Comprehensive NCLEX Maternity and University Maternity & University Graduate Study Notes for Maternity and Obstetrics

Signs of Pregnancy and Fetal Development

Presumptive Signs (Subjective): These are signs that the woman experiences and reports, but could have other causes besides pregnancy. * Amenorrhea: Cessation of menstruation. * Fatigue. * Urinary Frequency. * Nausea / Vomiting ("Morning Sickness"). * Breast Changes: Darkening of the areola, tenderness. * Quickening: Maternal perception of fetal movement, occurring around $16-18$ weeks (multipara may feel it earlier than primipara).
Probable Signs (Objective): These are physical findings observed by the examiner. * Goodell Sign: Softening of the cervix. * Chadwick Sign: Bluish discoloration of the cervix/vagina. * Hegar Sign: Softening of the lower uterine segment. * (+) Pregnancy Tests: Detection of hCG in blood or urine. * Braxton Hicks Contractions: False labor, painless, irregular contractions. * Ballottement: Passive fetal movement that occurs when the examiner pushes against the cervix.
Positive Signs (Diagnostic): These signs provide definitive evidence of a fetus. * Ultrasound: Visual verification of the fetus. * X-ray: Visualization of fetal skeleton. * Fetal Heart Rate: Heard via Doppler or stethoscope. * Palpable Fetal Movements: Felt by an examiner.

Obstetric Indicators and Measurements

Fundal Height: Used as a clinical indicator of fetal growth. * Pre-assessment: Ensure the patient empties the bladder first. * At $20^{th}-22^{nd}$ week: The fundus is located at the umbilicus. * Measurement Rule: Fundal height in centimeters equals the fetal age in weeks $\pm 2\,cm$ . * At $36^{th}$ week: The fundus reaches the xiphoid process. * At $38^{th}$ week: The fundus descends, a process known as Lightening.
Nägele’s Rule: Used to estimate the due date. * Formula: $\text{LMP} - 3\text{ months} + 7\text{ days} + \text{adjust year}$ . * Example: For LMP of August $29$ : * August $- 3\text{ months} =$ May $29$ . * May $29 + 7\text{ days} =$ June $5$ .

Obstetric History: The GTPAL System

G: Gravidity: The total number of pregnancies, including the current one, miscarriages, and abortions. Twins or triplets count as one pregnancy.
T: Term Births: Number of pregnancies born at or after the $37^{th}$ week of gestation. Includes alive or stillborn; twins/triplets count as one.
P: Pre-term Births: Deliveries between the beginning of the $20^{th}$ week and the end of the $36^{th}$ week (specifically $36^{6/7}$ weeks). Includes alive or stillborn; twins/triplets count as one.
A: Abortions / Miscarriages: Number of pregnancies delivered before $20$ weeks gestation. Counts with gravidity; twins/triplets count as one.
L: Living Children: The total number of currently living children. In this category, twins/triplets count individually.
Practice Questions and Answers: * Question 1: A client delivered a boy on her due date ( $40$ weeks). She has a $3$ -year-old daughter delivered a week past her due date ( $41$ weeks) and had a miscarriage last year at $8$ weeks. * Answer 1: Option D ( $3-2-0-1-2$ ). Calculation: $G=3$ (current, daughter, miscarriage), $T=2$ (current boy, daughter), $P=0$ , $A=1$ (miscarriage), $L=2$ (boy, daughter). * Question 2: A client has $3$ previous pregnancies and all children are living. One born at $39$ weeks, twins at $34$ weeks, and one at $38$ weeks. She is currently $38$ weeks pregnant. * Answer 2: Option D ( $4-2-2-0-4$ ). Calculation: $G=4$ (current plus $3$ previous), $T=2$ ( $39$ weeker and $38$ weeker), $P=2$ (twins born at $34$ weeks), $A=0$ , $L=4$ (all children living, twins count individually).

Nutrition and Weight Management

Nutritional Requirements: * Caloric Increase (Pregnant): Add $300\text{ K calories/day}$ . * Caloric Increase (Breastfeeding): Add $500\text{ K calories/day}$ . * High Calcium Diet: Milk, yogurt. * High Iron Diet: Accompanied by Vitamin C for absorption. * Folic Acid: Supplementation of $400-800\,\text{mcg/day}$ . * Foods to Avoid (Mercury Risk): Swordfish, Shark, King Mackerel, Tuna, Mahi Mahi.
Weight Gain Guidelines by BMI: * Underweight ( $\text{BMI} < 18.5$ ): Total gain $28-40\,\text{lb}$ ( $1.0\,\text{lb/wk}$ in $2^{nd}/3^{rd}$ trimester). * Appropriate Weight ( $\text{BMI } 18.5-24.9$ ): Total gain $25-35\,\text{lb}$ ( $1.1-4.4\,\text{lb}$ in $1^{st}$ trimester; $1.0\,\text{lb/wk}$ thereafter). * Overweight ( $\text{BMI } 25-29.9$ ): Total gain $15-25\,\text{lb}$ ( $0.6\,\text{lb/wk}$ in $2^{nd}/3^{rd}$ trimester). * Obese ( $\text{BMI } \ge 30$ ): Total gain $11-20\,\text{lb}$ ( $0.5\,\text{lb/wk}$ in $2^{nd}/3^{rd}$ trimester).

Infections and Immunizations

TORCH Syndrome: A group of infections that can infect a developing fetus/newborn: * T: Toxoplasmosis. * O: Other agents (e.g., Syphilis, Varicella-Zoster, Parvovirus B19). * R: Rubella (German measles). * C: Cytomegalovirus (CMV). * H: Herpes Simplex Virus. * Clinical Signs: Microcephaly, intracranial calcifications, cataracts, heart defects, enlarged spleen, skin hemorrhages.
Vaccinations During Pregnancy: * Recommended: Tdap (Tetanus, Diphtheria, acellular Pertussis), Inactivated influenza, Rho(D) immunoglobulin. * Indicated for High-Risk: Hepatitis B, Hepatitis A, Pneumococcus, Haemophilus influenzae, Meningococcus. * Contraindicated (Live Vaccines): MMR (Measles-mumps-rubella), Varicella, Live attenuated influenza, HPV (Human papillomavirus).

Rh Incompatibility and Coombs' Test

Indirect Coombs' Test (Maternal Blood): * Performed before birth on the mother. * Positive Result: The mother is producing anti-Rh+ antibodies. RhoGAM is not beneficial if the test is already positive. * Negative Result: Administer RhoGAM to every Rh-negative woman to prevent antibody formation.
Direct Coombs' Test (Fetal/Cord Blood): * Performed after birth using cord blood. * Positive Result: Presence of maternal antibodies in the fetus' blood, leading to destruction of fetal Rh+ red blood cells. * Consequences: Anemia, jaundice, and potential Kernicterus (unconjugated bilirubin in the brain).

Preterm Birth and Cervical Assessment

Preterm Birth: Defined as birth before $37\text{ weeks and } 0\text{ days}$ gestation.
Risk Factors: Infection (periodontal disease, UTI), History of spontaneous preterm birth (single largest risk), Previous cervical surgery (e.g., cone biopsy), Tobacco/illicit drug use, Maternal age $< 17$ or $> 35$ , Black ethnicity.
Cerclage: A surgical procedure to place sutures in the cervix to prevent premature dilation in cases of cervical insufficiency.

Fetal Heart Rate (FHR) Monitoring and Labor Assessment

Uterine Contractions (First Stage): * Duration: $45-80\text{ seconds}$ ; should not exceed $90\text{ seconds}$ . * Frequency: $2-5$ contractions every $10\text{ minutes}$ ; should not occur more frequently than every $2\text{ minutes}$ . * Intensity: $25-50\text{ mm Hg}$ (peak); should not exceed $80\text{ mm Hg}$ . * Resting Tone: Average $10\text{ mm Hg}$ ; should not exceed $20\text{ mm Hg}$ . Essential for fetal oxygenation.
Nitrazine pH Test for ROM: * Negative (Intact): pH $5.0-6.0$ (Yellow/Olive). * Positive (Ruptured): pH $6.5-7.5$ (Blue-green/Deep blue).
VEAL CHOP MINE Mnemonic: * Variable Deceleration = Cord compression = Maternal repositioning. * Early Deceleration = Head compression = Identify labor progress (reassuring). * Acceleration = Okay! = No interventions needed. * Late Deceleration = Placental insufficiency = Execute interventions (Stop oxytocin, Left lateral position, Oxygen $10\text{ L/min}$ , Notify HCP, IV fluids).
Monitoring Details: * Accelerations: Reactive Non-Stress Test (NST) requires $2$ accelerations in $20\text{ minutes}$ , each lasting $15\text{ seconds}$ and peaking $15\text{ bpm}$ above baseline ( $2/20/15/15$ ). * Early Decelerations: Nadir (lowest point) coincides with the peak of the contraction. Caused by head compression. Vagally mediated. * Late Decelerations: Nadir occurs after the peak of the contraction. Returns to baseline after the contraction ends. Indicates fetal hypoxia. * Variable Decelerations: "V" shape. Indicates umbilical cord compression. Action: Change position.

High-Risk Pregnancy and Complications

Ectopic Pregnancy: Signs include sharp abdominal pain, shoulder pain (referred pain), and symptoms of shock (tachycardia, hypotension). Major risk factor: Pelvic Inflammatory Disease (PID) from Chlamydia.
Diabetes in Pregnancy: * Insulin Needs: Decrease in $1^{st}$ trimester; increase in $2^{nd}$ and $3^{rd}$ trimesters. * Gestational Diabetes Screening: $24-28\text{ weeks}$ . $50\text{ g}$ Glucose Loading Test; results $> 140\text{ mg/dL}$ require OGTT. * Risks: Macrosomia, hypoglycemia at birth, polyhydramnios.
Hypertension (HTN) Classification: * Chronic HTN: Before $20\text{ weeks}$ . * Gestational HTN: After $20\text{ weeks}$ , no proteinuria. * Preeclampsia: HTN + Proteinuria ( $3+$ or $\ge 5\text{ g}$ for severe) + Edema. * Eclampsia: Preeclampsia + Seizures. * HELLP Syndrome: Hemolysis, Elevated Liver enzymes (ALT/AST), Low Platelets ( $< 100,000/mm^3$ ).
Magnesium Sulfate ( $MgSO_4$ ): * Used for seizure prophylaxis in preeclampsia. * Toxicity Signs: RR $< 12\text{ rpm}$ , Patellar reflex $< 2+$ , Urinary output $< 30\text{ mL/h}$ , Mg levels $> 8\text{ mg/dL}$ . * Antidote: Calcium Gluconate or Calcium Chloride stay at the bedside.
Third Trimester Bleeding: * Placenta Previa: Painless, bright red bleeding. No vaginal exams. Requires C-section. * Abruptio Placentae: Painful, dark red bleeding, uterine rigidity (tetany). Fetal distress and risk for DIC.

Labor and Delivery Stages

Stage One: Start of contractions to full dilation ( $10\text{ cm}$ ). * Latent Phase: $0-3\text{ cm}$ . * Active Phase: $4-7\text{ cm}$ (Start epidural). * Transition Phase: $8-10\text{ cm}$ (Intense; keep on bed rest after ROM).
Stage Two: Full dilation to birth (Pushing phase).
Stage Three: Delivery of placenta ( $< 30\text{ minutes}$ ). Signs: Cord descent, globular uterus, gush of blood.
Stage Four: $2-4\text{ hours}$ postpartum (Recovery and monitoring).

Medications in Obstetrics

Oxytocin (Pitocin): Utero stimulant. Hold for uterine tetany (frequency $< 2\text{ min}$ , duration $> 90\text{ sec}$ ). Antidote: Magnesium Sulfate.
Methylergonovine (Methergine): Utero stimulant used PO or IM only after delivery to prevent postpartum hemorrhage. Side effects: Hypertension.
Terbutaline (Brethine): Beta-2 agonist used as a tocolytic (uterine inhibitor). Side effects: Tachycardia, hyperglycemia.

Postpartum Care and The Newborn

BUBBLE Mnemonic: Breasts, Uterus, Bladder, Bowel, Lochia, Episiotomy.
Fundal Height Post-Delivery: Firm fundus $1-2\text{ cm}$ above umbilicus, midline. Decreases by $1\text{ cm/day}$ .
Lochia: Rubra ( $2-3\text{ days}$ ), Serosa, then Alba. Excessive if $> 1\text{ pad}$ every $1-2\text{ hours}$ .
The Newborn Priorities: Airway, thermoregulation (Newborns cannot shiver; use radiant heat $97.5-98.6^{\circ}\text{F}$ ), and hypoglycemia prevention (Normal BS $> 40-45\text{ mg/dL}$ ).
Apgar Assessment (1 and 5 minutes): * $8-10$ : Excellent. * $4-7$ : Stimulate, administer Oxygen. * $0-3$ : Resuscitate.
Physical Findings: * Caput Succedaneum: Soft tissue edema; crosses suture lines. Benign, resolves in $48\text{ hours}$ . * Cephalohematoma: Blood between periosteum and bone; does not cross suture lines. Risk for hyperbilirubinemia.

Neonatal Health Challenges

Phenylketonuria (PKU): Autosomal recessive. Deficiency of phenylalanine hydroxylase. Leads to brain damage. Requires lifelong low-protein diet. Guthrie test performed after $24-72\text{ hours}$ of feeding.
Fetal Alcohol Syndrome (FAS): Symptoms include small palpebral fissures, smooth philtrum, thin upper lip, microcephaly, and cognitive impairment.
Neonatal Abstinence Syndrome (NAS): Withdrawal from opioids. Symptoms: High-pitched cry, irritability, tremors, sneezing, poor feeding. Treatment: Opioid therapy (morphine).