High Risk Perinatal

Assessment during Antepartum

• Verify pregnancy

• Evaluate health history and baseline data

• Evaluate physical health

• Evaluate psychosocial needs

• Assess fetal well-being

• Counseling and teaching

• Plan of Care

A high-risk pregnancy refers to a pregnancy that has an increased likelihood of maternal and fetal complications.

• Antepartum

  • Age

  • Nutrition

  • Special Populations

  • Pregnancy-Miscarriage, Ectopic

  • Hyperemesis

  • Infections

  • Disorders of the placenta

  • Preterm labor, preterm rupture

  • Diabetes

  • Hypertensive Disorders

• Age

  • The age of the pregnant person plays an important role before, during, and after pregnancy.

  • Age extremes in which outcomes are poorer <20 and >35.

  • Adolescence

    • An adolescent pregnancy is one that occurs in persons between 10 and 19 years of age.

    • Adverse maternal outcomes related to adolescent pregnancies include infection, hemorrhage, anemia, preeclampsia, and postpartum depression

    • Neonatal adverse outcomes include prematurity, fetal growth restriction, stillbirth, and congenital anomalies

    • Pregnancy during adolescence is linked to poverty, unemployment, and social and psychologic problems

    • The incidence of late or no prenatal care is increased

    • Nursing interventions at an individual level include education on contraceptives and prenatal care.

    • The nurse can refer the patient to resources such as social support groups, counseling, and educational programs.

  • Age 35 and older

    • Advanced maternal age

    • Advanced maternal age increases the pregnant person’s risk of ectopic pregnancy, multiple gestation, gestational diabetes, hypertensive disorders in pregnancy, cesarean delivery, and postpartum hemorrhage

    • Fetal risks include spontaneous miscarriage, chromosomal abnormalities, congenital anomalies, prematurity, fetal growth restriction, and stillbirth

    • Preexisting medical conditions more common in this age group (such as hypertension, diabetes, and hypothyroidism) may also complicate pregnancy.

    • Recommendations include identifying patients and counseling them about risks to the pregnant person’s and fetus’s health, considering prescribing low-dose aspirin to reduce the risk of preeclampsia, using ultrasound to evaluate for multiple gestations and congenital anomalies, monitoring fetal growth, initiating close patient monitoring for stillbirth risk, and promoting vaginal delivery, if it is safe.

• Nutritional Deficiencies and Excess

  • Nutritional imbalances place a pregnancy at risk because certain nutrients are necessary to ensure maternal health as well as fetal growth and development.

    • Can negatively impact fetal health by causing brain defects, psychiatric disorders, vision and motor defects, and altered cognition

  • Obesity places the pregnant person at increased risk for preeclampsia, gestational diabetes, obstructive sleep apnea, cardiac dysfunction, stillbirth, and cesarean delivery

    • Risks to the fetus include congenital anomalies such as neural tube defects, congenital heart defects, limb or orofacial abnormalities, gastroschisis, and abnormal growth

  • Of note, nutritional deficits still occur in cases of overnutrition.

  • Nurses should provide education on the intake of nutrients such as folic acid, iron, vitamin B12, calcium, vitamin D, iodine, and choline during pregnancy.

    • Pregnant patients should take 400 mcg of folic acid per day starting at conception to decrease the risk of neural tube defects, prematurity, and low birth weight

• Special Populations

  • Social determinants of health, such as income, education, support systems, and physical living and working conditions, play an important part in determining if a pregnancy is at risk.

  • Nurses provide education on and support for overcoming barriers to optimum health throughout the pregnancy

  • Socioeconomic status

    • Risks: Limited prenatal care, Preeclampsia, Gestational diabetes, Malnutrition, Increased maternal health problems, Limited social support

    • Effects on fetus: preterm birth, miscarriage, decreased newborn care

  • Migrant farm work

    • Risks: Limited prenatal care, Exposure to occupational hazards, Poor living conditions, Malnutrition, Infection, Limited education of prenatal care

    • Effects on fetus: preterm birth, low birth weight, birth defects, decreased newborn care

  • Undocumented immigrant status

    • Risks: Limited or delayed prenatal care, Mental health disorders, Increased maternal health problems, Infection, Lack of social support, Chronic stress

    • Effects on fetus: preterm birth, low birth weight, decreased newborn care

  • Homelessness

    • Risks: Limited prenatal care, Limited access to food, Substance use or misuse, Mental health disorders, Exposure to environmental hazards, Chronic stress, Physical harm and violence

    • Effects on fetus: Preterm birth, Low birth weight, Decreased newborn care

  • Substance use or misuse

    • Risks: Infections, Increased maternal health problems, Inadequate self-care, Mental health disorder

    • Effects on fetus: Fetal drug exposure, Birth defects, Low birth weight, Intrauterine fetal death, Neonatal withdrawal, Neurodevelopmental impairment

      
      

A high-risk pregnancy refers to a pregnancy that has an increased likelihood of maternal and fetal complications.

• Antepartum

  • Age

  • Nutrition

  • Special Populations

  • Pregnancy-Miscarriage, Ectopic

  • Hyperemesis

  • Infections

  • Disorders of the placenta

  • Preterm labor, preterm rupture

  • Diabetes

  • Hypertensive Disorders

• Pregnancy-Miscarriage, Ectopic

  • Human chorionic gonadotropin (hCG) is produced as soon as the embryo’s trophoblast starts forming, leading to the development of the placenta.

    • Serum levels of hCG peak at 10 weeks of pregnancy and continue to fall throughout the remainder of the pregnancy.

    • The purpose of hCG is to support the pregnancy at the beginning by thickening the uterine lining and stimulating the placenta to produce estrogen and progesterone.

    • Abnormal patterns in human chorionic gonadotropin (hCG) levels—specifically a failure to double as expected, a plateau, or a continuous drop—can signal a miscarriage or an ectopic pregnancy. Healthcare providers evaluate serial blood tests (quantitative hCG) alongside ultrasounds and physical symptoms because a single test value is rarely diagnostic on its own

      

    • An ectopic pregnancy occurs when a fertilized egg becomes implanted outside the uterus.

      • Key risk factors include prior ectopic pregnancy, pelvic infection, infertility treatment, and tubal surgery

      • Patients may present with signs or symptoms such as vaginal bleeding, abdominal or pelvic pain, syncope, or shock; however, a patient may be asymptomatic until rupture occurs.

      • Transvaginal ultrasound and serial hCG levels are used to rule out an intrauterine pregnancy and diagnose an ectopic pregnancy.

      • An ectopic pregnancy may be managed medically or surgically. Medical or surgical intervention is indicated in the presence of worsening abdominal or pelvic pain, increasing hCG levels, or evidence of tubal rupture

      • hCG levels typically rise much more slowly than expected or plateau.

      • Ectopic pregnancy means that pregnancy has attached to another place that is not the uterus. Most common place is the fallopian tubes. Hemorrhage is the biggest risk factor here. In the first trimester, if a woman keeps complaining of spotting and bleeding, you need to rule out ectopic pregnancy. History of infertility, STD and history of abdominal surgery will be at more risk for ectopic pregnancy. ******

    • Miscarriage a spontaneous abortion, which is any pregnancy loss during the first trimester or before 20 weeks of gestation.

      • During a spontaneous miscarriage, the placenta stops producing hCG, causing blood levels to continuously drop toward a non-pregnant baseline

      • S & S: vaginal bleeding, cramping and pain

      • Diagnosis: ultrasound and serial measurement of hCG to check if levels are rising as expected or dropping.

      • Risk factor for miscarriage - nurse should prepare patient to recognize threshold and touch basis with medical team to verify if they are miscarrying.

        • You don't need to go to the doctor necessarily if you are having a miscarriage. Emotional damage is the worst thing.

        • If someone is pregnant, spotting and it is Rh -, we need to assess the need for Rhogam****

          • If a patient if Rh- and experiencing bleeding, contact provider immediately, they need to be evaluated for administration of Rh immunoglobulin (RhoGAM)

          • Prevention of Rh isoimmunization includes the administration of Rh immune globulin (RhoGAM) to Rh-negative pregnant persons during pregnancy when there is any chance of maternal exposure to fetal blood, as with a spontaneous abortion, invasive procedure, trauma, termination of pregnancy, at 28 weeks’ gestation, or prior to delivery (ACOG, 2022b). Rh immune globulin may be given again within 72 hours after birth to Rh-negative patients to neutralize any fetal red blood cells that entered the patient’s bloodstream during birth. Rh

***Referred pain from abdomen is felt in the shoulder straps.

A high-risk pregnancy refers to a pregnancy that has an increased likelihood of maternal and fetal complications.

• Antepartum

  • Age

  • Nutrition

  • Special Populations

  • Pregnancy-Miscarriage, Ectopic

  • Hyperemesis

  • Infections

  • Disorders of the placenta

  • Preterm labor, preterm rupture

  • Diabetes

  • Hypertensive Disorders

• Hyperemesis Gravidarum

  • Severe nausea and vomiting during the first trimester, leading to electrolyte imbalances, weight loss, malnutrition, and dehydration, is a condition called hyperemesis gravidarum.

  • The specific pathophysiology behind hyperemesis gravidarum is unknown;

  • While nausea and vomiting commonly occur during the first trimester, hyperemesis gravidarum is the most severe form and may require hospitalization for fluid and electrolyte replacement.

  • Complications related to hyperemesis gravidarum can negatively impact fetal outcomes and lead to low birth weight and preterm birth.

  • Patients may be prescribed antiemetic medications.

  • Patients may be directed to take thiamine (vitamin B1) to reduce the risk of refeeding syndrome and Wernicke encephalopathy related to thiamine deficiency

  • Once diagnosis is confirmed, management focuses on optimizing the patient’s fluid and nutritional status and often follows an algorithm.

  • The nurse’s role in managing nausea and vomiting during the first trimester includes the following:

    • Assessment: The nurse should assess the severity of symptoms to determine the level of intervention.

    • Support: The nurse can provide emotional support as indicated to promote an improved quality of life.

    • Education: Mild symptoms may require diet and lifestyle modifications. The nurse can educate patients to eat small frequent meals, avoid spicy foods, drink fluids, and rest.

    • Medication administration and education: Moderate symptoms may require additional intervention, such as through complementary or pharmacologic treatments. The nurse may administer or recommend treatments based on patient assessment and should educate the patient on potential side effects.

    • Outpatient or inpatient care: Severe symptoms may require hospitalization for management of dehydration and electrolyte imbalances such as decreased potassium. In cases of malnutrition, patients may be prescribed parenteral nutrition or enteral tube feedings. The nurse may be caring for the patient on an inpatient basis.

  • Types of Hyperemesis:

    • Mild NVP:

      • Recommend small, frequent meals

      • High protein and carbohydrate diet

      • Avoidance of spicy foods

      • Consumption of fluid with electrolytes between meals

      • Adequate rest

    • Moderate NVP

      • Assess need for vitamin supplementation

      • Ginger

      • Acupressure and Accupuncture

      • Nerve stimulation of the P6 point

      • Pharmacological treatment

    • Severe NVP

      • Additional antiemetics

      • Assess need for hospitalization

      • Rehydration with sodium chloride

      • Correct electrolyte deficiencies

      • Assess need for vitamin supplantation

      • Thiamine infusion

      • Dextrose

      • Enteral tube feeding

      • Parenteral nutrition

• Infections

  • Patients can develop infection at any time during pregnancy.

  • Infections that occur early in pregnancy typically have more detrimental effects on the fetus due to organogenesis and critical fetal development that occurs during that time.

  • Infections can be vertically transmitted across the placenta, as with TORCH infections and COVID-19, or the fetus can be exposed during the labor and delivery process, as with group B streptococcus.

  • Screening for infection during the first trimester can many times lead to identification and treatment to minimize risk to the pregnant person and the fetus.

  • The nurse’s role in caring for patients who are impacted by infection during pregnancy includes education, prevention, assessment, screening, collaboration, referral, treatment and medication administration, and counseling and support.

    • Education and prevention involve discussing safe sex practices, discussing the maternal-fetal risks related to infection, administering vaccinations, and promoting consistent prenatal care.

    • The nurse assesses for signs and symptoms of infections and performs routine screenings, such as for group B streptococcus and sexually transmitted infections.

    • The nurse collaborates with the health-care team to develop a multidisciplinary care plan, then administers treatments and medications accordingly.

    • Throughout the patient’s pregnancy, the nurse provides counseling and support to optimize maternal-fetal health and minimize risks.

  • Other Infections (from class)

    • Toxoplasmosis

      • Parasite, life cycle in cat

      • Transmission: cat feces, soil, litter, contaminated undercooked pork, lamb, beef

      • Complications:

        • Low birth weight, jaundice, enlarged spleen liver, anemia, long term –microcephaly, chorioretinitis

        • 17% fetuses affected –1st trimester, spont. abortion

        • 25% 2nd trimester

        • 65% 3rd trimester

      • Maternal treatment to reduce risk of transmission → don’t change the litter box

A high-risk pregnancy refers to a pregnancy that has an increased likelihood of maternal and fetal complications.

• Antepartum

  • Age

  • Nutrition

  • Special Populations

  • Pregnancy-Miscarriage, Ectopic

  • Hyperemesis

  • Infections

  • Disorders of the placenta

  • Preterm labor, preterm rupture

  • Diabetes

  • Hypertensive Disorders

• Disorders of the placenta

  • Once a mom had a baby, check the placenta after delivery for malodor, calcification and embarks that tells you about infection and how pregnancy went. Pay attention to where cord is inserted and how many vessels are present in the cord. ****

  • Placenta Previa

    • In placenta previa, the placenta is located on the lower aspect of the uterus near the internal cervical os (opening that connects vagina and uterus).

    • Risk factors for the development of a placenta previa include a history of placenta previa, multiple gestation pregnancy, multiparity, history of prior uterine surgeries (including C-sections), uterine abnormalities, advanced maternal age, use of assisted reproductive technology, and smoking.

    • Severity ranges from the placenta lying near the internal cervical os to the placenta completely covering the os and lower uterine segment

    • Diagnosis is often made during the second trimester through ultrasound.

    • The biggest risk of a placenta previa is hemorrhage. This can occur during pregnancy or labor. The signs include bright red vaginal bleeding with or without pain.

    • Close monitoring for signs of bleeding and maternal-fetal status should occur during the second and third trimesters.

    • Patients with placenta previa must undergo a cesarean birth. Vaginal delivery is contraindicated in cases of partial and complete placenta previa due to risk of bleeding and placental tearing.

    • Similarly, vaginal exams should be avoided to prevent additional injury in the presence of a known placenta previa or other incidences of vaginal bleeding. A hysterectomy may be performed if hemorrhage occurs.

    • The nurse should counsel patients to monitor for any signs of bleeding and to seek medical attention immediately if it occurs. Additionally, the nurse should educate the patient about what to expect in a cesarean birth.

    • Physical activity may be restricted once placenta previa is diagnosed. In cases of high risk for hemorrhage, patients may be placed on bed rest and pelvic rest until delivery.

    • From class:

      • Placenta implants low, blocking the way out for the baby. Leads to post-partum hemorrhaging. If bloods is coming out of the vagina and no pain is associated with it is the major telling sign. DON'T PUT anything inside the vagina such as your finger. This is the recommendation if you were diagnosed with placenta previa. It will cause women to start bleeding like a faucet. ****

      • Placenta previa = low attachment

        • Diagnosis via ultrasound

      • Symptoms - painless bleeding

      • Treatment - no vaginal exams

  • Placental Abruption

    • A placental abruption occurs when the placenta or part of the placenta separates from the uterine lining, which may lead to significant maternal-fetal blood loss, intrauterine fetal demise, or maternal death.

    • Risk factors for placental abruption include hypertension, smoking, cocaine use, and abdominal trauma during pregnancy.

    • Signs of abruption of the placenta include sudden onset of severe abdominal pain with or without dark red bleeding.The signs the nurse may see include prolonged uterine contractions or a uterus that remains contracted without achieving a resting tone and changes in the fetal heart rate pattern.

    • Management includes close fetal monitoring with imminent delivery based on the severity of maternal or fetal distress. Hemodynamic monitoring (pulse, urine output, blood pressure) of both the pregnant person and the fetus is imperative.

    • Fluid replacement with blood products or other fluids may be indicated in cases of significant blood loss with hemodynamic instability.

    • From class:

      • Early separation of placenta from uterine wall

      • Diagnosis via ultrasounf

      • Complete or partial

      • Symptoms: contractions, uterine irritability, abdominal pain, bleeding, non-reassuring FHR pattern

      • Treatment: depends on abruption percentage, mothers health, fetal health

      • Happens when placenta peels off the uterus wall, caused by changes in pressure (caused by epidural, use of cocaine, preeclampsia, a person hit by a car (trauma)). Baby can tolerate a small partial separation of the placenta, but complete separation is fatal.

      • Titanic contractions (up and down) accompanied by pain. Bleeding can be present or not.

    • From internet:

      • Fetal heart rate (FHR) patterns during a placental abruption typically reflect acute fetal hypoxia and distress due to reduced oxygen and blood flow from the detached placenta and uterine hypertonus

      • Recurrent Late Decelerations: Gradual decreases in the FHR below the baseline, starting after the peak of a contraction, indicating uteroplacental insufficiency

Disorder	Signs and Symptoms
Placenta previa	Vaginal bleeding, painless May cause fetal distress Cramping, uterine contractions
Placental abruption	Vaginal bleeding, painful May cause maternal and fetal distress Signs of maternal and fetal hemorrhage Abdominal pain Cramping, uterine contractions Back pain

A high-risk pregnancy refers to a pregnancy that has an increased likelihood of maternal and fetal complications.

• Antepartum

  • Age

  • Nutrition

  • Special Populations

  • Pregnancy-Miscarriage, Ectopic

  • Hyperemesis

  • Infections

  • Disorders of the placenta

  • Preterm labor, preterm rupture

  • Diabetes

  • Hypertensive Disorders

• Preterm labor

  • The onset of labor before term gestation, which occurs at 37 weeks’ gestation, is considered preterm labor.

  • The nurse’s primary role is to monitor the patient for contractions that are increasing in frequency and severity, which, along with cervical change, indicate impending preterm delivery.

  • Risk factors for preterm labor include previous preterm birth, infection, cervical abnormalities, chronic medical conditions, multiple gestation pregnancy, and certain lifestyle factors, such as substance use, smoking, poor diet, stress, and limited access to health care

  • Management is done by using medication to delay partum (tocolytics), medication to promote fetal lung maturity, magnesium sulfate for neuroprotection and stop labor

  • Diagnosis:

    • Pooling

    • Ferning (under microscope)

    • Aminsure - detects placental alpha microglobulin-1 (PAMG-1), a protein present in high amounts in amniotic fluid, swab test

    • Ultrasound

  • From class:

    • Nursing Care & Preterm Labor

      • Definition and symptoms:

        • Between 20 and 37 weeks gestation, progressive cervical changes

      • Assessment

        • Cervical length, previous history, Fetal Fibronectic (FFN)

      • Treatment

        • Underlying conditions (cause unknown)

        • Prevention

        • Contractions

          • Pelvic/ bed rest

          • Magnesium Sulfate, Indomethacin, Nifedipine

        • Fetal lung maturation

          • L/S ratio

          • Corticosteriods (24 hrs)

          • Highest risk for baby that is born preborn is respiration. Corticosteroid injection is given to mom to increase the baby's lung surfactant production. ***

• Preterm Premature Rupture of Membranes

  • Rupture of the amniotic sac before term gestation at 37 weeks, with leakage of amniotic fluid and concern for imminent delivery, is called preterm premature rupture of membranes (PPROM).

  • Risk factors include infection, multiple gestation, and a history of prior preterm birth.

  • Leakage of amniotic fluid from the vagina is the primary sign.

    • Confirming preterm premature rupture of membranes requires the nurse to insert a sterile swab into the vaginal discharge and place it into a tube containing the solvent vial for a minimum of 1 minute. After removing the swab, the solvent fluid is tested and if positive, confirms rupture of membranes.

  • Complications of preterm premature rupture of membranes are infection, oligohydramnios, cord prolapse, and preterm labor.

  • In cases of unstable pregnant person or fetal status, induction of labor or cesarean delivery may be performed.

    • If the rupture of membranes occurs at a very early gestational age, the patient may remain as an inpatient to allow the fetus time to mature.

  • Nursing care includes monitoring for signs and symptoms of infection and preparing for a preterm birth.

  • From Class

    • Associated condition:

      • Maternal risks: chorioamnionitis, preterm labor, abruption

      • Fetal risks: Prematurity, Pulmonary hypoplasia, Limb position defects, Impaired fetal growth, Neonatal sepsis, Fetal hypoxia due to cord compression or prolapse

    • Management:

      • Gestational age

      • Maternal/fetal well being

A high-risk pregnancy refers to a pregnancy that has an increased likelihood of maternal and fetal complications.

• Antepartum

  • Age

  • Nutrition

  • Special Populations

  • Pregnancy-Miscarriage, Ectopic

  • Hyperemesis

  • Infections

  • Disorders of the placenta

  • Preterm labor, preterm rupture

  • Diabetes

  • Hypertensive Disorders

• Hypertensive Disorders

  • Hypertensive disorders during pregnancy place the fetus at increased risk for complications due to impaired blood flow to the placenta.

  • Management of hypertension aims to reduce blood pressure to normal ranges while monitoring for adverse maternal conditions, such as HELLP syndrome and eclampsia, uteroplacental insufficiency, fetal growth restriction, and intrauterine fetal demise.

  • Hypertension Types:

    • Chronic HTN

      • < 20 weeks

      • Pre-pregnancy

      • Post-pregnancy

      • Preexisting

      • It is not preeclampsia until more than 20 weeks

    • Gestational HTN

      • >20 weeks onset

      • PIH, preeclampsia-eclampsia, or toxemia

    • Chronic HTN with superimposed symptoms of gestational HTN

      • HTN with proteinuria, thrombocytopenia, or elevated liver enzymes

    • Transient HTN

      • Intrapartum to 24h postpartum

      • Resolves during postpartum course

  • Preeclampsia and hemorrhage are the biggest factor of death for moms. Hemorrhage is the most controllable and monitorable factors.***

  • Gestational Hypertension

    • Gestational hypertension is hypertension that occurs after 20 weeks’ gestation and may also be termed preeclampsia.

    • Risk factors for gestational hypertension include obesity, nulliparity, history of preeclampsia, preexisting diabetes, renal disease, and multiple gestation pregnancy

    • A formal diagnosis can be made when systolic blood pressure exceeds 140 mm Hg or diastolic blood pressure exceeds 90 mm Hg on more than one occasion.

    • Gestational hypertension carries increased risk to both the pregnant person and the fetus.

    • Antihypertensive therapy is often prescribed to prevent severe hypertension.

    • Patients who develop severe gestational hypertension may need to be admitted to the hospital with close blood pressure and maternal-fetal monitoring. Delivery may be indicated at 37 weeks or before, depending on clinical status and lab findings.

  • From class:

    • Vasoconstriction due to vasospasm leading to hypoperfusion

    • Decreased blood flow to all maternal organs including the fetus

    • Occurs after 20 weeks

    • Treatment: delivery

    • Diagnosis:

      • Preeclampsia, mild

      • Preeclampsia, severe

      • HELLP

      • Eclampsia

    • Risk Factors:

      • Primigravida, maternal age <20 and >40

      • Obesity, history of preeclampsia

      • 10 years or more since a last baby, multiples

      • History of hypertension, diabetes or kidney disease

      • Pregnancy abnormalities

      • Stress, lower socioeconomic group, poor nutrition

      • **Diabetes and preeclampsia tend to happen together. So if you have one, watch out for the other

  • Preeclampsia

    • The multisystem disorder preeclampsia can occur after 20 weeks’ gestation and up to 6 weeks postpartum and, if untreated, can lead to damage of the vital organs and seizures.

    • Compared with gestational hypertension, preeclampsia has a greater risk of adverse outcomes, such as cesarean delivery, preterm birth, low Apgar scores, placental abruption, and small-for-gestational-age infants.

    • The exact etiology of preeclampsia is unknown, but it is thought to be related to vascular changes in the placenta and uterus. The vascular changes damage the endothelial cells of the blood vessels, increasing vascular permeability leading to edema and increased glomerular damage leading to proteinuria.

    • Risk factors for preeclampsia include nulliparity, extremes in maternal age, obesity, multiple gestation pregnancy, kidney disease, chronic hypertension, diabetes, and a personal or family history of preeclampsia.

    • Signs of preeclampsia are high blood pressure, proteinuria, edema, headaches, vision changes, epigastric pain, and nausea or vomiting. Patients should be instructed to immediately see their health-care provider if they experience any of these signs or symptoms.

    • Risk reduction is the first step toward management of preeclampsia. Daily low-dose aspirin beginning early in the second trimester is recommended for patients who are at risk (ACOG, 2020c).

      • The most effective treatment of preeclampsia is delivery. However, prior to delivery, hypertension can be managed with antihypertensive therapy.

      • In cases of preeclampsia with severe features, the patient may be started on magnesium sulfate to prevent the progression of preeclampsia to seizures. Therefore, the patient with severe symptoms will need to be hospitalized for monitoring until stabilization of blood pressures or until delivery. Delivery will depend on the severity of preeclampsia.

    • During hospitalization, the nurse closely monitors for signs of worsening preeclampsia, which can lead to the onset of eclampsia.

      • Hyperreflexia and the presence of clonus are warning signs for seizure risk.

      • In addition to vital sign monitoring, the nurse should regularly assess the patient’s neurologic status, including level of consciousness, reflexes, and signs of magnesium toxicity (loss of deep tendon reflexes, respiratory depression, and decreased urine output).

      • Continuous electronic fetal monitoring may be ordered to evaluate fetal heart rate and uterine contractions.

      • Additional monitoring of serial lab tests, such as magnesium levels and liver and renal function tests, may be indicated. Any significant change to maternal clinical status or fetal heart rate should be immediately reported to the health-care team.

    • Preeclampsia Treatment (from class)

      • Severe

        • Hospitalization

        • Anticonvulsants:

          • Magnesium Sulfate (CNS depressant)

          • Phenobarbital (anxiety and seizures)

        • Fluid and electrolyte replacement

          • Strict I&O balance, hypovolemia, circulatory overload and poor kidney function

        • Calm, dark, quiet environment

        • Antihypertensives

        • Deliver

      • Hypoperfusion will eventually cause seizures and affect the amount of oxygen that reaches the fetus.

        First they use medication to avoid seizures to happen, but the ultimate action is to remove baby if things don't improve.

      • Assessing tonus and reflexes will allow you to know that you are about to have a seizure to hyporeflexion.

        • Women with preeclampsia also have hypoperfusion to kidneys and liver. If they are taking magnesium sulfate, that will cause accumulation of magnesium toxicity. That leads to cardiac arrest because it affects the diaphragm since it's a CNS depressant.

        • Calcium gluconate reverses magnesium sulfate toxicity. Have in hand!

  • HELLP Syndrome

    • HELLP syndrome is an acronym that stands for Hemolysis, Elevated Liver enzymes, and Low Platelet count.

    • Patients often experience signs and symptoms of preeclampsia, such as epigastric pain, headache, and vision changes, but the patient may not necessarily develop hypertension or proteinuria

    • Signs and symptoms specific to HELLP syndrome include fatigue and abnormal bruising (related to hemolysis), abdominal pain (often right upper quadrant [RUQ]), edema, nausea, and vomiting (related to elevated liver enzymes), and petechiae or prolonged bleeding time (related to low platelets)

    • Diagnosis is based on low platelets and lab values that indicate liver involvement (alt, als).

    • HELLP syndrome can be life-threatening to both the pregnant person and the fetus, so close monitoring and prompt evaluation are necessary.

    • Treatment options include anticipated delivery if > 34 weeks’ gestation based on lab values, supportive care, and management of possible hemorrhage

    • The nurse’s role includes close monitoring of vital signs, assessing for worsening symptoms, and promptly notifying the health-care team of any changes to clinical status. Prepare mom for preterm delivery.

    • From class:

      • HELLP = Microangiopathic hemolytic anemia

      • H: Hemolytic anemia, EL: elevated liver enzymes, LP: low platelet count, + DIC = disseminated intravascular coagulation

      • Disseminated intravascular coagulation (DIC) develops in response to organ dysfunction with interruption of the coagulation process. In these cases, DIC produces tiny blood clots that can lead to increased hemorrhage or further organ damage. DIC can occur secondary to severe preeclampsia, infection, or placental abruption.

    • From internet:

      • HELLP syndrome is a rare, life-threatening pregnancy complication that is closely related to preeclampsia.

      • What HELLP Stands For

      • The acronym stands for three core features:

        • H – Hemolysis: The breakdown of red blood cells, which reduces the body's ability to carry oxygen.

        • EL – Elevated Liver enzymes: Liver damage or dysfunction that causes high levels of liver enzymes in the blood.

        • LP – Low Platelet count: A drop in platelets, which are blood cells that help the blood clot properly.

      • It usually develops during the third trimester (between 26 and 40 weeks) or, less commonly, in the postpartum period within 48 hours after delivery. Common symptoms include upper right or mid-abdominal pain, severe headaches, nausea, vomiting, and blurry vision

      • Risks for the fetus

        • Preterm birth

        • Fetal Growth Restriction (FGR)

        • Placental abruption

        • Intrauterine fetal demise (IUFD)

      • HELLP syndrome is most commonly considered a severe variant or complication of preeclampsia, affecting about 10% to 20% of women who have preeclampsia

  • Eclampsia

    • A diagnosis of eclampsia is made when signs of preeclampsia progress to seizure activity.

    • Eclampsia can occur during pregnancy or after birth.

    • Eclampsia is associated with increased risk of death to the pregnant or newly delivered person and the fetus.

    • Maternal complications include pulmonary edema, acute renal failure, hemorrhage, placental abruption, preterm delivery, neurologic damage, and cardiac arrest (Laskowska, 2023).

    • Management of eclampsia focuses on prevention by quickly identifying and treating preeclampsia.

      • Magnesium sulfate may be prescribed to control seizure activity.

      • An emergent cesarean delivery may be performed to prevent adverse outcomes, including maternal and fetal death.

    • Nursing Actions:

      • Recognize Seizure Activity

      • Prevent Injury - remove objects from patient bed, loosen anything tight around neck, lift side rails and cover with blankets, stay with patient

      • Maintain Open Airway: lower the head of the bed to <30 degrees, turn the patient to their side

    • From class:

      • Definition: seizure activity or coma unrelated to other cerebral conditions in an obstetrical

        patient with preeclampsia.

      • Risk - 3rd trimester through 48° postpartum

      • Hypoperfusion of brain - headache, hypoperfusion of eye - floaties, heartburn, leaky vessels because of vasospasms = edema in the face, weight gain greater than 5 lbs in a week, proteinuria, high BP (hypertension)

      • Treatment

        • 4-6 gms MgSO4 IV over 5 minutes

        • Pad side rails

        • O2 mask

      • You can have eclampsia after birth, LIFE THREATNING

      • Sings/Symptoms of MgSO4 Toxicity

        • Absent reflexes

        • Depressed respirations <10-12/min (CNS depressant)

        • Deteriorating level of consciousness

        • SOB

        • Chest heaviness

        • Antidote - Calcium Gluconate

  • Superimposed Hypertensive Disorders or Pregnancy

    • Chronic hypertension can progress to superimposed preeclampsia during late pregnancy.

    • Superimposed preeclampsia may be suspected if a patient diagnosed with chronic hypertension during the first trimester develops increasing blood pressures after 20 weeks’ gestation.

    • Because of the similar presentation of elevated blood pressure and proteinuria in chronic hypertension and preeclampsia, superimposed preeclampsia may be difficult to differentiate.

    • Management should focus on the administration of antihypertensives and the treatment of preeclampsia to reduce morbidity and mortality.

    • HTN with proteinuria, thrombocytopenia, or elevated liver enzymes

      • During thrombocytopenia purpura (ITP), the immune system mediates the destruction of platelets. Patients may develop severe thrombocytopenia with signs of bleeding and require a platelet transfusion.

A high-risk pregnancy refers to a pregnancy that has an increased likelihood of maternal and fetal complications.

• Antepartum

  • Age

  • Nutrition

  • Special Populations

  • Pregnancy-Miscarriage, Ectopic

  • Hyperemesis

  • Infections

  • Disorders of the placenta

  • Preterm labor, preterm rupture

  • Diabetes

  • Hypertensive Disorders

• Diabetes

  • Preexisting diabetes

    • Type I - insulin deficient

    • Type II -insulin resistant

  • Pregnancy

    • Maternal metabolism adjusts to provide adequate nutrition for mother and fetoplacental unit

    • Glucose, ketone acids cross placenta, insulin does not

    • As the placenta grows, direct correlation with increases in somatotropin and human placental lactogen

    • If mom blood sugar is not in control during pregnancy, baby can have fetal defects

  • Goals

    • Preconception control, glycosylated hemoglobin (HgA1C)

    • Control during embryogenesis = neural tube defects, cardiac defects, caudal regression syndrome

    • Deliver fetus at the best time

  • Diabetes Type I, II - Maternal Effects

    • Blood glucose instability

      • 1st trimester insulin needs decrease: N/V, increase fat storage, hypoglycemia

        • Nausea and vomiting (morning sickness) mean the mother digests fewer carbohydrates. Simultaneously, early pregnancy hormones cause the body to burn glucose faster and increase fat storage, pulling sugar out of the bloodstream.

      • 2nd trimester insulin needs increase (risk of hyperglycemia): increasing metabolic demands increasing placental hormones that create resistance to insulin

        • The placenta grows larger and produces high levels of hormones (like human placental lactogen, cortisol, and progesterone). These hormones act as insulin blockers, causing severe insulin resistance to ensure plenty of glucose stays in the blood to feed the growing baby.

      • Intrapartum: Continuous IV insulin, tritrate to FBS, increased metabolic demands

        • Labor is intense physical work that rapidly consumes energy (increased metabolic demands). To maintain absolute control, the mother is put on a continuous IV insulin drip, which is titrated (adjusted hour-by-hour) based on her Fasting Blood Sugar (FBS) to prevent the baby from dropping its blood sugar at birth.

      • Postpartum: decreasing insulin needs with delivery of placenta

        • The moment the placenta is delivered, the source of the insulin-blocking hormones is entirely removed. The mother’s insulin sensitivity returns almost instantly, requiring a swift reduction in her insulin medication to avoid severe crashes.

    • Ketoacidosis (DKA)

      • Diabetic Ketoacidosis (DKA) is a life-threatening medical emergency where the body runs out of insulin and starts burning fat for fuel, turning the blood acidic.

      • Develops at lower thresholds

        • In pregnant women, DKA develops at much lower blood sugar thresholds than normal.

    • Urinary tract infections

      • Pregnant women with diabetes are at a significantly higher risk for UTIs.

      • When blood sugar is high, the kidneys spill excess glucose into the urine (glycosuria). This turns the urinary tract into a warm, sugary breeding ground for bacteria.

    • Exacerbation of chronic complications

      • Retinopathy

      • Nephropathy

      • Coronary artery disease

  • Diabetes Type I, II - Pregnancy Effects

    • Spontaneous Abortion

    • Congenital Malformation

    • Pregnancy Induced Hypertension (PIH)

    • Preterm Labor

    • Polyhydraminos

      • Premature rupture of membranes (PROM)

      • Cord colapse

    • Cesarean Section

      • Macrosomia >4000g or >90%ile

      • Birth Trauma

    • IUGR - small size of baby

    • Three signs of diabetes: polyuria, polyphagia, polydipsia

  • Gestational Diabetes (GDM)

    • Gestational diabetes is diagnosed when high maternal glucose levels are present during the second or third trimester.

    • Gestational diabetes occurs secondary to hormonal changes during pregnancy that lead to increased insulin resistance with insufficient insulin secretion to meet pregnancy needs, and genetic factors may also play a role.

    • Preexisting diabetes can be ruled out during the first trimester through a glucose challenge test (GCT) in patients at high risk.

    • In patients who are not at increased risk, the 1-hour glucose challenge test may be administered during the second trimester at 24 to 28 weeks’ gestation.

    • If the test results reveal concern for gestational diabetes, a 3-hour glucose tolerance test is administered to confirm a diagnosis (ACOG, 2020c).

    • Like preexisting diabetes, gestational diabetes can be associated with adverse maternal and fetal outcomes when blood glucose levels are not well controlled.

    • Because of the risks of hyperglycemia, treatment targets normalizing blood glucose levels. Management of blood glucose levels can occur through dietary and lifestyle modifications, frequent glucose monitoring, and insulin therapy

    • From class:

      • 1st Trimester, estrogen/progesterone stimulate insulin production to ↑glycogen stores in liver

      • As the fetus develops, placenta produces Human Placental Lactogen (hPL)

      • hPL ↓cell uptake of glucose, →↑insulin production to maintain normal blood sugar range

      • In 8% of pregnancies, pancreas cannot produce enough insulin

      • Starts and ends in pregnancy

      • Pregnancies are screened 24-28 weeks

    • Risk Factor of Gestational Diabetes (Class)

      • Obesity

      • Age >35

      • GB with previous pregnancy

      • Glycosuria

      • Strong Family history of diabetes

      • History of LGA baby >9 lbs

      • History of fetal losses or congenital anomalies

      • Hispanic, African-American, Native American ethnicity

    • Screening and diagnosis

      • First OB labs: Hgb A1c

      • 26-28 weeks screening

        • Glucose Challenge Test (GCT)

          • Ingest 50 gram glucose, 1 hour later serum glucose. If >130 gm/dl indicated need for further testing

      • Diagnosis

        • 3 hr. Glucose Tolerance Test (GTT)

          • Prep of fasting. Measure fasting serum glucose.

          • Ingest 100g glucose, measure serum glucose 1hr, 2hr and 3hr after ingestion

          • Gestational diabetes if 2 or more are elevated

    • Long Term Considerations

      • Six-week postpartum screening for gestational diabetics 2hr. GTT (Glucose Tolerance Test)

        • Increased risk, >50%, of developing Type 2 diabetes

      • Children of women with Gestational Diabetes

        • Increased risk of obesity

        • Glucose intolerance

        • Diabetes in young adulthood and later life

    • Infant of Diabetic Mother

      • Scope

        • Type of diabetes

        • Control (preconception counseling)

      • Complications

        • Macrosomia

        • IUGR, SGA

        • Respiratory distress

        • Hypocalcemia, polycythemia

        • Hyperbilirubinemia

      • Symptoms

        • Hypoglycemia

        • Jitteriness

        • Tachypnea

        • Low temperature

        • Poor muscle tone

• Intrapartum

  • Problems with Powers, Passage and Passenger

  • Chorioamnionitis

  • Emergencies:

    • Abnormal fetal heart rate Category III

    • Prolapsed cord

    • Shoulder dystocia

    • Post-partum hemorrhage

• Problems with Powers, Passage and Passenger

  • Lack of progress during labor, which could make it prolonged or difficult is called dystocia is defined as difficult labor.

  • Uterine dystocia

    • Caused by lack of power, meaning that uterine contractions or the maternal pushing effort is inadequate to progress to birth.

      • Lack of cervical dilation occurs due to insufficient contraction strength, frequency, or duration

      • Multiple factors cause inadequate uterine contraction activity. Causes related to the pregnant person are chorioamnionitis, dehydration and malnutrition, exhaustion, and emotional stress (cortisol inhibits oxytocin).

      • Multiple gestation, large for gestational age, and polyhydramnios (an excessive amount of amniotic fluid) distend the uterus and decrease the strength of the contractions, causing uterine dystocia.

      • Grand multiparity and prolonged labor are associated with a uterus too tired or overstretched to contract efficiently.

      • Epidural anesthesia may decrease uterine contraction strength and frequency and has been linked to a nonengaged fetal head

      • Uterine tachysystole does not allow enough time between contractions for placental perfusion and fetal reoxygenation. If allowed to continue, this can lead to fetal hypoxia or uterine rupture.

        • Common causes: oxytocin/pitocin, maternal dehydration, preeclampsia, placental abruption, and chorioamnionitis

        • Intervention: stop oxytocin/pitocin

      • To enhance uterine contraction and augment labor: amniotomy or administering oxytocin

  • Pelvic dystocia

    • A problem of the passage, meaning that the pelvic outlet does not allow the passage of the fetus for birth.

    • A labor complication that occurs when the size of the fetal head is larger than the size of the maternal pelvis due to a small capacity of the pelvic inlet, midpelvis, or pelvic outlet

    • Risk factors: age of laboring person (< 16 and > 40), obesity, short stature, shape and size of pelvis, nulliparity

  • Fetal dystocia

    • Fetal dystocia is a problem of the passenger, meaning that the fetus is unable to maneuver through the pelvis to descend and birth.

    • Reasons for fetal dystocia can be a persistent occiput posterior or transverse, face, or brow presentation

    • Risk factors: estimated fetal weight large for gestational age, mispositioning or malformation of the fetus

  • These three types of dystocia create long, difficult labors.

  • The common factors associated with labor dystocia are the following:

    • power: uterine contractions and laboring person’s pushing effort

    • passenger: fetal malposition or malpresentation

    • passage: inadequate pelvis inlet, midpelvis, or outlet

    • psyche: laboring person’s preparedness and anxiety regarding the labor and birth process

    • position of the laboring person

  • Labor dystocia increases with age

• Intrapartum

  • Problems with Powers, Passage and Passenger

  • Chorioamnionitis

  • Emergencies:

    • Abnormal fetal heart rate Category III

    • Prolapsed cord

    • Shoulder dystocia

    • Post-partum hemorrhage

• Chorioamnionitis

  • It is the infection and inflammation of the amniotic fluid, placenta, fetus, fetal membranes, or decidua

  • Chorioamnionitis is caused by different types of bacteria present in the vagina that ascend into the amniotic area.

  • Risk factors:

    • prolonged labor

    • prolonged rupture of membranes

    • multiple vaginal exams

    • bacterial vaginosis

    • group B streptococcal colonization

    • meconium-stained fluid

    • internal fetal monitors

    • epidural anesthesia

    • use of internal fetal monitors

    • meconium stained fluid

  • Complications associated with chorioamnionitis are neonatal morbidity from pneumonia, meningitis, sepsis, and death.

  • Complication in the laboring person: PROM, preterm labor, fever, tender uterus, foul-smelling discharge, fetal tachycardia, nonreassuring FHR

  • Treatment: IV antibiotics

• Polyhydramnios

  • An increase in amniotic fluid amount, or polyhydramnios, may be caused by fetal abnormalities or genetic syndromes and conditions of the pregnant person.

  • Two common reasons for polyhydramnios are fetal anomalies and diabetes in the pregnant person.

• Oligohydramnios

  • Oligohydramnios is the lack of sufficient amniotic fluid. This amount is usually measured during ultrasound examination.

  • Causes of oligohydramnios can be fetal or maternal. Identifying the causative agent is important to determine treatment.

  • Complications of oligohydramnios during pregnancy can be fetal growth restriction and fetal malformations. In cases of severe oligohydramnios, induction of labor is warranted.

  • Amnioinfusion can replace fluid in the uterus to relieve umbilical cord compression during labor

• Intrapartum

  • Problems with Powers, Passage and Passenger

  • Chorioamnionitis

  • Emergencies:

    • Abnormal fetal heart rate Category III

    • Prolapsed cord

    • Shoulder dystocia

    • Post-partum hemorrhage

• Fetal Assessment

  • The fetal status is evaluated by assessing the FHR pattern, either through intermittent auscultation using a doppler device, or via external or internal electronic monitoring. 

    Frequency of assessment of the FHR pattern can vary based on the client’s condition and provider preference. However, the following timeframes are recommended. 

    • In low-risk pregnancies, FHR is monitored at least every 30 min during the first stage of labor and every 15 min during the second stage of labor. 

    • In high-risk pregnancies, FHR is monitored at least every 15 min during the first stage of labor and every 3 to 5 min during the second stage of labor. 

  • Assessment of FHR patterns include the baseline rate and variability, presence or absence of accelerations, and presence or absence of periodic and episodic decelerations. Tracings are interpreted based on the National Institute of Child Health and Human Development (NICHD) standards definition. 

  • FHR baseline (110-160 bpm)

    • The baseline rate is rounded to the nearest 5 beat/min increment.

      • Normal

      • Bradycardia (<110 bpm for mor than 10 min)

        • Can occur following administration of maternal IV analgesics, fetal sleep states, or rarely, due to congenital fetal heart block

      • Tachycardia (>164 bpm for more than 10 min)

        • Can be an indication of hypoxemia.

        • If baby is tachy, you should monitor mom temperature. If baby is hot, heart rate is high. If mom has a temp, treat it. If mom doesn't have a temp -> access baby overall wellbeing (i.e. perfusion, lack of O2)​

        • If fetal tachycardia is present, assess the client for causes, such as infection, recent nicotine use, medications (hydroxyzine, terbutaline), or use of illicit substances such as methamphetamine or cocaine and notify the provider.

  • FHR variability

    • Fluctuations in the baseline FHR of at least 2 cycles/min that are irregular in amplitude and frequency is called variability. Variability is measured over a 10-min window of time, and the amplitude is measured from peak to trough.

      • Absent – undetected from baseline​

      • Minimal - < 5 bpm ​

      • Moderate – 6 to 25 bpm​

      • Marked – abrupt O2 loss​

    • Most important indicator of acid/base balance, cerebral tissue perfusion

    • Moderate variability is the best indicator of a healthy baby. If there is absent, marked or minimum variability, than that is a bad sign for the baby

    • Moderate variability indicates adequate oxygenation of the central nervous system (CNS) and is a reliable predictor of the absence of hypoxia-induced metabolic acidemia at the time it is observed.

      • Minimal or absent variability may indicate fetal metabolic acidemia or hypoxemia.

      • Minimal variability can also have fetal causes such as extreme prematurity, sleep cycle, congenital cardiac anomalies, neurologic injury, or following administration of maternal medications.

      • Marked variability may be present in early stages of fetal hypoxemia or an exaggerated autonomic response to a disruption in fetal oxygenation.  

  • Fetal Heart Rate Tracing Patterns

    • Aceleration

      • An abrupt (less than 30 seconds from the onset to its peak or nadir) increase in the FHR above the baseline. 

      • To be identified as an acceleration, the peak of the increase must be greater than or equal to 15 beats/min above the baseline, last at least 15 seconds, and return to baseline within 2 min of the start of the increase. Acceleration is considered prolonged if it lasts more than 2 min but less than 10 min. If an acceleration lasts more than 10 min, it is considered the new baseline FHR. 

      • For a client who is at 32 or less weeks of gestation, an FHR acceleration is defined as an increase in FHR of at least 10 beats/min above the baseline, lasting for at least 10 seconds. 

      • Possible Etiologies and Interpretations: Associated with fetal movement, autonomic stimulation of the heart, and increased catecholamine release.  

        • Presence of acceleration indicates absence of acidemia and considered an indication of fetal well-being. 

      • Nursing Intervention: no intervention required.

    • Variable deceleration

      • An abrupt (less than 30 seconds from the onset of the acceleration to its peak or nadir) decrease in the FHR below the baseline. The decrease is greater than or equal to 15 beats/min, lasting greater than or equal to 15 secs and less than 2 min from onset to return to baseline. Variable deceleration’s onset, depth, and duration vary with successive uterine contractions.

      • Possible Etiologies and Interpretation: An autonomic response to umbilical cord compression. Unexpected finding requiring further evaluation. 

      • Nursing Intervention: Reposition client to left or right lateral. Stop oxytocic medications. Give intravenous fluid bolus. Administer oxygen at 10 L/min via non-rebreather face mask*.

    • Variable deceleration and acceleration can happen without contractions​

    • Early deceleration

      • The FHR nadir and the peak of contraction occur at the same time. The onset, nadir, and termination of the deceleration coincide with the onset, peak, and termination of the contraction.  

      • It’s on time with the contraction.

      • Possible Etiologies and Interpretations: An autonomic response to changes in intracranial pressure and/or cerebral blood flow caused by intrapartum compression of the fetal head during a uterine contraction. Expected during the second stage of labor.

        • When uterus contract, it squeezed baby's head, which leads to lowering baby HR​

      • Nursing Interventions: No intervention required. 

    • Late deceleration

      • A gradual (greater than than or equal to 30 seconds from the onset to its nadir) decrease in the FHR below the baseline. A late deceleration begins during or immediately after the peak of a contraction and does not return to baseline until after the contraction ends. The onset, depth, and duration of late decelerations can vary with successive contractions.

        • Starts mid contraction, and dip post contraction, that is why it is called late

      • Possible Etiologies and Interpretation: Caused by uteroplacental insufficiency resulting in severe hypoxemia and metabolic acidemia. Unexpected finding requiring prompt attention.  

      • Nursing Interventions: Reposition client to left or right lateral. Stop uterotonic medications. Give intravenous fluid bolus. Administer oxygen 10 L/min via non-rebreather face mask*.

    • Prolonged Deceleration

      • A deceleration from the baseline FHR of 15 bpm or more, lasting at least 2 min but less than 10 min from the onset to return to baseline. A prolonged deceleration of greater than 10 min is considered change in the baseline. 

      • Possible Etiologies and Interpretations: Acute onset can be due to hypotension, umbilical cord occlusion, rapid fetal descent, tachysystole, abruption, and uterine rupture.

      • Nursing interventions: Manage based on underlying cause. 

  • Classification of FHR Patterns

    • Category I - Normal patterns

      • Baseline FHR of 110 to 160/min 

      • Moderate baseline FHR variability 

      • No late or variable decelerations 

      • Present or absent early decelerations  

      • Present or absent accelerations 

    • Category II - Intermediate

      • Includes tracings that did not meet the Category I or Category III criteria.

    • Category III - Abnormal Patterns

      • Absent baseline FHR variability, and any of the following 

        • Recurrent variable decelerations 

        • Recurrent late decelerations 

        • Bradycardia 

        • A sinusoidal pattern 

• Nursing Assessment & Interventions

  • VEAL - CHOP

    • Variable - cord, reposition

    • Early - head compression, no intervention

    • Acceleration - optimal, no intervention

    • Late - placental problems, oxygen delivery compromised to fetus, reposition client + stop medication + give fluids + give oxygen

  • Fetal compromise due to:

    • Maternal cardiopulmonary alterations

    • Uterine activity

    • Placental disruptions

    • Interruptions in umbilical flow

    • Fetal Alterations

    • Risk factors

• Intrapartum

  • Problems with Powers, Passage and Passenger

  • Chorioamnionitis

  • Emergencies:

    • Abnormal fetal heart rate Category III

    • Prolapsed cord

    • Shoulder dystocia

    • Post-partum hemorrhage

• Prolapsed cord

  • When the umbilical cord lies beside or in front of the fetal presenting part, it is called a prolapsed cord.

  • This is an emergency because oxygen is unable to reach the fetus due to cord occlusion.

  • A prolapsed cord is usually diagnosed after rupture of the amniotic membranes, either spontaneously or artificially. The fetal monitor tracing will usually show a prolonged deceleration.

  • The nurse suspects a prolapsed cord and does a vaginal exam. Many times, the cord with pulsation is felt in the vagina. At other times it cannot be palpated, but the assumption is made because of the prolonged deceleration.

  • The nurse will lift the presenting part off the cord to allow for perfusion to the fetus. The nurse calls for assistance while keeping the presenting part elevated. An emergency cesarean birth will be performed, and the nurse’s hand will remain lifting the presenting part until the fetus is delivered.

    • A gloved hand in the vagina pushes the fetus upwards and off the cord

    • Knee-chest position uses gravity to shift the fetus out of the pelvis.

    • Stick finger inside the pelvis, push the head in. Turn mom upside down to take pressure off the baby's head.

• Shoulder dystocia

  • The impaction of the fetal shoulder into the symphysis pubis or sacral promontory, preventing the delivery of the fetus is called shoulder dystocia.

  • The health-care provider attempts to deliver the anterior shoulder, but the shoulder lodges under the pubic bone and is not delivered.

  • Complications of shoulder dystocia include increased risk of postpartum hemorrhage and perineal lacerations.

  • Fetal complications include brachial plexus injuries and fractures of the clavicle and humerus. Additionally, it can cause fetal hypoxia and death if not addressed quickly

  • Management of shoulder dystocia should be systematic and rapid.

    • McRoberts + suprapubic pressure

    • McRoberts = put knee to the ear, open pelvis as much possible + suprapubic pressure = pushes shoulder down

  • The nurse and health-care providers must act quickly to resolve the dystocia.

    • The nurse positions the person to help the provider perform maneuvers. The first maneuver is McRoberts maneuver, which is the process of flexing the laboring person’s legs until the thighs touch the abdomen.

    • Posterolateral suprapubic pressure is then provided in hopes of dislodging the shoulder from underneath the pubic bone.

    • The nurse will need a stool to get above the person and give downward, lateral pressure with one or both hands toward the fetal-facing side.

    • 
      

      

Suprapubic pressure

Letter	Stands For	Intervention
H	Help	Shoulder dystocia is an emergency, and the nurse will need assistance.
E	Episiotomy	An episiotomy might be made; the nurse will assist the provider as necessary.
L	Legs	Pull the legs back (McRoberts).
P	Pressure	Give posterolateral suprapubic pressure.
E	Enter	The provider enters the vagina and attempts to rotate the shoulder.
R	Remove	Remove the posterior arm.
R	Roll	Roll the person to all fours.

• Immediate Postpartum Hemorrhage

  • Total blood loss greater than or equal to 1,000 mL or blood loss and signs or symptoms of hypovolemia within 24 hours after birth is considered postpartum hemorrhage.

  • When hemorrhage occurs during the third stage of labor or the first hour after birth, it is considered an immediate postpartum hemorrhage.

  • Causes for postpartum bleeding:

    • Uterine atony (lack of tonus) - give pitocin

    • Lacerations or uterine rupture

    • Retained placenta or clots

    • Clotting-disorders

• Postpartum

  • Infections

  • Postpartum Hemorrhage (PPH)

  • Post-operative

  • Mood Disorder

• Infections

  • From class:

    • Fever >38°C or 100.4°F after first 24 hours

    • Organisms usually those of normal vaginal flora (aerobic and anaerobic)

    • Metritis: infection of endometrium, decidua, and adjacent myometrium

    • Wound infections (Urinary tract infections)

    • Mastitis: inflammation of the breast)

  • From book:

    • Postpartum infections can be caused by multiple factors.

    • Endometritis: infection of the uterus that occurs in the postpartum period

      • Endometritis and wound infections are more likely to occur in persons with prolonged rupture of membranes and chorioamnionitis.

      • Infections occur more often in persons with STIs, chorioamnionitis, prolonged rupture of membranes, and third- or fourth-degree lacerations.

  • Urinary tract infections can be caused by indwelling catheters.

  • Mastitis can occur with a break in skin integrity from a poor latch.

    • Causes of mastitis include clogged ducts, engorgement, hyperlactation, nipple trauma, decreased immune system, or poor handwashing routine.

  • Some of these infections are preventable, while others are not. The nurse assesses for signs of postpartum infections and provides education to help prevent and decrease the risk for infections.

• Postpartum hemorrhage

  • Blood loss

    • >500 mL following a vaginal birth

    • >1,000 mL following a cesarean birth

    • Any amount of bleeding that places the mother in hemodynamic jeopardy

  • Labor and postpartum nurses must be aware of risk factors, prevention, and treatment of PPH.

    • Risk factors include large for gestational age (LGA) infant, multiple gestation, grand multiparity, prolonged labor, chorioamnionitis, prolonged or precipitous labor, and placenta previa or placental abruption.

  • Clinical Manifestations of Shock due to Blood Loss

    • Mild Shock - 20% blood loss, S&S - diaphoresis, increased capillary refilling, cool extremities, maternal anxiety

    • Moderate shock - 20 to 40% blood loss, S&S - tachycardia, postural hypotension, oliguria

    • Severe shock - 40% blood loss, S&S - hypotension, agitation/confusion, hemodynamic instability

  • PPH “Four Ts”

    • Tone: uterine atony

      • Overdistention of the uterus due to multiple gestation, excess amniotic fluid, large baby, or multiparity.

      • Prolonged labor.

      • Induction or augmentation of labor.

      • Precipitous labor (labor lasting less than 3 hours).

      • Full bladder.

    • Tissue: retained placenta and clots

    • Trauma: vaginal, cervical, or uterine injury •

    • Thrombin: coagulopathy (preexisting or acquired)

  • PPH Assessment and Management

    • Nursing assessment BE READY AND VIGILANT!!

      • Risk factors Uterine tone; vaginal bleeding

    • Nursing management

      • Fundal massage; pad count

      • Administration of uterotonic

      • Replace volume

  • Types:

    • Early PPH

      • More common, occurs after birth up to 24 hours PPD

      • Common causes: four T’s

    • Late PPH

      • Occurs after the first 24 hours up to 12 weeks postpartum

      • The most common cause of late PPH is subinvolution, which is the inability of the uterus to return to its original size. At the 6-week follow-up, subinvolution is diagnosed when the patient’s uterus is larger than expected and the lochia has not progressed to lochia alba.

      • Retained placenta or membranes can be another cause of late PPH and can also lead to infection and bleeding.

      • Just as coagulation disorders can cause early PPH, these disorders can also cause late PPH.

• Postpartum

  • Infections

  • Postpartum Hemorrhage (PPH)

  • Post-operative

  • Mood Disorder

• Post-operative Cesarean

  • Additional assessments of the postpartum person after a cesarean birth include the dressing over the incision for the first 24 hours and the incision itself after that, nausea and vomiting and abdomen, deep vein thrombosis (DVT), mobility, and the lungs for signs of infiltrates if general anesthesia was used.

  • The nurse recognizes certain discomforts related to cesarean birth, such as abdominal pain, incision pain, increased constipation and gas, and difficulty with ambulation.

    • The nurse encourages ambulation, pain management prior to the pain becoming extreme, eating a healthy diet, and asking for help with activities of daily living.

    • When coughing, the person is encouraged to splint the incision by placing a pillow over the lower abdomen to decrease pain

    • The nurse will assess pain frequently and administer medications as needed.

    • The nurse assesses the incision and instructs the postpartum patient to keep the incision clean and dry.

    • Persons experiencing a cesarean birth are at higher risk for blood clots.

      • Ambulation keeps the blood moving in the extremities helping to prevent venous stasis and DVTs. Ambulation

• Postpartum Mood Disorders

  • Lack of sleep, pain, feelings of being overwhelmed, and changing hormone levels in the postpartum patient can cause baby blues. If these symptoms do not resolve, postpartum depression (PPD) can occur.

  • Baby Blues versus Depression

    • The baby blues are described as an adjustment disorder (Alba, 2021); symptoms include anxiety, irritability, crying, and insomnia. Baby blues occur more often in first births, generally beginning on postpartum day 2 or 3.

    • A distinguishing factor between postpartum blues and postpartum depression (PPD) is that PPD lasts for at least 14 days (Galęziowska et al., 2021). Furthermore, PPD is debilitating and causes extreme sadness, anxiety, hopelessness, and inability to perform simple tasks. PPD also causes issues with bonding and attachment with the newborn.

  • Postpartum Psychosis (PPP)

    • The mood disorder that occurs suddenly and can be very dangerous, with symptoms occurring within a few hours to weeks after birth, is postpartum psychosis (PPP). PPP is characterized by delusional thinking, hallucinations, and other psychotic symptoms (Alba, 2021).

    • Other symptoms are manic elation, deep anxiety and depression, fear, and guilt (Alba, 2021). PPP is considered an emergency because paranoid thoughts can lead to homicide, infanticide, or suicide.

  • Nursing Assessment and Diagnosis

    • Nurses assess all postpartum persons for risk factors associated with PPD and perform a risk assessment.

    • During routine assessments, the nurse evaluates for signs of PPD or lack of coping. The nurse assesses newborn bonding, partner participation, social support, and family relationships throughout the postpartum period.

    • When the nurse recognizes signs of PPD, the nurse diagnoses ineffective coping, impaired bonding, risk for impaired parenting, and risk for self-harm.

  • Nursing Plan and Implementation

    • The nurse describes the signs and symptoms of PPD and discusses any concerning symptoms with the patient and family. The nurse explains the difference between baby blues and PPD and lists reasons why the patient and/or family should call their health-care provider

Disorder	Symptoms	Treatment
Baby blues	short-term drop in mood (2–3 days); should be over by 2 weeks symptoms less severe 80% of birthing persons affected not associated with depression prior to pregnancy mood swings from happy to sad feel irritable, exhausted, overwhelmed, anxious does not cause despair	sleeping when the baby is sleeping eating nutritious food exercising, going for a walk accepting help, not worrying about chores
Postpartum depression	occurs longer than several days and can occur up to 1 year after birth symptoms more severe 10% of birthing persons affected higher risk if depression occurred prior to pregnancy anxiety or panic attacks feel worthless, sad, alone; cannot eat, bond with the baby, or take care of the baby feel an overwhelming despair	counseling medications asking for help

• Newborn conditions

  • Birth Related complications

  • FAS

  • Newborn Resuscitation

  • Preterm (previous class)

• Birth Related Complications

  • Any physical injury to a newborn caused by labor and delivery is a birth injury or birth trauma

  • Most birth injuries are minor and resolve on their own, others require immediate and possibly long-term treatment, and a few can be fatal.

  • The evidence-based practice of limiting the use of forceps or vacuum extraction during delivery and the increased use of cesarean surgery for birth have decreased the number of birth injuries

  Type of Injury	Physical Symptoms
  Caput succedaneum, subgaleal hemorrhage, and cephalohematoma	Scalp and underlying tissue (Caput succedaneum crosses suture lines; a cephalohematoma does not)
  Subdural hematoma and skull fracture	Intracranial and skull damage
  Clavicle fracture	Clavicle
  Brachial plexus injury	Brachial plexus (upper extremity) involving nerves C5 to T1
  Erb-Duchenne paralysis	Flaccid arm and adducted shoulder, injury to nerves C5 to C6
  Klumpke palsy	Lower arm is flaccid with an absent grasp reflex, nerves C8 to T1

  • Risk factors for birth injuries include those of the person giving birth and those of the fetus.

  Affected Person	Risk Factors
  Birth parent	Birthing parent over 35 years of age or under 16 years of age Preterm or postterm labor Cephalopelvic disproportion Labor dystocia Maternal obesity
  Infant	Macrosomia Multiples (twins, triplets, etc.) Congenital anomalies Large for gestational age (LGA) or macrosomia

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• Teratogens

  • Any medication, chemical, environmental agent, virus, or bacteria that might interfere with the normal development of a fetus and result in the loss of a pregnancy, a birth defect or a pregnancy complication.

  • Fetal Alcohol Syndrome (FAS)

    • FAS is a severe, lifelong condition that occurs when a fetus is exposed to alcohol during pregnancy. Alcohol passes through the placenta, interfering with the baby's central nervous system and brain development.

      • Key Signs & Symptoms:

        • Distinctive facial features (such as a smooth ridge between the nose and upper lip, a thin upper lip, and a small eye opening width)

        • Growth deficits/restriction (low birth weight or slow growth)

        • Central nervous system problems (learning disabilities, memory issues, poor coordination, and behavioral challenges like hyperactivity or attention deficits)

• Newborn Resuscitation

  • Newborns who cannot breathe on their own need timely interventions from the administration of oxygen to full resuscitation.

  • A newborn’s temperature is monitored frequently after birth to maintain a temperature between 36.5° C and 37.5° C (97.7° F and 99.5° F) through admission and stabilization

    • A measured axillary temperature below 36.5° C is considered hypothermia and is associated with increased neonatal mortality and morbidity (AHA, 2020; Laptook et al., 2018) and can easily be prevented with the use of warmers, drying the newborn, swaddling, or skin-to-skin contact if further resuscitation is not needed.

    • A hypothermic newborn is at risk of hypoglycemia, respiratory distress, metabolic acidosis, and jaundice

  • Most newborns will spontaneously breathe within 30 to 60 seconds after birth. Simple drying and tactile stimulation may encourage ventilation, or effective breaths that result in chest rise with air entry to the lungs

    • If the newborn does not start breathing within that first minute, bradycardia, a heart rate under 100 beats per minute in a neonate, will be ongoing.

    • The nurse should clear the airway, mouth, and nose, if needed. Providing positive pressure ventilation (PPV), with breaths at a rate of 40 to 60 per minute, is the treatment to both improve heart rate and facilitate ventilation for the newborn.

    • For neonates, respiratory failure occurs first, followed by cardiac arrest, while in adults this is reversed. This physiologic response of the newborn requires that resuscitation prioritize PPV.

Breastfeeding

Score	0	1	2
Latch	Sleepy, no latch	Holds nipple in mouth, sucks only when stimulated	Holds nipple and areola in mouth, tongue below nipple, lips flanged, sucks rhythmically
Audible swallowing	None	Rarely when sucking	Frequently when sucking
Type of nipple	Inverted	Flat	Everted
Comfort	Severe pain with sucking Cracked, bruised, or bleeding nipples Blisters on nipples	Moderate pain with sucking Nipples reddened, bruised or blisters present	No pain with sucking Nipples intact
Hold	Requires assistance to position and maintain hold of baby	Minimal assistance needed to position or hold baby	Patient able to correctly position and hold baby

• Blood Tests to Check for Hemorrhage

• What is the most accurate to measure blood loss?

• How often should you feed a baby?

• How to assess if a baby is feeding enough?

1. Hemoglobin - an indicator of the number of RBCs and decreases during hypovolemia and hemorrhage

2. Hematocrit - which is the percent of RBCs in the total blood volume, and decreases during hypovolemia and hemorrhage

3. Platelets - cell fragments that facilitate blood clotting and decrease in the number of circulating platelets can increase a client’s risk for bleeding

• Question 2: Weight the perineal soiled pads in the past hour

• Question 3: 8-12 times in a 24-hr period

• Question 4: Count the number if wet diapers. 6-8 diapers should be expected.

• Question 1: Preterm pregnant woman showing signs of contraction. What are the priority interventions

• Question 2: Effects of anticontraction medication?

• Question 3: Signs of Magnesium Sulfate toxicity when assessing a patient?

• Question 4: How preeclampsia affects clonus and reflexes?

• Question 5: After ROM/ water breaking, what is always the first intervention?

• Question 6: What order of intervention should the nurse perform when recognizing a fetus has late decelerations?

• Question 7: How should you conduct the 3-hour glucose test in a pregnant patient?

• Questions 8: What are some of the risks for the baby of a mom that has gestational diabetes?

• Question 1: give medication to reduce contractions, give medications to mature fetus lungs, put patient at bed rest + catheter

• Question 2: tachycardia, drop in BP, edema, facial flushing

• Question 3: lower RR, lower urinary output (affect kidneys), altered LOC

• Question 4: clonus is present and it is hyperreflective

• Question 5: Check FHR!!!!!

• Question 6: Place patient in the lateral position. Then increase fluid amount. Check uterine contractions for number of contractions and if they are excessive. Place patient on oxygen.

• Question 7: Patient should be fasting. After consuming glucose, take patient’s glucose every hour. Positive for gestational diabetes would be abnormal reading for at least 2 of the 3 readings.

• Question 8: baby can have hypoglycemia and birth trauma from macrocephaly

Examine the role of the professional nurse, and one’s personal beliefs, values, and biases as they relate to equitable care of the childbearing/childrearing family population

• The professional nurse plays a critical role in securing health equity for childbearing and childrearing families. Because nurses interact with families at pivotal life milestones—from pregnancy through early childhood development—their ability to deliver unbiased, equitable care directly impacts long-term maternal and infant health outcomes.

• To achieve equity, a professional nurse must continuously evaluate the intersection of clinical responsibilities with personal beliefs, values, and implicit biases

• 1. The Role of the Professional Nurse

  In maternal and pediatric care, the nurse's role expands beyond technical medical tasks to encompass holistic advocacy, education, and navigation support: [1, 2]

• According to ATI, the professional nurse serving maternal-child populations acts as a care provider, patient advocate, educator, and coordinator of care. In the context of childbearing (pregnancy through postpartum) and childrearing (infancy through adolescence), the nurse’s role expands from individual care to family-centered care.

  • Assessment of Social Determinants of Health (SDOH): Screening families for vulnerabilities such as food insecurity, lack of transportation, or inadequate safe housing that directly impact prenatal and pediatric outcomes. [1]

  • Patient Advocacy: Ensuring that the family’s voice, autonomy, and cultural practices are respected in the clinical setting. [1, 2]

  • Evidence-Based Education: Providing accessible, linguistically appropriate education regarding prenatal care, safe sleep practices, vaccinations, and developmental milestones to empower parents.

  • Family-Centered Interventions: By providing antenatal education, breastfeeding support, and home-visiting care, nurses empower parents and improve self-efficacy during stressful transitions. [1]

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  2. The Impact of Personal Beliefs and Values

  Every nurse brings their own lived experiences, cultural background, and values into their clinical practice. [1]

• ATI heavily emphasizes that nurses do not practice in a vacuum; they bring their own lived experiences, cultural backgrounds, and moral frameworks into the clinical space. [1]

  • Beliefs & Values: Personal convictions regarding religion, traditional gender roles, family structures (e.g., nuclear families vs. same-sex parents or co-parenting relatives), and reproductive choices (such as contraception, abortion, or adolescent pregnancy) shape how a nurse views a patient’s situation.

  • Implicit Bias: These are unconscious attitudes or stereotypes that affect understanding, actions, and decisions. In maternal-child health, implicit biases frequently manifest as assumptions about a parent's competence based on their age, race, socioeconomic status, marital status, or English proficiency.

  • The Bridge of Empathy: When aligned with the profession’s core tenets, personal values like empathy, inclusion, and respect act as foundational tools. They allow the nurse to establish therapeutic, trusting relationships, ensuring that patients and their families feel physically and emotionally safe. [1]

  • Ethical Dilemmas: When a family's choices (e.g., specific birthing plans, family structures, or refusal of childhood vaccinations) conflict with a nurse's personal belief system, ethical friction can occur. Professional nurses must anchor their practice in the ANA Code of Ethics, prioritizing patient self-determination over personal morals. [1, 2, 3]

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  3. Mitigating Implicit Biases to Ensure Equitable Care

  Implicit (unconscious) biases are automatic stereotypes or attitudes individuals hold without conscious awareness. In the childbearing/childrearing spectrum, unchecked biases present severe risks to patient safety and equity. [1]

• When personal beliefs and biases are left unexamined, they pose a direct threat to health equity and patient safety, leading to disparities such as:

  • Dismissal of Symptoms: Biases can lead clinicians to under-evaluate pain or complications reported by minority or low-income obstetric patients, directly contributing to the disproportionately high maternal mortality rates among Black and Indigenous women.

  • Judgmental Communication: Subtle verbal or non-verbal cues can make a non-traditional family feel stigmatized, causing them to withdraw from the healthcare system and miss critical prenatal or well-child checks.

  • Violations of Autonomy: Imposing personal beliefs on a family regarding infant feeding (breastfeeding vs. formula) or medical interventions violates the ethical principle of autonomy

  Type of Bias	How It Manifests in Care	Impact on the Family Population
  Racial & Ethnic Bias	Dismissing or minimizing the pain and symptoms reported by minority postpartum patients.	Contributes heavily to disproportionately high maternal and infant mortality rates among Black and Indigenous communities.
  Socioeconomic Bias	Assuming a low-income or young parent is unmotivated or incapable of providing adequate childcare.	Causes under-education, missed clinical guidance, and reluctance of the family to seek timely medical help.
  Family Structure Bias	Treating non-traditional families (e.g., LGBTQ+ parents, single parents, co-parenting relatives) with less validity.	Alienates secondary caregivers, leading to parental stress, poor communication, and isolated family units.

  
  

• Strategies for the Professional Nurse (ATI Framework)

  To mitigate these risks and ensure equitable care, ATI guides nurses to utilize specific clinical tools and self-regulation strategies:

  • Cultural Humility & Self-Assessment

    • Engaging in continuous self-reflection to identify personal biases before interacting with patients. Acknowledging what you do not know about a family's culture

  • Adherence to Ethical Principles

    • Prioritizing Beneficence (acting in the patient's best interest), Justice (fair distribution of care resources), and Autonomy (respecting the family's right to choose their path of care).

  • Using Standardized Screening Tools

    • Relying strictly on evidence-based assessment data rather than subjective intuition to determine patient risk and care plans.

  • Safe Transfer of Care

    • If a nurse experiences a profound moral or religious conflict that compromises their objectivity (e.g., specific reproductive care), they must ensure a safe, non-judgmental transfer of care to a colleague without abandoning the patient.

• Moving Forward: Cultural Humility

  To dismantle these biases, professional nurses must transition from "cultural competence" to cultural humility. This requires a lifelong commitment to self-reflection, an openness to learning from patients, and a willingness to actively check one's own assumptions at the door to ensure every childbearing and childrearing family receives optimal, respectful care. [1, 2]

Integrate knowledge to inform decision-making to guide safe care of the childbearing/childrearing family population

According to ATI Maternal Newborn Nursing, integrating knowledge to inform decision-making and guide safe care of the childbearing/childrearing family means using nursing knowledge, clinical judgment, assessment findings, evidence-based practice, and patient preferences to make safe decisions for pregnant patients, newborns, children, and their families.

Key concepts to study for ATI1. Apply the nursing process and clinical judgment

• Recognize cues: Identify abnormal maternal or fetal assessment findings.

• Analyze cues: Determine what the findings may indicate.

• Prioritize hypotheses: Identify the most urgent potential complication.

• Generate solutions: Select appropriate nursing interventions.

• Take action: Implement priority interventions promptly.

• Evaluate outcomes: Determine whether the interventions improved the patient's condition.

2. Prioritize care based on maternal and fetal risks

Condition	Important findings	Priority nursing action
Placental abruption	Painful, dark or bright red bleeding, rigid or tender uterus	Notify the provider, assess maternal stability, monitor fetal heart rate, and prepare for possible delivery.
Placenta previa	Painless, bright red vaginal bleeding	Avoid vaginal examinations until placenta previa is ruled out; assess maternal and fetal status.
Umbilical cord prolapse	Sudden fetal bradycardia after membrane rupture; cord may be visible or palpable	Call for help, relieve pressure on the cord, and prepare for emergency birth.
Shoulder dystocia	Fetal head delivers, but shoulders become impacted	Call for help; assist with McRoberts maneuver and suprapubic pressure. Never apply fundal pressure.
Postpartum hemorrhage	Heavy bleeding, boggy uterus, tachycardia, hypotension	Assess uterine tone, massage a boggy uterus, call for assistance, and initiate prescribed interventions.
Preeclampsia with severe features	Severe hypertension, headache, visual changes, epigastric or right upper quadrant pain	Assess promptly, institute seizure precautions as indicated, administer prescribed medications, and monitor mother and fetus.

3. Use evidence-based practice

• Follow current clinical guidelines and facility protocols.

• Verify medication dosages, contraindications, and patient allergies.

• Use appropriate fetal monitoring and newborn assessments.

• Recognize when a patient's condition requires escalation of care.

4. Make safe medication decisions

• Oxytocin: Monitor contractions and fetal heart rate for uterine tachysystole and fetal intolerance.

• Magnesium sulfate: Monitor respiratory rate, deep tendon reflexes, and urine output for toxicity.

• Insulin: Monitor blood glucose and assess for hypoglycemia.

• Newborn medications: Verify the correct dose, route, timing, and newborn identity.

5. Provide developmentally appropriate care

• Adapt communication to the child's age and developmental level.

• Include parents or caregivers in care decisions when appropriate.

• Use safe sleep practices for infants.

• Apply age-appropriate pain assessment methods.

• Provide family education on feeding, immunizations, injury prevention, and warning signs.

6. Recognize when to escalate care

Prioritize immediate intervention for airway or breathing problems, severe bleeding, shock, seizures, significant changes in fetal heart rate, and acute newborn deterioration. Use the facility's emergency response procedures and communicate clearly with the healthcare team.

7. Include the family in decision-making

• Respect cultural beliefs and patient preferences.

• Obtain informed consent through the appropriate provider process.

• Explain procedures and provide understandable education.

• Use teach-back to confirm that the family understands instructions.

Identify factors designed to promote safety in health care settings of the childbearing/childrearing family populations

Factors that promote safety

1. Patient identification

- Use two patient identifiers before administering medications, performing procedures, or collecting specimens.

- Apply matching identification bands to the mother and newborn according to facility policy.

2. Medication safety

- Verify medication orders, dosage, route, and patient identity.

- Use extra caution with high-alert medications, such as oxytocin, magnesium sulfate, and insulin.

- Calculate weight-based medication dosages carefully for infants and children.

3. Infection prevention

- Perform hand hygiene before and after patient contact.

- Use appropriate personal protective equipment (PPE) and aseptic technique.

- Follow standard and transmission-based precautions.

4. Maternal and fetal monitoring

- Monitor maternal vital signs, contractions, and fetal heart rate.

- Recognize warning signs such as vaginal bleeding, severe abdominal pain, persistent fetal bradycardia, and signs of maternal hemorrhage.

- Report abnormal findings promptly.

5. Newborn security

- Use approved newborn identification and security systems.

- Verify the identity of anyone transporting or receiving the newborn.

- Never leave a newborn unattended in an unsafe location.

6. Newborn and infant safety

- Place newborns on their backs to sleep on a firm, flat surface.

- Keep pillows, blankets, and toys out of the infant's sleep space.

- Educate parents about safe sleep practices to reduce the risk of sudden infant death syndrome (SIDS).

7. Fall prevention

- Keep the bed in a low position and wheels locked.

- Assist mothers with ambulation after delivery, especially after anesthesia or when experiencing dizziness.

- Teach parents to place the newborn in the bassinet when they feel sleepy or unable to safely hold the baby.

8. Prevention of infant abduction

- Follow facility security protocols and restrict unauthorized access to maternity and newborn units.

- Teach parents not to give their newborn to anyone without proper identification.

9. Emergency preparedness

- Recognize obstetric and neonatal emergencies, including postpartum hemorrhage, shoulder dystocia, umbilical cord prolapse, and neonatal respiratory distress.

- Know emergency procedures and how to activate the appropriate response team.

10. Patient and family education

- Teach parents about newborn care, feeding, bathing, car seat use, and warning signs that require medical attention.

- Use teach-back to verify understanding.

11. Child safety and injury prevention

- Educate caregivers about appropriate car seats, medication storage, choking prevention, and water safety.

- Keep small objects, cleaning products, and medications out of children's reach.

- Encourage age-appropriate supervision.

12. Communication and reporting

- Use standardized communication, such as SBAR, when reporting changes in a patient's condition.

- Report suspected child abuse or neglect according to applicable laws and facility policy.

- Document assessments, interventions, and patient responses accurately.