Maternity Nursing

First Trimester (Weeks 1-13)

Presumptive Signs of Pregnancy

  • Amenorrhea (absence of menstruation):
    • The hormone responsible is progesterone, not HCG.
    • The corpus luteum, remaining after follicle rupture, secretes progesterone.
    • Progesterone causes amenorrhea and raises body temperature after ovulation. Egg is only good for 24 hours, so the egg may be worn out.
    • Counseling for conception via temperature chart:
      • Chart monthly to learn temperature spike patterns.
      • Have intercourse before the temperature spike, not after.
      • Every other day intercourse is optimal to maintain sperm count.
  • Nausea, Vomiting, Frequency:
    • Frequency can be an early sign due to uterus enlargement and bladder pressure.
  • Breast Tenderness:
    • Caused by excess hormones throughout pregnancy.

Probable Signs of Pregnancy

  • Positive Pregnancy Test:
    • Based on HCG levels.
    • Other conditions can elevate HCG (e.g., hydatidiform mole/molar pregnancy).
  • Goodell's Sign:
    • Softening of the cervix around the second month.
  • Chadwick's Sign:
    • Bluish color of vaginal mucosa and cervix around week four.
  • Hegar's Sign:
    • Softening of the lower uterine segment around the second or third month.
  • Uterine Enlargement
  • Braxton Hicks Contractions:
    • Occur throughout pregnancy to move blood through the placenta.
  • Pigmentation Changes of the Skin:
    • Linea Nigra: Dark line down the abdomen.
    • Abdominal Striae: Stretch marks.
    • Facial Chloasma: Mask of pregnancy.
    • Darkening of the areola.

Positive Signs of Pregnancy

  • Fetal Heartbeat:
    • Detected by Doppler at 10-12 weeks.
    • Detected by fetoscope at 17-20 weeks.
  • Fetal Movement:
    • Palpated by the nurse (not just reported by the mother).
  • Ultrasound:
    • Visual confirmation of the fetus.

Gravidity and Parity

  • Gravidity: Number of times a woman has been pregnant, regardless of duration.
    • A gravida five can have no children due to multiple miscarriages.
  • Parity: Number of pregnancies reaching viability (20 weeks).
    • Viability: 20 weeks (though the baby may or may not survive).

TPAL

  • Acronym providing detailed parity information:
    • T: Term births
    • P: Preterm births
    • A: Abortions (spontaneous and elective)
    • L: Living children

Nagele's Rule

  • Calculating estimated due date:
    • Find the first day of the last menstrual period.
    • Add seven days, subtract three months, and add one year (if applicable).

Patient Teaching

  • Nutrition:
    • Increase calories by 300 per day after the first trimester.
    • Adolescents: Increase by 500 calories due to their own growth needs.
    • Increase protein to 60 grams per day (normal is 40-45 grams).
  • Weight Gain:
    • Expect an average of 4 pounds in the first trimester.
  • Prenatal Vitamins:
    • Iron can cause constipation and GI upset.
      • Take with food to reduce GI upset, though empty stomach is better for iron absorption.
      • Take with Vitamin C to enhance absorption.
    • Folic acid prevents neural tube defects (e.g., spina bifida).
      • Normal dose of Folic Acid (400 mcg daily).
  • Exercise:
    • No high-impact exercises.
    • Walking and swimming are best.
    • Do not start a strenuous program.
    • Heart rate should not exceed 140 bpm to maintain cardiac output and uterine perfusion.
      • Decreased cardiac output can compromise fetal oxygenation.
    • Avoid overheating (no hot tubs, electric blankets) to prevent birth defects.
      • Increased temperature equals birth defects.

Danger Signs

  • Though taught in the first trimester for readiness to learn, these are more relevant in the third trimester.
  • Sudden gush of vaginal fluid.
  • Bleeding.
  • Persistent vomiting.
  • Severe headache.
  • Abdominal pain.
  • Increased temperature.
  • Edema.
  • No fetal movement.
    • Assume the worst; never brush off a patient's complaint.

Common Discomforts of Pregnancy

  • Manage constipation: increase fluids, fiber, and walking.
  • Elevate for ankle edema.
  • Saline spray or steam for nasal congestion (avoid decongestants).
  • Medications: only with doctor's approval.
  • Smoking: stop; if unable, smoke outside to avoid re-inhaling smoke.
    • Smoking is associated with low birth weight or small for gestational age babies.

Doctor Visits

  • First 28 weeks: once a month.
  • 28-36 weeks: twice a month or every two weeks.
  • After 36 weeks: weekly until birth.

Ultrasounds

  • Plain ultrasound: Drink to distend the bladder (pushes the uterus out on the abdomen).
  • Transvaginal ultrasound: Bladder distension not required.
  • Ultrasound prior to amniocentesis: Empty the bladder.

Second Trimester (Weeks 14-26)

  • Expected weight gain: one pound per week (four pounds per month).
  • Nausea and vomiting should not be present; if they are, investigate.
  • Breast tenderness may still occur.
  • Urinary frequency should decrease (uterus rises, relieving bladder pressure).
  • Quickening (fetal movement): felt around 16-20 weeks (earlier with more pregnancies).
  • Fetal heart rate: Normal range is 120-160 bpm.
    • 110-120 bpm: worried and watching.
    • Less than 110 bpm: Panic.

Kegel Exercises

  • Start early and continue throughout pregnancy.
  • Strengthen pubococcygeal muscles.
  • Benefits:
    • Help stop urine flow.
    • Prevent uterine prolapse.

Third Trimester (Weeks 27-40)

  • Expected weight gain: No more than one pound per week.
  • Weight gain exceeding one pound per week could indicate pregnancy-induced hypertension (PIH).
    • Check urine for protein and blood pressure.
    • Advise on diet and fluid intake.
  • Fetal heart rate: 120-160 bpm.
  • Blood pressure monitoring:
    • 30/15 Rule of Thumb: A systolic increase of 30 mmHg or diastolic increase of 15 mmHg over baseline requires evaluation of PIH.

Leopold maneuvers

  • Determine fetal position and presentation.
  • Have patient void first.
  • Perform between contractions.

Patient Education: Signs of Labor

  • Lightening:
    • Presenting part (ideally the head) descends into the pelvis, usually two weeks before term.
    • Easier breathing but increased urinary frequency.
  • Engagement:
    • Presenting part at zero station.
  • Fetal Stations:
    • Measured in centimeters, relating the presenting part to the ischial spine.
    • Well-engaged head is crucial to prevent cord prolapse upon membrane rupture.
  • Other signs:
    • More frequent and stronger Braxton Hicks contractions.
    • Softening of the cervix.
    • Bloody show (not heavy bleeding; bleeding indicates hemorrhage).
    • Sudden burst of energy (nesting), often leading to delivery within 24-48 hours.
    • Diarrhea.

When to Go to the Hospital

  • Contractions five minutes apart.
  • Membrane rupture (worry about infection after 24 hours and prolapsed cord which is more acute).

Non-Stress Test (NST)

  • Evaluates fetal well-being.
  • Two or more accelerations of 15 bpm or more with fetal movement, each lasting 15 seconds, within a 20-minute period.
  • Reactive Test: Accelerations are present (good).
  • Assesses fetal heart rate variability, indicating the ability to withstand labor.
    • Give the mother a button and when the baby moves to hit it for a reading. Shows accelerations when pressed.

Contraction Stress Test (CST) / Oxytocin Challenge Test (OCT)

  • Performed on high-risk pregnancies to assess fetal ability to handle uterine contractions.
  • Contractions decrease blood flow to the uterus.
    • If decreased flow causes fetal hypoxia, the heart rate will decelerate.
  • Late decelerations indicate uteroplacental insufficiency (placenta wearing out), which is bad.
  • Negative Test: No late decelerations (desired).
  • Rarely done before 28 weeks (risk of preterm labor).
  • Results are valid for only one week.

True vs. False Labor

  • True Labor:
    • Regular contractions.
    • Increased frequency and duration of contractions.
    • Discomfort in the back, radiating to the abdomen.
    • Pain increases with activity.
  • False Labor:
    • Irregular contractions.
    • Discomfort mainly in the abdomen.
    • Pain decreases or goes away with activity (Braxton Hicks).

Epidural Anesthesia

  • Given in stage one at 3-4 cm dilation.
  • No headache because spinal fluid is not accessed.
  • Main complication: Hypotension.
    • Bolus with 1000 mL of NS or LR IV fluids ahead of time to combat hypotension.
  • Position: Semifowlers on their side to prevent vena cava compression.
    • Avoid vena cava compression at all costs.
    • Change position hourly.

Oxytocin (Pitocin)

  • Requires one-on-one care due to potential complications.
  • Complications: hypertonic labor, fetal distress, uterine rupture.
  • Uterine Rupture:
    • Complete: Tear through the uterine wall into the peritoneal cavity.
      • Signs: Sudden sharp pain, contractions stop, signs of hypovolemic shock.
    • Incomplete: Tear through the uterine wall stopping in the peritoneum.
      • Signs: Internal bleeding, pain, late decelerations, hypotonic contractions.
  • VBAC (Vaginal Birth After Cesarean Section) moms are at highest risk due to scar tissue.
  • Other risks: uterine trauma/surgery, malpresentation, forceps delivery.
  • Contraction rate: One every 2-3 minutes, lasting 60 seconds.
  • Discontinue oxytocin if contractions are too frequent, too long, or fetal distress occurs.
  • Piggyback oxytocin into main IV fluids.
  • Position: Any position except flat on their back (supine is contraindicated).
  • If fetal bradycardia occurs, turn patient onto their left side to enhance uterine perfusion.

Emergency Delivery

  • Bo (Beau) & Hope Scenario
  • Wash hands, minimize vaginal touching, and position the patient sitting up.
  • Clean material under the buttocks.
  • Have them to pant and blow to decrease the urge to push until fully dilated.
  • When head crowns, tear amniotic sac if not already ruptured.
  • If you feel the cord around the neck, slip cord over head with forefinger (do not cut cord).
  • Ease each shoulder out (do not pull).
  • Keep baby's head down to avoid aspiration.
  • Dry the baby to prevent temperature regulation.
  • Keep the baby at the level of the uterus to prevent excess bilirubin and hemorrhage.
  • Place the baby on the mother's abdomen for skin-to-skin contact.
  • Wait for the placenta to separate (do not pull).
    • Hemorrhaging is the major concern of retained placentas.
    • Wait 30 minutes.
  • Cord Care:
    • Double clamp and cut (if in hospital).
    • Tie off with clean material four inches and eight inches from the umbilicus (if outside hospital).
    • Cover the end with a clean cloth (if cord is cut).
  • Wrap placenta in a bag and take it to the hospital for inspection (intactness= no bleeding).
    • Some cultures bury placenta for good luck ,other eats placenta. Good due to iron.
  • Massage the fundus if boggy.

Postpartum Period

  • Signs:
    • Temperature up to 100.4°F in the first 24 hours.
    • Stable blood pressure.
    • Heart rate of 50-70 bpm for 6-10 days.
      • Tachycardia indicates hemorrhage.
      • Fluid increases to 50% during pregnant then diuresis after delivery, which lowers heart rate.
  • Breast:
    • Soft for 2-3 days, then engorgement occurs.
  • Abdomen:
    • Soft and loose.
    • Diastasis Recti: Separation of abdominal muscles (vigorous exercise or plastic surgery to correct).
  • GI:
    • Hunger is common because the patient isn't allowed to eat during labor. May get ice chips.
  • Uterus:
    • Immediately after birth, the fundus is midline, 2-3 fingerbreadths below the umbilicus.
    • A few hours after birth it rises to the level of the umbilicus (or one fingerbreadth above).
    • If boggy, massage until firm, check for bladder distention.
    • Fundal height descends by one fingerbreadth per day (involution).
      • If improper, worry about bleeding/hemorrhaging.
    • Afterpains are common for the first 2-3 days, especially when breastfeeding (oxytocin release).
  • Lochia:
    • Rubra: 3-4 days, dark red.
    • Serosa: 4-10 days, pinkish brown.
    • Alba: 10-28 days, whitish yellow.
      • Clots are okay if no larger than a nickel.
  • Urine Output:
    • Diuresis should begin 24 hours after delivery as the volume decrease to the original levels/ homeostasis of the person before pregnancy.
      • Important to not get dehydrated
  • Legs:
    • Inspect closely for DVTs.
  • Perineal Care:
    • Intermittent ice packs for 6-12 hours to decrease edema.
    • Warm water rinses/sitz baths 2-4 times per day.
    • Anesthetic sprays (if episiotomy, laceration, hemorrhoids).
    • Change peripads frequently (no more than one peripad per hour).
    • Patients can have peripads questions. Also, the computer does not have a soul
    • Report locia changes. Albato Aruba report 911. Nklexy!
      • Back to Rubato - Call 911!!!

Breast Care

  • Breastfeeding Moms:
    • Cleanse with warm water after each feeding, and let air dry (no soap).
    • Support bra is needed.
    • Ointments for soreness or express some colostrum, let it dry.
    • Breast pads to absorb moisture (prevent skin breakdown).
    • Start breastfeeding as soon as possible after birth.
      • Bonding, helps contract the uterus.
    • If interrupted, mom should pump.
    • Increase calories by 500.
    • Fluid and Milk Intake:
      • Drink eight to ten 8-ounce glasses per day to prevent dehydration and plugged ducts.
  • Non-Breastfeeding Moms:
    • Decrease engorgement with:
      • Ice packs, breast binders, chilled cabbage leaves.
      • No stimulation of the breast.
      • Ace wrap alternatives.

Postpartum Infection

  • Occurs within 10 days after birth.
  • Major Cause: E. Coli and GBS (Beta-hemolytic strep).
  • Teach proper hygiene (front to back wiping, hand washing).
  • Cultures and antibiotics.

Postpartum Hemorrhage

  • Early: More than 500 mL blood loss in the first 24 hours.
  • Late: After 24 hours and up to 6 weeks postpartum.
  • Uterine Atony: Uterus has no tone (worried about hemorrhage).
  • Other causes: lacerations, retained fragments, forceps delivery.
  • Bleeding. Hemorrhaging. Bleeding.
  • Pick the answer. Bleeding. Pick it Bleed.

Mastitis

  • Major cause: Staphylococcus.
  • Occurs 2-4 weeks postpartum.
  • Causes: Poor hygiene, plugged duct, and stagnation of milk.
  • The milk is okay!!!
  • Treatment:
    • Bed rest, support bra, binding, chilled cabbage leaves (if discontinuing breastfeeding).
    • Breast pump (use to prevent clogged breast milk).
    • Medication: Penicillin okay for breastfeeding moms (take right after breast feeding).
    • Hot shower hit back.
    • Feed the baby frequently.
      • Offer the affected breast first (empty so no plugged breast).
      • Non Mastitis Moms- Alternate. 8 P.M to the left, 10 A.M to the right to prevent the plugged breast.

Immediate Newborn Care

  • Suction the baby if cyanotic or if needed for airway management.
  • Clamp and cut the cord.
  • Maintain body temperature.
  • Apgar Score: Done at 1 and 5 minutes.
    • Looks at heart rate, respirations, muscle tone, reflex irritability, and color.
    • Want at least 8-10.
      8 to 10= Want This!!!
    • Most babies get a 9 (purple hands and feet = acrocyanosis).
  • Erythromycin Eye Prophylaxis: For Neisseria gonococcus (also kills chlamydia).
  • Aquamephyton (Vitamin K): Promotes clotting factors.
    • Given IM in vastus lateralis.
  • Cord Care:
    • Dries and falls off in 10-14 days.
    • Cleanse with each diaper change using alcohol or normal saline.
    • Fold the diaper below the cord.
    • No immersion until it falls off (worried about infection and not properly dry up and not come off).
  • Hypoglycemia after birth: results due to the baby is not receiving glucose from mother.
    * Babies with the highest risk: large for gestational age, small for gestational age, preterm babies, and babies of diabetic moms.
  • Pathological Jaundice: Occurs in the first 24 hours usually RHABO incompatibility.
  • Physiological Jaundice: Occurs after 24 hours.
  • Due to normal hemolysis of excess RBCs releasing bilirubin.

Rh Sensitization / Rh Factor

  • Occurs when Rh-negative mom carries Rh-positive baby.
    • Rh-positive blood from the baby contacts mom's blood.
    • This is seen as a foreign body so makes antibodies
  • Mixing of blood usually occurs at birth.
  • The first offspring is NOT effected because the antibodies have not been formed yet.
  • These can worsen in each pregnancy
  • But once antibodies are created one cannot removed them.
  • If the mother's antibodies are present, it comes through blood and RBC break down releasing a immature form of blood.
  • Erythroblastosis Fetalis: the increase in the immature RBCs in the fetal circulation.
    * leads to anemia, hypoxia, congestive heart failure, hyperbilirubinemia and neurological damage. Hydrops fetalis is a severe form.
  • Indirect Coombs: Done on the mother; it measures the number of antibodies in the blood.
  • Direct Coombs: Done on the baby's cord blood; tells if any antibodies are stuck to RBCs.
  • Mother Sensitized (Developed Antibodies= Frequent ultrasounds- when baby stops growing, C-Section. RhoGAM.
    • Not doing good!!!
  • RhoGAM:
    • Given within 72 hours after birth (also given at 28 weeks gestation).
    • How does it work- Destroys fetal circulation; destroys cells before antibodies are formed.
    • It's too late when you have antibodies .
    • Give in any bleeding episode , abortion.