Maternity
Introduction to Maternity & Pediatric Nsg; Leifer,
7th ed., Ch. (1, 2, 3 review), 4, 6, 7, 8
1. Discuss stages of fetal development.
2. Discuss major functions of each reproductive
structure.
3. Explain expected Δ’s in the major body systems
during pregnancy.
4. Describe diagnostic tests & estimating due dates.
5. Describe the 4 components of the birth process.
6. Explain the normal processes of childbirth:
premonitory signs, mechanisms of birth & stages
& phases of labor.
The Present: Maternity
https://www.youtube.com/watch?v=q0NRngqwqEg
• Family involvement during pregnancy & birth
• Necessary for bonding & support
Hospitals
• 3 separate sections of the maternity unit
• Labor-delivery
• Postpartum
• Newborn nursery
• Some facilities have merged all 3 areas into 1
Birthing Centers
• Provide comprehensive care
• Antepartum
• Labor-delivery
• Postpartum
• Mothers’ classes
• Lactation classes
• Follow-up family planning
Midwives
• First school of nurse-midwifery
• Opened in NYC, 1932
• Certified Nurse-Midwife (CNM)
• RN
• Graduate from an accredited midwife
program
• National certification
• Provides comprehensive prenatal &
postnatal care
• Attends uncomplicated deliveries
Advanced-Practice Roles in
Maternity & Pediatric Nursing
• Certified Nurse Midwife (CNM)
• Clinical Nurse Specialist (CNS)
• Neonatal Nurse Practitioner (NNP)
• Pediatric Nurse Practitioner (PNP)
• School Nurse Practitioner
• Family Nurse Practitioner (FNP)
Female Reproductive System
Uterus
• Pear-shaped organ in pelvis btw.
bladder & rectum
• Receives & nourishes fertilized egg
• 3 muscular layers
Endometrium – inner (decidua
basalis during pregnancy)
Perimetrium - outer
Myometrium - middle
Uterus
• Fundus - Upper rounded part
• Corpus - Middle - body
• Cervix - Lower part
• Internal Orifice (OS) opens
into uterus
• Canal
• External OS opens into vagina
Vagina
• Muscular tube that extends from cervix to
the vaginal opening in the perineum
• Known as the birth canal
• Passageway for menstrual blood flow,
penis intercourse, & the fetus
•
•
Ovaries
Form the expel ova
Primary source of estrogen &
progesterone
Fallopian Tubes
• Attached to each side of uterus
• Passageways for ovum to travel to
uterus
• Fertilization occurs in middle or outer
part of tubes & then fertilized egg
travels to uterus to implant itself
• ~ 5 – 7 days for ovum to travel
Fertilization & Implantation
Fertilization
• Occurs in the ampulla of the fallopian (uterine)
tube when sperm & ova unite
• When fertilized, the membrane of the ovum
undergoes changes that prevent entry of other sperm
• 23 chromosomes per reproductive cell
• Sperm carry X or Y chromosome, XY, male;
XX, female
Implantation
• The zygote implants in the uterus 6 to 8 days
after ovulation.
• The blastocyst secretes chorionic gonadotropic, so
the luteum remains viable & secretes estrogen &
progesterone for the first 2 - 3 months of gestation.
https://www.youtube.com/watch?v=UDpTaUtgf0g
Pelvis
• Ilium forms hip bones
• 2 pubic bones fuse at symphysis pubis
• Sit-down bones or ischial tuberosities
• ischial spines: bony projections on
ischium
• Pelvic joints lined w/cartilage which
soften (d/t relaxin) during
pregnancy & allows greater mobility
of pelvic bones
Prenatal Development
Embryo at 3 weeks, 4 weeks, 8 weeks
Growth of Embryo - Fetus
• 1 month – heart begins
to beat
• 2 months –
calcification of bones
• 3 months – facial
features are distinct
• 1-3 months - internal
organ development
• 4 - 9 months refinement of
development
http://www.youtube.com/watch?v=gfgq7WiHbh4
Placenta
Organ that sustains & nourishes the
growing pregnancy
3 main functions
• Provide for the transfer &
exchange of substances
• To act as a barrier to certain
substances
• To function as an endocrine
gland by producing hormones
Placental Hormones
• When pregnancy occurs the
fertilized egg implants in uterine
lining & secretes hCG human
chorionic gonadotropin
• hPL: promotes lactation
• Estrogen & progesterone: prepare
uterus for pregnancy, & breast for
lactation
Trophoblast develops into the placenta
Placenta has 2 membranes: chorion & amnion
https://www.youtube.com/watch?v=MzkIE8zn3b4
Amniotic fluid
Fills the amniotic cavity
Serves 4 main functions
• Physical protection
• Temperature regulation
• Provision of unrestricted
movement
• Symmetrical growth
Yolk sac: small structure attached
to embryo – produces blood cells
for ~ 6 weeks
Umbilical cord
• Fetus is attached to placenta by
umbilical cord
• Umbilical cord: contains 2 arteries & 1
vein (“AVA”)
• Surrounded by gel-like substance:
Wharton’s jelly
• Protects blood vessels & prevents
kinking of cord
Fetal Circulation
• Fetal HR: 160 to 170 beats/min during
first trimester, slowing to 110 to 160
beats/min near or at term
Fetal circulation bypass
• Ductus arteriosus connects pulmonary
artery to aorta, bypassing lungs
• Ductus venosus connects umbilical vein
& inferior vena cava, bypassing liver
• Foramen ovale is opening between
right & left atria of heart, bypassing
lungs
http://www.youtube.com/watch?v=-IRkisEtzsk
Δ’s in Circulation After Birth
http://www.youtube.com/watch?v=jFn0dyU5wUw
• Foramen ovale closes within 2 hrs after birth
(permanently by age 3 mons)
• Ductus arteriosus closes within 15 hrs
(permanently ~3 wks)
• Ductus venosus closes functionally when cord
is cut (permanently in about 1 wk)
• After permanent closure, the ductus
arteriosus & ductus venosus become
ligaments
• Multifetal pregnancy
– Monozygotic twins
• Identical twins derived from 1 zygote
• Share same genetic material; always
the same sex
– Dizygotic twins
• Fraternal twins develop from
separate egg & sperm fertilizations
• Genetic material is not identical; may
or may not be the same sex
Female Pelvis & Measurements
True pelvis
Lies below pelvic brim;consists of pelvic inlet,
midpelvis, & pelvic outlet
False pelvis
Shallow portion
above pelvic brim;
supports abd
viscera
Female Pelvis & Measurements (cont’d)
Types of pelvis
Gynecoid: normal female pelvis;
transversely rounded or blunt;
Android: heart-shaped or
angulated; resembles a male pelvis;
narrow pelvic planes
Female Pelvis & Measurements
Types of pelvis (cont’d)
Anthropoid: oval shaped, the outlet
is adequate, with a normal or
moderately narrow pubic arch
Platypelloid: flat shape with an oval
inlet; the transverse diameter is
wide, the anteroposterior diameter
is short
Important pelvic inlet diameters
Diagonal conjugate
Obstetric conjugate
Transverse diameter
Physiological Maternal Δ’s
Reproductive system -Δ’s in the Uterus
• Uterus enlarges with ↑ in # & size of
blood vessels
• wt & capacity
• from almost solid structure to thin,
muscular sac
• from pear-shaped to globular
• location from pelvis to abd cavity
• 20% of cardiac output supplies
uterus/pelvic cavity alone
Physiological Maternal Δ’s cont’d
Reproductive system -Δ’s Cervix & ovaries
• Cervix becomes shorter, more elastic,
& larger in diameter
• Ovulation stops (Maturation of new
follicles is blocked)
• Vascularity ↑’s, & glandular tissue
multiplies during pregnancy
• Thick mucous plug develops in the
opening of the cervix
• Corpus luteum continues to function &
produces progesterone for ~ 6-7 wks
Physiological Maternal Δ’s cont’d
Reproductive system
• Vaginal secretions are ↑’ed
• Vagina & perineum are affected
by hormonal Δ’s & ↑’ed blood
supply to the area
• Vagina takes on a bluish-purplish
hue, Chadwick’s sign
Physiological Maternal Δ’s cont’d
• Reproductive System
– Breasts
• Breast size ↑’s
• Colostrum may appear
• Tenderness in 1st few wks of pregnancy
• Nodularity of breast tissue
• Prominent areola with deepened
pigmentation
• Prominent projections of Montgomery’s
tubules
Physiological Maternal Δ’s cont’d
Respiratory system
• Oxygen consumption ↑’s by 15%
to 20%
• Diaphragm is elevated because of
enlarged uterus; SOB may be
experienced
• Possible slight ↑ in respir. rate
Physiological Maternal Δ’s
Cardiovascular System
• Circulating blood volume ↑‘s by 40% to
50%
• Physiological anemia may occur; ↑ in
body's iron demand
• Heart size ↑‘s & is elevated upward to
left as uterus enlarges
• Na+ & water retention may occur
• Pulse may ↑ about 10 to 15 beats/min
Physiological Maternal Δ’s
Renal system
• frequency of urination ↑’s in 1st & 3rd trimesters
• Decreased bladder tone & ↑’ed bladder capacity
response to increased levels of progesterone &
estrogen
• Excretes waste products of mom & fetus
• Progesterone causes renal pelvis & ureters to lose tone,
leads to urinary stasis
• Susceptible to UTIs
• Fluid retention
Metabolism
• Metabolic function ↑’s
• Body wt ↑’s
Physiological Maternal Δ’s cont’d
Integumentary system (skin)
• Pigmentation is increased
• Linea nigra is apparent
• Chloasma may appear
• Striae may appear
• Vascular spider nevi may appear
Chloasma
Linea nigra
Physiological Maternal Δ’s (cont’d)
Gastrointestinal system
•Intestines are displaced to sides & upward
• N/V may occur from 1st through 3rd months
• Constipation may occur
• Lack of appetite because of ↓’ed gastric
motility & alteration in taste & smell
• Flatulence & heartburn because of slow
stomach emptying caused by ↑’ed
progesterone
• Hemorrhoids caused by ↑’ed venous pressure
• Swollen, bleeding gum tissue & excessive
secretion of saliva caused by ↑’ed levels of
estrogen
Physiological Maternal Δ’s cont’d
Musculoskeletal system
• Center of gravity changes in 2nd trimester;
lumbosacral curve ↑’s
• Aching, numbness, waddling results; walking
may be difficult
• Lordosis ↑’s
• Diastasis recti abdominis
• Relaxation & ↑’ed mobility of pelvic joints
• Abdominal wall stretches
• Umbilicus flattens or protrudes
• Encourage pt to maintain good posture as
pregnancy progresses
Physiological Maternal Δ’s cont’d
Endocrine system
basal metabolic rate rises
– Pituitary enlarges
– Prolactin levels ↑ progressively
– ↑’ed protein binding
– Thyroid gland ↑’s in size
– Need for insulin ↑’s
Nervous system
– numbness, tingling in hands, arms, fingers
r/t pressure on nerves,
– carpel tunnel syndrome
Physiological Maternal Δ’s cont’d
• Hematologic Δ’s
• Blood volume ↑’s by 40%–50%
• RBC volume ↑’s up to 30%
• Plasma volume ↑’s by 50%
• Hemoglobin Δ’s to 11–12 g/100mL
• Hematocrit ↓’s
• WBC count ↑’s up to 16,000 mm3
(Normal Hgb 11.7 - 15.5, & Hct 38 - 44)
Discomforts of Pregnancy
Nausea & vomiting
Begins 1st trimester & subsides by 3rd month
Caused by elevated hCG levels & Δ’s in
carbohydrate metabolism
Interventions
Eat dry crackers before rising; eat small,
frequent, low-fat meals.
Drink liquids between rather than at meals.
Avoid brushing teeth after rising; avoid fried
& spicy foods.
Ask health care provider (HCP) about
acupressure & use of herbal remedies.
Discomforts of Pregnancy (cont’d)
• Syncope
• Occurs during 1st trimester
• Supine hypotension occurs during 2nd & 3rd
trimesters
• May be caused by hormones, anemia, fatigue, lying
flat
• Interventions: elevate feet, Δ positions slowly
• Urinary urgency & frequency
• Occurs during 1st & 3rd trimesters because of
pressure of uterus on bladder
• Interventions
• Drink at least 2000 mL of fluid daily.
• Limit fluids during evening; void regularly.
• Sleep on side; wear perineal pads; perform Kegel
exercises
Discomforts of Pregnancy (cont’d)
• Breast tenderness
• Occurs from 1st through 3rd trimesters
• Caused by ↑’ed levels of estrogen &
progesterone
• Interventions: encourage supportive bra
wear; avoid soap on nipples & areolae
• ↑’ed vaginal discharge
• Occurs from 1st through 3rd trimesters
• Caused by hypertrophy & thickening of
vaginal mucosa
• Interventions: proper cleansing & hygiene;
wear cotton underwear; avoid douching
Discomforts of Pregnancy (cont’d)
• Nasal stuffiness or nosebleeds
• Occurs during 1st through 3rd trimesters
• Result of increased estrogen that causes swelling of nasal tissues
& dryness
• Interventions: humidifier; avoid nasal sprays or antihistamines
• Fatigue
• Occurs during 1st through 3rd trimesters
• Result of hormonal Δ’s
• Interventions
• Frequent rest periods during day; avoid eating or
drinking foods with stimulants.
• Use correct body mechanics
• Regular exercise as approved by HCP; muscle
relaxation & strengthening exercises for legs & hip
joints
Discomforts of Pregnancy (cont’d)
• Heartburn
• Occurs during 2nd through 3rd trimesters
• Results from ↑’ed progesterone levels,
↓’ed GI motility, displacement of
stomach by enlarging uterus
• Interventions
• Eat small, frequent meals & avoid
fatty & spicy foods.
• Sit upright for 30 mins after meals.
• Drink milk between meals.
• Consult HCP about antacids.
Discomforts of Pregnancy (cont’d)
• Ankle edema
• Occurs during 2nd & 3rd trimesters
• Result of vasodilation, venous stasis, &
↑’ed venous pressure below uterus
• Interventions
• Elevate legs twice daily & when
resting; wear supportive stockings.
• Sleep on side.
• Avoid sitting or standing in one
position for long periods.
Discomforts of Pregnancy (cont’d)
• Varicose veins
• Occurs during 2nd & 3rd trimesters
• Caused by weakening walls of veins or valves
& by venous congestion
• Interventions
• Wear supportive stockings.
• Elevate feet when sitting; elevate feet &
hips when lying down.
• Avoid long periods of standing or sitting.
• Move about while standing.
• Avoid leg crossing & constricting clothing.
• Exercise legs, avoid airline travel to
prevent thrombophlebitis.
Discomforts of Pregnancy (cont’d)
• Headaches
• Occur during 2nd & 3rd trimesters
• Result of Δ’s in blood volume &
vascular tone
• Interventions
• Δ positions slowly.
• Apply cool cloth to forehead.
• Eat small snacks.
• Use acetaminophen if prescribed.
Discomforts of Pregnancy (cont’d)
• Hemorrhoids
• Occur during 2nd & 3rd trimesters
• Result of ↑’ed venous pressure &
constipation
• Interventions
• Soak in warm sitz bath; sit on soft
pillow.
• Eat high-fiber foods & drink
sufficient fluids.
• ↑ mild exercise; apply tx’s as
prescribed
Discomforts of Pregnancy (cont’d)
• Constipation
• Occur during 2nd & 3rd trimesters
• Results from ↑ in progesterone, ↓’ed intestinal
motility, displacement of intestines, pressure
of uterus, iron supplements
• Interventions
• Eat high-fiber foods.
• Drink at least 2000 mL daily.
• Exercise regularly.
• Consult with HCP about stool softeners,
laxatives, & enemas
Discomforts of Pregnancy (cont’d)
• Backache
• Occur during 2nd & 3rd trimesters
• Result of exaggerated lumbosacral curve
• Risk for falls; use deliberate, slow movements
• Interventions
• Rest; sleep on a firm mattress.
• Use correct body posture & mechanics.
• Wear comfortable, supportive shoes.
• Perform pelvic tilt exercises.
Discomforts of Pregnancy (cont’d)
• Leg cramps
• Occur during 2nd & 3rd trimesters
• Result of altered calcium–phosphorus balance,
pressure of uterus, fatigue
• Interventions
• Engage in regular mild exercise.
• Dorsiflex foot of affected leg.
• ↑ calcium intake.
• Shortness of breath
• Occur during 2nd & 3rd trimesters
• Result of pressure on diaphragm form enlarged
uterus
• Interventions: take small rest periods; avoid
overexertion; sleep on side or with head elevated
Psychological Maternal Δ’s
Ambivalence
May occur in early pregnancy
Mother may experience a dependence–
independence conflict related to role Δ’s
Partner may experience ambivalence r/t new
role, financial responsibilities, & sharing
attention
Acceptance
Factors include readiness for experience &
identification with motherhood role
Emotional liability
Manifested by frequent or extreme Δ’s in
emotional state, which are common
Psychological Maternal Δ’s cont’d
Body image Δ’s
Positive or negative Δ’s in woman's
perception of her image occur gradually
during pregnancy.
Physical Δ’s & symptoms contribute to body
image.
Relationship with fetus
Woman may daydream & think about desired
maternal qualities
Accepts biological fact of pregnancy
Accepts fetus is a distinct person to nurture
Prepares realistically for birth and parenting
Psychological Paternal Δ’s
The father
• ambivalent feelings
• Fears
• question his ability
• feel rejected
Pregnancy Signs
3 Categories:
• Presumptive signs (subjective)
• Probable signs (objective)
• Positive signs
Pregnancy Signs
Presumptive signs (subjective)
• Amenorrhea
• N/V
• ↑’ed size & fullness in breasts;
pronounced nipples
• Urinary frequency
• Fatigue
• Quickening: first perception of fetal
movement around the 16th to 20th
week of gestation
• Discoloration of vaginal mucosa
Pregnancy Signs (cont’d)
Probable signs (objective)
• Hegar’s sign: softening & thinning of
lower uterine segment at about 6 wk of
gestation
• Goodell’s sign: softening of cervix,
beginning at 2nd month of gestation
• Chadwick’s sign: violet coloration of
mucous membranes of cervix, vagina,
vulva at ~ 6th wk of gestation
• Ballottement: rebounding of fetus
against examiner’s fingers on palpation
16-20 wks floating fetus
Probable signs (cont’d)
• Uterus enlargement
• Positive pregnancy test d/t presence of hCG
which appears in the urine 8-10 days after
conception
• Braxton-Hicks contractions – irregular
contractions occur intermittently throughout
pregnancy but don’t ↑ in intensity or duration
or cause cervical dilation
• Darkening of nipples & areola
• Linea nigra- dark line from symphysis to
xiphoid process, chloasma of the face, striae
gravidarum- stretch marks
Pregnancy Signs (cont’d)
Positive signs confirm pregnancy:
SIGNS OF THE SENSES– 6 wks+
• Visualization of fetus by U/S
– 20 wks+
• Fetal heart sounds by fetal stethoscope
– 22 wks+
• Fetal movements palpable by a trained
practitioner
– Late pregnancy
• Fetal movements visible
Recommended Schedule of Prenatal
Visits—Uncomplicated Pregnancy
• Conception to 28 weeks—every 4 weeks
• 29 to 36 weeks—every 2 to 3 weeks
• 37 weeks to birth—weekly
• Certain laboratory &/or diagnostic tests are
performed at various times throughout the
pregnancy
•
https://www.youtube.com/watch?v=jThcEjwLri0
Prenatal Visit
• Obtain the baseline data
• Confirm or r/o a dx of pregnancy
• Ascertain risk factors
• Determine the estimated date of delivery
(EDD)
• Provide education on maintaining a
healthy pregnancy
• Hx taking
‒Chief complaint
‒Reproductive hx
‒Medical-surgical hx
‒Family & Social hx
Prenatal Visit (cont.)
•Physical examination
•Head-to-toe physical
•Vaginal speculum examination
•Bimanual examination of the uterus
Diagnostic Tests
•Laboratory work
CBC (Hemoglobin & hematocrit
levels)
•Tests for presence of infection
•Group B streptococcus (GBS) after
35 wks & before the end of 37 wks.
Pregnancy Tests
• Based on the presence of the
hormone hCG which is secreted by
the chorionic villi of the placenta
• Appears in the urine or blood 9-10
days after conception (or 24-48
hrs) after implantation
• HPT (home pregnancy tests 97%
accurate
Diagnostic Tests cont’d
Blood type & Rh factor
https://www.youtube.com/watch?v=7OWp8d8WKkg
• Mother is Rh-negative & has negative
antibody screen
• Will need to repeat antibody screens
• Should be given Rho(D) immunoglobulin
(RhoGAM) within 72 hrs of birth of
first baby when detected
• With every pregnancy, should be given
RhoGAM at 28th wk of gestation &
within 72 hrs of birth of baby
Diagnostic Tests (cont’d)
• Rubella titer
• Pt with negative titer (<1:8) is at
risk of contracting rubella, which
can be transmitted to fetus & cause
birth anomalies; thus, titer should
be assessed before conception
• If negative titer, pt must be using
effective birth control at time of
immunization, must be counseled to
not become pregnant for 3 mons
following immunization
Diagnostic Tests(cont’d)
• Papanicolaou’s smear
• Sexually transmitted infection
• Sickle cell screening
• Tuberculin skin test
• Positive test indicates need for chest x-ray
to rule out active disease
• In pregnant pt, x-ray can’t be performed
until after 20th week of gestation
• Hepatitis B surface antigens
• Recommended for all women because of
prevalence of disease in general population
Diagnostic Tests cont’d
• Urinalysis & urine culture
• Levels of 2+ to 4+ protein in
urine may indicate infection or
preeclampsia
- Ultrasonography
• Outlines, identifies fetal &
maternal structures
Diagnostic Tests cont’d
-Assists in confirming gestational age & estimated
date of confinement
• Alpha-fetoprotein screening
• Can detect neural tube defects,(spina bifida &
Down syndrome)
• Maternal blood sample drawn at 15th to 18th
week of gestation
• Chorionic villus sampling
•
https://www.youtube.com/watch?v=Axt2Ae9mNec
• Detects genetic abnormalities by sampling
chorionic villus tissue at 8th to 12th wk of
gestation
• Kick counts (fetal movement counting)
Diagnostic Tests (cont’d)
• Amniocentesis https://www.youtube.com/watch?v=bZcGpjyOXt0
• Aspiration of amniotic fluid may be done from
13th to 14th wk of gestation
• Used to determine genetic disorders,
metabolic defects, fetal lung maturity
• Risks of maternal hemorrhage, infection,
abruptio placentae, premature rupture of
membranes
• Fern test
• Microscopic slide test to determine presence
of amniotic fluid leakage
Diagnostic Tests (cont’d)
- Nitrazine test
• Determines presence of amniotic fluid in
vaginal secretions; shades of blue indicate
that membranes probably ruptured
• Nonstress test
• Performed to assess placental function &
oxygenation
• Assesses fetal well-being
• Contraction stress test
• Performed to assess placental oxygenation &
function
• Assesses fetal ability to tolerate labor, fetal
well-being
Gravidity & Parity
• Gravidity: # of pregnancies
• Gravida: woman who is pregnant
• Nulligravida: woman who has never been pregnant
• Primigravida: woman pregnant for the first time
• Multigravida: woman having had 2 or more
pregnancies
• Parity: number of births carried past 20 weeks’
gestation, whether or not the fetus was born alive
• Nullipara: woman who has not had a birth at more
than 20 weeks’ gestation
• Primipara: woman who has had one birth that
occurred after 20 weeks’ gestation
Gravidity & Parity (cont’d)
Parity (cont’d)
• Multipara: woman who has had 2 or more
pregnancies that resulted in viable offspring
Use of GTPAL: pregnancy outcomes can be described
with the GTPAL acronym
• G = gravidity, including present pregnancy
• T = term births, after 37 weeks
• P = preterm births, before 37 weeks
• A = abortions or miscarriages
• L = live births
Prenatal Visit
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Teaching
Avoiding substance abuse
Diet, nutrition, & exercise
Infection control & medications
Dental hygiene
Hygiene & clothing
Breast care
Sexual activities
Employment & travel
Methods of Determining the Due Date
• Nagele’s rule
• Add 7 days to the date of the first day of the LMP, then
subtract 3 months & add 1 yr.
• Pelvic examination
• The practitioner feels the size of the uterus to
determine the term of the pregnancy
• Obstetric sonogram
• High frequency sound waves reflect off fetal & maternal
pelvic structures, allowing visualization
Trimesters
• Pregnancy divided into 3- 13-week parts
• Important to know what occurs during
each trimester to both woman & fetus
• Helps provide anticipatory guidance
• Identify deviations from the expected
pattern of development
Physical examination
• Baseline TPR, BP, ht., wt
• Head-to-toe physical
Vaginal speculum examination
Bimanual examination of the
uterus
McDonald's rule
the length in cms of the abdominal contour from the upper
margin of the pubic symphysis to the fundus of the uterus,
divided by 3.5, gives the duration of pregnancy in lunar
months; applicable only after the 6th month of pregnancy.
Fundal Height
– Measured to evaluate gestational age of
fetus
– During the 2nd & 3rd trimesters, fundal ht in
cms ~ equals the fetus' age in wks plus or
minus 2 cm
– At 16 wks, fundus can be found
approximately halfway between the
symphysis pubis & the umbilicus
– At 20 to 22 wks, fundus is ~ at the location
of the umbilicus
– At 36 wks, fundus is at the xiphoid process
Nutritional Requirements of Pregnancy
• ↑ kCal by 300 per day, & should include
– Protein—60 g/day
– Calcium—1200 mg/day
– Iron—30 mg/day
– Folic acid—400 mcg (0.4mg)/day
• Recommended wt gain
–First trimester: 3–4 lbs total
–Remainder of pregnancy: 1 lb/wk
–Total wt gain: 25–35 lbs for a woman with a
normal BMI
• Breast feeding– ↑ 500 kCal or total 2700 kCal
Weight Gain
• Women of normal weight: 25 to 35 lbs (11.5 to 16
kg)
• Obese women: 11 to 20 lbs (5 to 9 kg)
• Overweight women: 31 to 50 lbs (14 to 22.7 kg)
• Multifetal pregnancy: twins—woman should gain 4
to 6 lbs in first trimester, 1½ lbs per week in
second & third trimesters, for a total of 37 to
54 lbs
Weight Gain Assessment
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Edema of lower extremities, face, hands
Discomforts of pregnancy
Eating & sleeping patterns
Psychosocial concerns
Fundal ht for uterine & fetal growth
Milestones of fetal growth: fundus over
symphysis at 12-16 wks, at umbilicus at
18-22 wks, at xiphoid at 36wks
S&S of Inadequate Nutrition
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Hair
Eyes
Mouth
Neck
Skin
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Extremities
Finger/toe nails
Mom’s wt.
BP
Fetal growth
Nutritional Risk Factors During Pregnancy
Adolescent
Excessive wt. gain
Anemia
Anorexia
Smoking
Frequent
pregnancies
• PICA
• Vegetarianism
• Cultural
considerations
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Low income
Food/diet fads
Drug/alcohol use
Overweight/underwt
Multiple pregnancy
Anemic at conception
Lactose intolerance
Sudden wt gain
Chronic illness
Drugs Used in Prenatal Period
Class: serum immune globulin
Drug: RhoGAM, Rho (D) Immune Globulin
Action: prevents production of anti-Rh
antibodies in Rh- people & therefore
prevents hemolytic disease in RH+ newborn
Route IM: Administered at 28 wks of
gestation & within 72 hrs of delivery, also
administered after amniocentesis,
miscarriage, abortion, ectopic pregnancy
Contra: Rh+ patients
Side effects: painful injection site, fever
Nursing: educate pt. in purpose of drug
Drugs Used in Prenatal Period cont’d
PNV
Vitamins – A,D,E,C, folic acid, thiamine,
riboflavin, niacinanmide, B6, B12
Minerals – Ca, copper, iron, zinc
Indications – vitamin & mineral supplement
throughout pregnancy & lactation
Dosage – 1 daily
Side effects – rare, epigastric distress
sometimes occurs when admin. On an empty
stomach, admin. With meals, citrus juice
enhances absorption
The Process: The Four P’s of Labor
Process of labor; coordinated sequence of
involuntary uterine contractions to move
fetus through birth canal, to delivery, actual
birth of newborn
• 4 major factors interact during normal
childbirth; four Ps of labor depend on
each other for safe delivery
• Power: uterine contractions
• Passageway: mother’s rigid bony pelvis,
soft tissues of cervix, pelvic floor,
vagina, introitus
• Passenger: fetus, membranes, placenta
• Psyche: woman’s emotional system
The Process: The Four P’s of Labor (cont’d)
• Attitude
• Relationship of fetal body parts to
one another
• Lie
• Relationship of spine of fetus to
spine of mother
• Presentation
• Portion of fetus that enters pelvic
inlet first
The Process: The Four P’s of Labor (cont’d)
• Presenting part: specific fetal
structure lying nearest cervix
• Position: relationship of assigned area
of presenting part to maternal pelvis
• Station
• Measurement of progress of descent
in centimeters above or below
midplane, from presenting part to
ischial spine
Variables Affecting Labor
4 P’s- Passageway, Passenger, Powers, Psyche
Passageway: bony pelvis, uterus, cervix, vagina,
perineum
• Pelvis: MD checks pelvis size by measuring
diagonal conjugate, palpating the ischial
tuberosities, or U/S
• Uterus: contractions begin in the fundus &
travel down thru cervix
• Cervix: uterine contractions pull cervix open
• Vagina: stretches
• Perineum: stretches & thins
Passenger
• Fetal skull
• Fetal accommodation to the
passageway
– Lie
•Longitudinal lie
•Oblique lie
•Transverse lie
Passenger (cont.)
– Presentation
• Foremost part of the fetus that
enters the pelvic inlet
‒Head
• Cephalic presentation
‒Feet or buttocks
• Breech presentation
‒Shoulder
• Shoulder presentation
Passenger (cont.)
– Attitude
• Relationship of fetal parts to one
another
• Vertex (attitude of flexion) is
most favorable for vaginal delivery
• Military (no flexion or extension)
• Brow (partial extension)
• Face (full extension)
Types of presentation
A. Vertex B. Military C. Brow D. Face
Passenger (cont.)
– Fetal Station: The relationship of
the presenting part to the ischial
spines
• Zero station: Presenting part is at
the level of the ischial spines
• Minus station: Presenting part is
above the ischial spines
• Plus station: Presenting part is
below the ischial spines
Fetal Position
• Leopold’s Maneuvers
•
http://www.youtube.com/watch?v=nIog3oizP8A
• LOA
• Station
• Engaged
Leopold’s Maneuvers
To determine presentation & position
of fetus
• If head is in fundus, hard, round
movable object is felt; if buttocks is
in fundus, then soft, irregular shape is
noted, more difficult to move
• Back of fetus should be felt on one
side of abd
• Irregular knobs & lumps, hands, feet,
elbows, & knees felt on opposite side
of abdomen
Powers
• Phases of involuntary uterine
contraction
– Increment: Building up of the
contraction - longest phase
– Acme: Peak of the contraction
– Decrement: Letting up phase
– Relaxation period: Rest period
between contractions
Descriptors of contractions
• Frequency: How often the
contractions are occurring
• Measured by counting the time
interval from the beginning of
one contraction to the beginning
of the following contraction
• Duration
• The interval from the beginning
of a contraction to its end
• Intensity
• The strength of the contraction
Uterine Contractions
• Effect of
contractions on the
cervix
• Efface
• Dilate
• Phase of
contractions
• Increment
• Peak
• Decrement
• Frequency
• Duration
• Intensity
• Mild
• Moderate
• Firm
• Maternal pushing
Cervical Effacement & Dilation
True labor
• Contractions ↑ in duration &intensity
• Cervical dilation, effacement are
progressive
False labor
• Normal contractions are
exaggerated
• Labor does not produce dilation,
effacement, or descent
• Contractions are irregular, without
progression
• Walking has no effect on
contractions; often relieves false
labor
Psyche
• Factors impacting the psyche of a
laboring woman
– Current pregnancy experience
– Previous birth experiences
– Expectations for current birth
experience
– Preparation for birth
Breathing Techniques
Provide focus during contractions
• Promote relaxation &
oxygenation between
contractions
• Slow deep breathes – in through
the nose, out through the mouth
Childbirth Education
• Δ’s of pregnancy
• Fetal development
• Prenatal care
• Hazardous substances to avoid
• Nutrition
• Common discomforts
• Work, benefits of exercise
• Coping with labor & delivery
Types of Classes Available
• Gestational DM
• Early pregnancy
• Exercise for pregnant women
• Infant care
• Breastfeeding
• Sibling
• Grandparent
• Adolescent childbirth
Variations of Basic Childbirth
Preparation Classes
• Refresher
• Cesarean birth
• Vaginal birth after cesarean
• Adolescent
Methods of Childbirth Preparation
• Dick-Read method
• Bradley method
• Lamaze method
•
https://www.youtube.com/watch?v=0xRl2s2zE78
Signs of Impending Labor (Prelabor)
•
•
•
•
•
•
Braxton Hicks contractions
Increased vaginal discharge
Bloody show ~ 1 wk before labor
Rupture of the membranes
Energy spurt
Weight loss
Process of Labor
Anticipatory signs of labor
• Prelabor
• Effacement
Measured in % from 0 – 100% .
0 = no effacement,
100%= complete
Induction of Labor
• Elective induction
• Major cause of ↑ in # of induced
labors
• Often result in
• More interventions
• Longer labors
• Higher costs
• Possible cesarean birth
Induction of Labor (cont.)
• Indications for induced labor
• Postdate pregnancy
• Premature rupture of membranes (PROM)
• Spontaneous rupture of membranes (SROM)
without the onset of spontaneous labor
• Chorioamnionitis
• Pregnancy-induced HTN
• Preeclampsia
• Severe intrauterine fetal growth restriction
• Maternal medical conditions
Induction of Labor (cont.)
• Contraindications
• Maternal contraindications for spontaneous
& induced labor
• Complete placenta previa
• Hx of a classical uterine incision
• Structural abnormalities of the pelvis
• Invasive cervical CA
• Medical conditions (active genital
herpes)
• Fetal contraindications
• Certain anomalies, (hydrocephalus)
• Certain fetal malpresentations
• Fetal compromise
Induction of Labor (cont.)
• Labor readiness
• Prerequisite for induced labor = “ripe cervix”
• Bishop Score often used to determine
readiness for labor
• 5 factors evaluated
• Each factor scored 0 to 3
• Score of 8 or greater associated with
successful oxytocin-induced labor
• Score of 5 or less indicates cervix is not
ripe – associated with unsuccessful
induction of labor
Induction of Labor (cont.)
• Labor readiness (cont.)
• Transvaginal ultrasound
• Relatively new method
• Cervix 27 cm or less is a predictor of
successful induction of labor despite Bishop
score
• Measurement of fetal fibronectin levels
• Newer method
• Presence in cervical secretions is
associated with labor readiness
• More often used as a predictor of preterm
labor risk
Induction of Labor (cont.)
• Labor readiness (cont.)
• Fetus should be mature
• Several ways to assess fetal maturity
• At least 38 weeks’ gestation
considered mature
• Date fetal heart tones first heard
• Other pregnancy milestones
• Fetal lung maturity is the major
point of consideration
• Measure L/S ratio by amniocentesis
Induction of Labor (cont.)
• Methods of cervical ripening
• Mechanical methods
• Membrane stripping
• Inserting a catheter into the
cervix & inflating the balloon
• Cervical dilators (laminaria)
Induction of Labor (cont.)
• Pharmacologic methods
• Prostaglandin E2 (dinoprostone)
• Prostaglandin E1 (misoprostol)
• Artificial rupture of membranes
(AROM)
• Also called amniotomy
• Oxytocin induction
• IV oxytocin (Pitocin) most common
Induction of Labor (cont.)
• Nursing care
• The LPN role during induction depends
upon the procedure
• Assist with pelvic exam in mechanical
ripening of cervix or amniotomy (AROM)
• Document FHR before & after
amniotomy
• Suprapubic or fundal pressure during the
procedure if trained
• RN responsible for monitoring mother &
baby during pharmacologic ripening of
cervix
When to go to the hospital
• Instruct Mom when to call MD & when
to go to the hospital
• Wait for contractions to be 5-10 mins
apart
• Clear liquids once labor begins
• Prenatal records, medical hx & prenatal
course sent to hospital before mother’s
admission & include any special requests
mother or father have regarding
procedures, meds, etc.
Admission to L&D suite
• Baseline VS’s, breath sounds, wt., urine
spec. for blood, protein & glucose,
nitrazine test prn.
• Leopold’s maneuvers
• Onset of labor, S&S of prelabor, Rh
factor, blood type, gravada/para
status, ? breast/bottle feeding
• Check Contractions
• Monitored Baseline FHR
• Vaginal exams
• Couple’s expectations & concerns
Stages & Duration of Labor
http://www.youtube.com/watch?v=b-CtjWf7K8w
• First stage: dilation & effacement (can last 4 to
6 hrs)
• Early labor (latent phase)
• Active labor (active phase)
• Transition (transition phase)
• Second stage: birth (30 mins to 2 hrs)
• Third stage: delivery of placenta (5 to 30 mins)
• Fourth stage: recovery
Stage 1
Effacement & dilation
Begin with true labor contractions & end with
complete dilation of cervix (0-10cm)
Effacement: thinning & shortening of
cervical canal
Dilation: enlargement of cervical opening
from 0-10cm. 10cm = complete dilation.
Divided into the latent, active & transition
phases
Nursing Process During the First
Stage of Labor: Dilation
• Focus is on assessment
• Providing physical care to the mother
& fetus
• Providing psychological care to the
mother
• Keeping the practitioner informed
about labor progress
Latent phase
• Cervix dilates from 0-4 cm
• Irregular, short, mild contractions
occur
• Contractions every 10 – 20 minutes
lasting 15- 45 seconds
• Intensity of contractions gradually
increases
• Mom up & about, talkative, anxious
Nursing Interventions During the
Latent Phase (Early Labor)
• Assessment
• Assess FHR & contractions at least
once every hour
• Assess maternal status
• Assess status of fetal membranes
• Assess the woman’s psychosocial
state
Active phase
• Cervix dilates from 4- 8 cm
• Contractions occur every 3- 5
minutes, last 40 -60 seconds & are
moderately intense
• Mom begins to use breathing
techniques to help reduce
discomfort
Nursing Interventions During
Active Labor
• Assessment
• Assess woman’s psychosocial
state
• Assess labor progress
• Assess fetal status
• Assess maternal status
Transition Phase
• Period of cervical dilation from 8–10 cm
• Most difficult time for Mom
• Intense contractions occur every 2- 3
mins. & last 60 -90 sec.
• Mom may experience loss of control of
breathing techniques & experience
N/V
• Other S&S: restlessness, anger,
difficulty following directions, rectal
pressure, “don’t touch me stage”
Nursing Interventions Stage 1
Offer fluids & ice chips; IV fluids
Record I&O’s
Provide oral care
Enc. Urination Q 2 hrs
Back Rubs
Freq. position Δ’s
Enc. Ambulation (membranes intact);
Pericare ruptured; Δ linens prn
• Offer pain meds prn
• Offer encouragement & praise
• Inform Mom & support person of progress
•
•
•
•
•
•
•
Fetal Monitoring
Means of assessing fetal heart rate (FHR) as it
relates to uterine contractions
• Normal FHR 110 to 160 beats/min
• External fetal monitoring
• Noninvasive; performed using tocotransducer
or Doppler ultrasonic transducer; transducer,
fastened with belt, should be placed on side of
mother where fetal back is located (find using
Leopold’s maneuvers)
• Internal fetal monitoring
• Invasive; requires rupturing of membranes;
attachment of electrode to presenting part of
fetus; mother must be dilated 2 to 3 cm to
perform this procedure
Fetal Monitoring (cont’d)
Periodic patterns in FHR
• Baseline FHR
• 110-160 BPM
• Fetal bradycardia
• <110 BPM
• Fetal tachycardia
• >160 BPM
• Baseline variability
• Moderate variability
• Marked variability
• Absent variability
• Accelerations
• Early decelerations
• Variable
decelerations
• Late decelerations
• Prolonged
decelerations
• Recurrent
decelerations
• Intermittent
decelerations
• Sinusoidal pattern
Nursing Care during Labor & Delivery
• Monitoring uterine contractions
– External Methods
• Palpation to evaluate the
contraction pattern
• Tocodynamometer (toco)
Nursing Interventions:
Uterine Contractions
• Reassuring periodic Δ’s
– Accelerations - above the baseline by at least
15 bpm for at least 15 secs (15 x 15 window)
• Benign periodic Δ’s
– Early decelerations
• Non-reassuring periodic Δ’s
– Variable decelerations indicating some type of
acute umbilical cord compression
– Late decelerations indicating uteroplacental
insufficiency
Stage 2
•
•
•
•
•
•
•
The expulsion stage
Complete dilation of cervix & ends with birth
of baby
Ferguson’s Reflex
Mom pushes baby through birth canal using
abd. muscles
Fetus has left uterus & is in vaginal canal
Vaginal tissues bulges, rectum dilates, pelvic
floor muscles stretch & head of fetus
appears at vaginal opening
Crowning
With additional pushing baby is born
Nursing Interventions During the 2nd
Stage of Labor: Expulsion of the Fetus
• Assessment
• Monitor VSs every 15 - 30 mins
• Assess contraction pattern every 15mins
• Assess the woman’s report of an
uncontrollable urge to push
• Check FHR every 15 mins for the lowrisk women & every 5 mins for women at
risk for labor complications
Mechanism of Labor: different positions the fetus
must assume as it travels the birth canal
• Descent
• Station
• Engagement
• Flexion
• Internal rotation
• Extension
• External rotation
• Expulsion
Episiotomy: surgical incision in perineum to widen
opening; helps prevent vaginal tears, can be left,
right, or midline
Stage 3
Placental Stage
• Begins with birth of baby & ends
with expulsion of placenta
• Uterus continues to contract,
becomes smaller causing placenta to
separate from uterine wall
• Voluntary pushing by mother help to
expel placenta
Nursing Process During the 3rd Stage of
Labor: Delivery of the Placenta
• Assessment
• Assess the woman’s
psychosocial state after she
gives birth
• Monitor for signs of
placental separation
Stage 4
Recovery Stage
• Expulsion of placenta & 2 hrs,
postpartum or until mother’s
condition has stabilized
• Close monitoring of vaginal bleeding
needed to detect hemorrhage
• Approx. blood loss = 250 – 500 mL
•
https://www.youtube.com/watch?v=zD8j2JG2y3A
Stage 4
• VS’s
• Assess Fundus; vaginal bleeding;
perineal sutures
• Ice packs applied to all perineum
• Monitor output
• Provide warm blankets, tremors are
common
• Maintain IV fluids
• Enc. Fluids, snacks
• Evaluate mobility of LE’s
• Admin. Analgesics prn
Nursing Responsibilities During Birth
• Preparing the
delivery instruments
& infant equipment
• Perineal scrub
• Administering
medications
• Providing initial care
to the infant
• Assessing Apgar score
• Assessing infant for
obvious abnormalities
• Examining the placenta
• Identifying mother &
infant
• Promoting parent-infant
bonding
Pharmacological Techniques
• The nurse’s role
• Begins at admission
• Woman’s preference for pain relief
• Keep side rails up
• Provide education regarding
procedures & expected effects
• Observe for hypotension
Pain Management
Principles & Techniques
• Non-Pharmacologic Pain
Interventions
• Continuous labor support
• Comfort measures
• Relaxation techniques
• Intradermal water injections
• Acupressure & acupuncture
Pharmacological Interventions
• Analgesia & sedation
• Use of med. to ↓ sensation of pain
• Sedatives given to promote
sedation & relaxation
• Opioids given to promote
analgesia during labor
• Anesthesia
• Use of med. to partially or totally
block all sensation to an area of the
body
• Local, regional, general
Pharmacological Interventions
• Types of anesthesia
• Local anesthesia
• Used to numb perineum just before
birth to allow for episiotomy & repair
• Regional anesthesia
• Involves blocking a group of sensory
nerves that supply a particular organ
or area of the body
• General anesthesia
• Not used frequently in obstetrics
because of the risks involved
Pharmacological Interventions (cont.)
• Types of regional anesthesia
• Pudendal
• Epidural anesthesia
• Intrathecal anesthesia
http://www.youtube.com/watch?v=bxcCh46Qug8
• Spinal block –type saddle block
Epidural analgesia
• Opioids are used for epidural
analgesia. An adverse effect of
epidural analgesia is a delayed
respiratory depression. Naloxone
(Narcan) is an opioid antagonist,
which reverses the effects of
opioids & is given for respiratory
depression.
Pharmacological Interventions (cont.)
• Complications Associated With Epidural &
Spinal Anesthesia
• Hypotension
• Maternal fever
• Shivering
• Pruritus
• Inadvertent injection into blood stream
• Spinal HA
• Fetal distress
Nursing Interventions
epidural/saddle blocks
• VS’s,
• Position on left side
• Monitor FHR
• Monitor Contractions
• I&O’s
• Examine epidural/spinal catheter
for placement
• Observe for side effects
Pharmacological Interventions (cont.)
• Life-Threatening Complications
Occurring With General
Anesthesia
• Failed intubation
• Aspiration
• Malignant hyperthermia
Oxytocic Medication:
Oxytocin (Pitocin)
• Stimulates smooth muscle of uterus; induces
contractions of the myocardium; promotes milk
letdown
• Uses
• Induces or augments labor; controls postpartum
bleeding; promotes milk letdown & facilitates
breast-feeding; induces or completes an abortion
• Adverse reactions
• May include allergies, dysrhythmias, Δ’s in blood
pressure, uterine rupture, hyperstimulation of
uterine contractions
• Contraindications
Shouldn’t be used in a woman who can’t deliver
vaginally or in a woman with hypertonic uterine
contractions.
Oxytocic Medication: Oxytocin
(Pitocin) (cont’d)
• Interventions
• Monitor maternal & fetal status closely,
including frequency, duration, force of
contractions, FHR every 15 minutes
• Administer med with IV infusion device
only
• Do not leave pt unattended during infusion
• If uterine hyperstimulation or
nonreassuring FHR occurs, stop med
immediately, turn pt to side, infuse IV NS,
administer oxygen via face mask as
prescribed; then notify healthcare provider
Prostaglandins
Ripen cervix, stimulate uterine contractions
• Adverse reactions
• Diarrhea; N/V; fever; chills; flushing; dysrhythmias;
bronchoconstriction; peripheral vasoconstriction
• Contraindications
• Clients with significant cardiovascular disease or history of
asthma, pulmonary disease
• Interventions
• Monitor maternal VSs, fetal status, including labor status as it
relates to mother & fetus
• Before administration, have woman void, then maintain supine or
side-lying position for 30 to 40 minutes after administration
Opioid Analgesics
• These are used to relieve moderate
to severe pain associated with labor
• Regular use during pregnancy may
produce withdrawal symptoms in
neonate
• Keep naloxone (Narcan) on hand at
all times as antidote
• Meperidine hydrochloride (Demerol)
• Not administered during advanced
labor (within 1 hour of delivery)
Opioid Analgesics (cont’d)
Morphine sulfate, fentanyl (Sublimaze)
• May cause respiratory depression
• Butorphanol tartrate (Stadol),
nalbuphine (Nubain)
• Have some opioid antagonist
effects
• Interventions
• Monitor VSs (especially for
respiratory depression), FHR
• Have antidote, naloxone (Narcan),
available at all times
Assisted Delivery
• Episiotomy
• A surgical incision is made into the
perineum to enlarge the vaginal opening
• Vacuum-assisted delivery
• A suction cup is placed on the fetus’s
head; suction is applied & used to guide
the delivery of the infant
• Forceps
• Instruments with curved, blunted blades
are placed around the head of the fetus
to facilitate delivery
Assisted Delivery (cont.)
• Complications of operative vaginal delivery
• Neonatal cephalhematoma, retinal,
subdural, & subgaleal hemorrhage occur
more frequently with vacuum extraction
than with forceps.
• Facial bruising, facial nerve injury, skull
fractures, & seizures are more common
with forceps.
• Maternal complications include
• Extension of episiotomy into anal
sphincter
• Uterine rupture, perineal pain,
lacerations, hematomas, urinary
retention, anemia, & rehospitalization
Assisted Delivery (cont.)
• Nursing care during an assisted delivery
• Obtain needed equipment & supplies
• Monitor maternal & fetal status before,
during, & after the procedure
• Assist the birth attendant
• Provide support for the woman
• Document the type of procedure
• Document maternal & fetal response to
the procedure
Indications for Cesarean Birth
•Hx of previous cesarean birth
•Previous surgery on the uterus
•Labor dystocia (failure to progress in
labor) Fetal compromise, Abnormal
labor
•Non-reassuring fetal status
•Fetal malpresentation
• Placenta previa or abruptio placentae
Maternal conditions (GH or DM)
•Active maternal herpes virus
Cesarean Birth (cont.)
• Maternal complications
• Laceration of uterine artery, bladder, ureter, or
bowel
• Hemorrhage requiring blood transfusion
• Hysterectomy
• Infection, Pneumonia
• Postpartum hemorrhage, thrombophlebitis, & other
surgical-related complications
• Fetal complications
• Delivery of an immature fetus
• Depressed fetal respiratory drive,
• Fetal injury can occur
Cesarean Birth (cont.)
• Incision types
• Abdominal incisions
• Vertical approach done in the midline
of the lower abdomen
• Pfannenstiel’s incision (bikini cut)
• Uterine incisions
• Classical incision
• Low cervical vertical incision
• Low cervical transverse incision
(preferred method)
Cesarean Birth (cont.)
• Steps in a cesarean delivery
• Called perioperative period
• Preoperative phase
• Team approach, sometimes referred
to as collaborative management
• Intraoperative phase
• LPN acts as scrub nurse
• Postoperative phase
• LPN can assume care of woman after
she has sufficiently recovered from
anesthesia
Cesarean Birth (cont.)
• Postop Nursing care
• VS’s
• CDB, Splinting incision
• I&O’s, Foley cath
• Assessing abd. incision or staples, Lochia for
quantity, color, & presence of clots
• PCA pumps, IV fluids
• Enc. ambulation
Vaginal Birth After Cesarean
• Prerequisites
• ACOG Recommendations:
• Adequate pelvis
• No previous uterine ruptures
• Personnel & facilities available to perform
an immediate cesarean delivery
• No more than 1 previous, low transverse
uterine scar
• Signed informed consent listing benefits &
risks
• Surgeon, anesthesia provider, & operating
room personnel in the hospital
• Practitioner who can read & interpret EFM
tracings & recognize the S&S of uterine
rupture
Vaginal Birth After Cesarean (cont.)
• Contraindications
• Previous classic C-section uterine scar
• Placenta previa
• History of previous uterine rupture
• Lack of facilities or equipment to
perform an immediate emergency
cesarean