:
o Bearing-down efforts
o Valsalva maneuver
Passageway
 Birth canal bony pelvis, soft tissues of the cervix, pelvic floor and introitus
 Soft tissues: lower uterine segment, cervix, pelvic floor muscles, vagina, introitus
 Bony pelvis - 4 main types (may determine need for C-section)
o Gynecoid (preferred)
o Android
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o Anthropoid
o Platypelloid
Passenger
 The Fetus
o Size of the fetal head
o Bones in the fetal skull
o Fontanels
o Molding
 Fetal Presentation
o The part of the fetus that enters the pelvic inlet first and leads through the birth
canal during labour
o Cephalic
 Most common and the goal; head-first
 **Vertex (occiput), military (sinciput), brow, face
o Breech
 Bum/legs first
 Complete (full), incomplete/footling, frank
 C-section may be required, vaginal still
possible
o Shoulder
 Transverse lie, or the arm, back, abdomen, or side first
 Hopeful for spontaneous rotation, if not manual
o If rotation unsuccessful  C-section
 Fetal Lie
o The relationship of the spine of the fetus to the spine of the pregnant woman
o Longitudinal (vertical)
 Fetal spine is parallel to mother’s spine
 Fetus is either in cephalic or breech presentation
o Transverse (horizontal)
 Fetal spine is perpendicular to mother’s spine
 Presenting part is shoulder
 C-section is required
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Fetal Position (only applicable to vaginal deliveries)
o The relationship of a reference point on the presenting
part to the four quadrants of the pregnant person’s
pelvis.
o Position is denoted by a three-part letter abbreviation
1. Location of the presenting part
 Left (L) or right (R) side of the mother’s pelvis
2. Specific part of the presenting fetus
 Occiput (O), sacrum (S), mentum/chin (M),
scapula (Sc), acromion process (A)
3. Location of the presenting part in relation to the
mother’s pelvis
 Anterior (A), posterior (P), transverse (T)
o Ideal position: ROA/LOA (head-down, chin tucked, facing mom’s back)
 Fetal Station
o Measurement of progress or descent in centimetres above or
below the mid-plane from the presenting part to the ischial
spine
o Station 0- ischial spine
o Minus station- above the ischial spine
o Plus station- below the ischial spine
o Fetal engagement- widest diameter of the presenting part has
passed the pelvic inlet; corresponds to 0 station
o Pressure of baby may be needed to help with effacement
Position (Maternal)
 A labouring patient should be encouraged and assisted to find a comfortable position
 Frequent positions help relieve fatigue, increase comfort, and improve circulation
 Gravity helps the fetus to move down the birth canal
Psyche
 Patient’s emotional well being and state during labor
 Intense anxiety may stall labour
Process of Labour
Process of moving fetus, placenta,
and membranes out of the uterus
and through the birth canal
Lightening or dropping
Signs preceding labour
Bloody show
Contractions
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Onset of labour (signaling start)
o Uterine stretch
o Progesterone withdrawal
o Increased oxytocin sensitivity
o Increased release of prostaglandins
True vs. False Labour
May need to assist through
administration of Pitocin or
prostaglandins
Stages of Labour
 First Stage
o Time dilation begins to the time the cervix is fully dilated
o Latent phase
 0-3cm dilated
 Contractions- mild intensity, q15-30mins, lasting 15-30 seconds
 Mom encouraged to remain at home- more comfortable
o Active phase
 4-7cm dilated
 Contractions- moderate intensity, q3-5mins, lasting 30-60 seconds
o Transition phase
 8-10cm dilated
 Contraction- strong intensity, q2-3mins, lasting 45-90 seconds
o First stage interventions:
 Encourage all partners to participate in labour
 Discharge home is possible; assist patient and partner(s) as needed
 Assist with comfort measures (e.g., breathing, ice chips, positioning)
 Keep all parties informed along the way
 Monitor maternal and fetal vital signs, especially during contractions
o Spot checking may be appropriate- allows freedom
 Assess cervical dilation and effacement
 Provide pain management interventions as needed
 Maintain privacy
 Prepare for birth
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o Breathing
 Cleansing breaths- each contraction begins and ends with a deep
inspiration and expiration
 Slow-paced breathing- promotes relaxation
o Used for as long as possible
 Modified-paced breathing- used when slow paced no longer effective
o Shallow and fast
 Patterned-paced breathing- rate is the same as modified-paced
o After a few breaths, the patient exhales with a slight blow
 Breathing to prevent pushing- patient blows repeatedly using short puffs
when the urge to push is strong
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Second Stage
o Lasts the time of full cervical dilated to birth of the fetus
o Contractions occur q2-3mins, lasting 60-90 seconds and are strong in intensity
o Seven cardinal movements of mechanism of labour
 Refer to changes in position of the fetal head during passage; described
in relation to vertex presentation
1. Engagement
2. Descent
3. Flexion
4. Internal rotation
5. Extension
6. Restitution and external rotation
7. Expulsion
o Vaginal delivery
 Crowning- top of baby’s head can be seen
through the opening in the vagina
 Episiotomy- incision made between the
vaginal opening and the anus to allow the baby to pass through the
vagina
 Vaginal tearing may also occur if the vaginal opening is not large enough
to pass the baby’s head
o 1st degree- 1-2cm past the vagina; usually heals on its own
o 2nd degree- between the vagina and rectum (requires sutures)
o 3rd degree- from the vagina to the rectum (requires sutures)
o 4th degree- from the clitoris to the rectum (requires sutures)
 Forceps/vacuum may be used to assist vaginal delivery when labor is not
progressing
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Third Stage
o Infant’s birth to expulsion of placenta
 Placenta expelled 5-30 minutes after birth
o Placental presentation has no clinical significance
o Interventions:
 Assess maternal VS and uterine status
 Ensure placenta intact
 Promote maternal-newborn attachment
 Fourth Stage
o Immediate postpartum period (2 hours following birth)
o Monitor for complications and promote maternal-newborn attachment
WHO’s Recommendations on Effective Communication Between Care Providers and Persons in
Labor
 Introduce yourself to all parties
 Keep all parties informed along the duration of the labour, using clear language and
avoiding medical jargon
 Respect the patient’s needs, preferences and question with a positive attitude
 Ensure privacy, confidentiality, and dignity are maintained at all times
 Referred to as respectful maternity care
 Encourage all parties to ask questions and express their concerns
 Offer encouragement, praise and reassurance
 Support the person in labour to understand that they have a choice
Fetal Heart Rate Monitoring
Monitoring Techniques
 Monitor fetal response to determine fetal wellbeing and determine oxygen supply has
not been compromised
 Intermittent Auscultation
o Assessing FHR in low-risk women
o Contractions assessed via palpation
o Spot checks- allows woman to ambulate and remain unrestricted
 External Fetal Monitoring
o Fetal monitor displays FHR and uterine activity
o Assesses frequency and duration of contractions in response to FHR
o Transducer is placed over the fundus where contractions are the strongest
o TOCO monitor
 Internal Fetal Monitoring
o Invasive and requires rupturing of the membranes
o Electrode is attached to the fetus
o Should be avoided when possible
Fetal Heart Rate Patterns
 When in labor we assess the FHR relative to mom’s contractions
Baseline Fetal Heart Rate
 Average rate during a 10-minute segment that excludes:
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o Periodic or episodic changes
o Periods of marked variability (segments of the baseline that differ by more than
25 beats/min)
 There must be at least 2 minutes of interpretable data
 Line of best fit
 Normal range is 110-160 at term
o Tachycardia: >160 beats/min x 10 minutes or more
o Bradycardia: <110 beats/min x 10 minutes or more
Changes in Fetal Heart Rate
 Variability- irregular fluctuations in the baseline FHR
o Absent variability is non-reassuring
o Moderate variability (6-25bpm) is the goal
 Periodic changes- occur with uterine contractions
 Episodic changes- not associated with uterine contractions
 Accelerations- brief temporary increase in FHR of at least 15bpm more than baseline
lasting at least 15 seconds
o Considered an indication of fetal well-being
o Periodic accelerations result from compression to fetal buttocks
o Episodic accelerations result from fetal movement
 Decelerations- decrease in FHR of at least 15bpm less than baseline
o Early decelerations- FHR dips at beginning of contraction and
returns to baseline at end of contraction
 Response to fetal head compression
 Good sign
o Variable decelerations- abrupt decrease in FHR not related to
contraction
 Response to umbilical cord compression
 U or V shaped (rapid descent and return to baseline)
 May be resolved by changing mom’s position or with an
amniotic infusion
 Occasionally line up with contractions by chance
o Late decelerations- FHR dips in the middle of contraction and
does not return to baseline when contraction finished
 Due to uteroplacental insufficiency (compromised blood
flow from placenta to fetus)
 May result from maternal supine hypotension change
position
 Administer oxygen
o Prolonged decelerations- decrease in FHR lasting 2-10 minutes
 Decreased blood supply decreased oxygen
 May be an emergency
o Nursing interventions for non-reassuring decelerations (late, variable, prolonged)
 D/C oxytocin
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Change maternal position
Administer oxygen via facemask 8-10L
Normal FHR Patterns:
 Described as reassuring
 Baseline FHR in normal range (110-160)
 Moderate FHR variability (6-25bpm)
 Accelerations
 Early decelerations may or may not be present
Abnormal FHR Patterns:
 Bradycardia or tachycardia
 Late decelerations
 Prolonged decelerations
 Hypertonic uterine activity (stacked contactions)
 Decreased or absent variability
 Variable decelerations falling to less than 70bpm for longer than 60 seconds
 Priority nursing actions for a non-reassuring/abnormal FHR pattern
o Discontinue the oxytocin
o Identify the cause
o Change the pregnant person’s position
o Administer oxygen by face mask at 8-10L/minute and infuse IV fluids as
prescribed
o Prepare to initiate continuous electronic fetal monitoring with internal devices (if
not contraindicated)
o Document the event, actions taken, and the patient’s response
FHR Monitoring Nursing Care & Management
 Five essential components of the FHR tracing that must be evaluated regularly:
o Baseline rate
o Baseline variability
o Accelerations
o Decelerations
o Changes or trends over time
 If any component of FHR tracing is abnormal, corrective measures must be taken
immediately to improve fetal oxygenation: intrauterine resuscitation
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o
o
o
o
o
Hold oxytocin (if currently running)
Provide supplemental oxygen
Assist patient to change positions
Increase intravenous fluids
Prepare for birth as needed
Postpartum
Fourth Stage of Labour
 First 2 hours after birth
 Essential for skin-to-skin contact- helps in forming bond and adjustment to extrauterine
life
 Monitor lochia and VS to assess for immediate postpartum complications
 Interventions:
o Perform maternal assessments q15min x 1 hour, q60min x 1, and then q4h
o Apply ice packs to the perinium
o Provide breastfeeding support as needed
Postpartum Period
 Postpartum (PP) period is the interval between birth and return of the reproductive
organs to their nonpregnant state
o Involution process- rapid decrease in the size of the uterus to pre-pregnancy
state (shrinks approx. 1cm per day)
 Begins immediately after birth and is normally completed by 6 weeks
 Contractions
 Afterpains- result of the contraction of the uterine
 Cervix- connective tissue and muscle begin to regenerate
 Perineal site/discomfort
o Administer perineal care to prevent infection (e.g. peri bottle, blot dry)
o Apply ice packs and pain medications as needed
Postpartum Assessments
 Fundus- uterus should be palpated to assess size and tone
o Fundus descending into the pelvis- approx. 1cm/day (should not be palpable by
day 10)
o Should be firm indicating uterine contraction
 Boggy uterus requires fundal massage- indicates uterine atony
 Extreme/worsening tenderness may indicate presence of infection
o Assessed and massaged using 2 hands to prevent uterine prolapse
 Lochia- post-birth uterine discharge that consists of blood from placenta and debris
from decidua
o Colour
 Rubra
 Bright/dark red discharge
 Lasts 3-4 days
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Serosa
 Pink-brown coloured discharge
 Lasts 4-10 days
 Alba
 Whitish-yellow colored discharge
 Lasts 10-28 days
o Amount
 Scant = < 2.5cm / 1 inch stain on pad
 Light = < 10cm / 4 inches stain on pad
 Moderate = < 15cm / 6 inch stain on pad
 Heavy = pad saturated within 1 hour
 Lochia should never exceed a moderate amount in an hour (approx. 6
inches of stain on pad)
 Small clots are okay
 Important to assess how often pad is being changed/when it was last
changed
 Should never go through more than 6 pads/day
 Everyone is different- trending and assessing clinical picture is important
Postpartum hemorrhage
o Traditionally defined as:
 Loss of 500 ml of blood after vaginal birth
 Loss of 1000 ml after caesarean birth
 A 10% change in Hct between labour and postpartum
o Leading cause of maternal morbidity and mortality- often unrecognized until
profound symptoms
 Close assessment and listening to patient key in differentiating normal
lochia from hemorrhage
 Healthy people are able to compensate blood loss initially
o Can occur early in postpartum period (24 hours PP) or late (24 hours-6 weeks PP)
 Most common around 2 week mark
 Education on S&S and when to seek help is vital
o Leading cause- uterine atony (marked hypotonia of the uterus)
 Associated with:
 High parity
 Hydramnios
 Macrosomic (>9lbs) fetus
 Multifetal gestation
 Retained placenta (adherent or nonadherent)
o Caused by too few contractions
o ‘Clots’ that can’t be broken apart (fat on steak texture)
may be placental fragments and require intervention
 Lacerations of genital tract
 Hematomas
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o Care Management:
 Early recognition and treatment of PPH are critical
 The initial intervention is firm massage of the uterine
fundus
 Elevate the patient’s legs to 30-degrees
 Administer O2 and monitor VS frequently
 Continuous intravenous (IV) infusion of 10 to 40 units of
oxytocin added to 1000 ml IV fluid
 If unresponsive to treatment, carboprost
thromethamine may be ordered to induce
contractions and reduce post-partum bleeding
 Administer blood products as needed
 Expression of any clots in the uterus
 Elimination of bladder distention- may cause uterine atony
 Have patient try to void, In-and-out catheter may be required
Vagina and perineum
o Episiotomy and laceration assessments- monitor for signs of infection
o Hemorrhoids- monitor bowel status, encourage ambulation
Pelvic muscular support
o Pelvic relaxation
o Kegel exercises
Postpartum Infections
o Also called puerperal infection
o Any clinical infection of the genital tract that occurs within 28 days after
miscarriage, induced abortion, or birth
o Defined as presence of a fever of 38oC or more on 2 successive days of the first
10 postpartum days (not counting the first 24 hours after birth- slight temp
increase expected)
o Endometritis- Infection of the lining of the uterus
 Most common postpartum infection
 Anorexia is a common clinical manifestation
o Wound infections
 Often develop after mothers are discharged home
 Education needed regarding incision care, S&S, and when to seek
medical attention
 Typically, caesarean incision, repaired laceration, or episiotomy site
 Localized redness and edema are common clinical manifestation
o Urinary tract infections
 Caused from urinary retention and stasis and catheter use
o Monitor for fever, chills, localized redness and edema, odorous discharge,
elevated WBCs
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Breastfeeding
o Put the newborn directly onto the mother’s chest
Fed is Best Movementimmediately after birth
 Important mothers who
 Babe will naturally move towards the breast
cannot/choose not to
o Assess LATCH:
breastfeed don’t feel
 Latch achieved by the newborn
judged
 Mouth should cover the areola
 Important to also teach
 Audible swallowing
on how to properly
 Type of nipple
feed baby with formula
 Comfort of mother
(kinds, preparation,
 Hold or position of baby
amount, etc.)
o First 24 hours colostrum
 Bond between mom
 Transitions to milk in 72 to 96 hours
and baby is utmost
o Engorgement comfort measures for breastfeeding
importance
patients versus bottle-feeding
 Engorgement resolves in 24 to 36 hours after
milk comes in
 Interventions vary based on whether breast of bottle feeding
 Breastfeeding moms want to express milk
 Bottle feeding moms don’t want to encourage expression (supply
and demand)
o Educate mother on the importance of keeping breasts clean and monitoring for
signs of infection
 Using soap to clean the breast is contraindicated (may lead to drying and
cracking)
 Rubbing breast milk into the nipples is moisturizing (prevention and
treatment)
o Breast pads may be utilized to absorb leaking milk between feeds
o Consult HCP before taking any medications (risk of transfer through breast milk)
o Monitor effectiveness of feeds by assessing baby’s output
 Number of wet diapers and stool characteristics (mustard appearance)
o Mastitis- infection resulting from a blocked milk duct
 Management:
 Continue to breastfeed
 Maintain good hand-washing techniques
 Appy heat
 Empty the breast frequently
 Ensure rest and adequate fluid intake
 Take analgesics and antibiotics as prescribed
Emotional Changes
o Provide education and anticipatory guidance on what to expect
o Provide strategies to cope with stress
o Monitor for sign of PP blues and depression
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Blues- unexplained crying, fatigue, headache, insomnia
 Can be normal in the beginning due to changing hormones
 Should be resolving
 Depression- appetite changes, crying, fatigue, lack of energy,
uninterested in infant, uninterested in activity, suicidal thoughts
o All patients should be assessed for depression during pregnancy and the
postpartum period
o Education provided to mom and partner to be aware of signs and symptoms
 BUBBLE HE
o Breasts- soft, filling, or firm; nipples
o Uterus- involution process; assess the tone, height and location; fundus should
be firmly contracted and midline
o Bowel- sounds, distension, constipation
o Bladder- distension, encourage patients to void
o Lochia- assess the amount, note time of last pad change, assess colour
o Episiotomy- redness, swelling, signs of infection
o Hemorrhoids- pain, swelling, burning
o Emotions- support adaptations to new role
Key Points
 The rapid decrease in estrogen and progesterone levels after expulsion of the placenta
is responsible for triggering many of the anatomic and physiologic changes in the
puerperium (6-week postpartum period)
 Within 6 weeks after birth, the physiologic changes induced by pregnancy have reverted
to their normal state
 Assessing lochia and fundal height is essential to monitor the progress of normal
involution and to identify potential problems
 The uterus involutes rapidly after birth and returns to the true pelvis within 10-14 days
 The return of ovulation and menses is determined in part by whether the woman
breastfeeds her infant
 Few alterations in vital signs are seen after birth under normal circumstances
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