Maternity 2
Chapter 13 – Labor and Birth Process
True Labor: Regular contractions, increase in intensity and frequency, cause cervical dilation.
False Labor: Irregular, go away with movement, no cervical change.
Rupture of Membranes (ROM)
Nursing care immediately after ROM:
Check Fetal Heart Rate (FHR) first
Assess for cord prolapse
Check amniotic fluid color and odor
Take maternal vital signs as per protocol
Check maternal temperature every 2 hours → high risk for infection
Prolonged ROM > 24 hrs before birth = ↑ risk for infection
Artificial ROM = Amniotomy
5 P’s Influencing Labor
Passenger – fetus and placenta
Fetal head size
Presentation
Lie
Attitude
Position
Passageway – pelvis and soft tissues
Powers – uterine contractions
Position of woman
Psyche – emotional state
Passenger Details
Fetal Head
Fetal Lie:
Longitudinal (parallel) ✅
Transverse ❌
Oblique ❌
Presentation:
Which part enters pelvis first (e.g., head, buttocks, feet)
Attitude:
Flexion (normal) vs. Extension (abnormal)
Fetal Position (3 letters):
1st: R or L (baby’s back)
2nd: O, S, M, Sc (part presenting: Occiput, Sacrum, Mentum, Scapula)
3rd: A, P, T (relation to mother’s pelvis)
Example: LOA = Left Occiput Anterior ✅
Fetal Station
Measures how far the head has descended into pelvis
0 station = at ischial spines
+ stations = moving out
– stations = still above pelvis
Chapter 15 – Fetal Assessment During Labor
Electronic Fetal Monitoring (EFM):
Displays Fetal Heart Rate (FHR) patterns on monitor
Commonly used in the U.S.
First used in 1970s
Goal: prevent fetal compromise (e.g., hypoxia, cerebral palsy)
Basis for Monitoring
Fetal oxygen may decrease due to:
↓ Blood flow (e.g., maternal hypotension/ hypertension)
↓ Oxygen in mom’s blood (e.g., anemia, hemorrhage)
Cord compression
↓ Flow in placenta (intervillous space)
Uterine Activity + FHR Monitoring:
Goal: Detect nonreassuring patterns
Hypoxemia → may lead to hypoxia
Monitoring Techniques:
Intermittent Auscultation (IA):
Tools: Fetoscope, Pinard, Doppler
Electronic Fetal Monitoring (EFM):
External:
FHR: Ultrasound transducer
Uterine contractions (UC): Tocotransducer
Internal:
Spiral electrode (FHR)
IUPC (intrauterine pressure catheter) – risk for infection
Cervix must be dilated, membranes ruptured
Amnioinfusion:
Fluid inserted via IUPC
Helps relieve variable decelerations (cord compression)
Nurse documents input/output carefully to avoid uterine rupture
Fetal Heart Rate Patterns:
Baseline FHR:
Average over 10 minutes
Normal: 110–160 bpm
Excludes:
Variability
Accelerations/decelerations
Changes >25 bpm
Variability:
Absent/minimal = bad
Moderate = good
Marked = unclear significance
Sinusoidal = wavy, ominous sign
Tachycardia (>160 bpm for 10+ min)
Possible causes:
Maternal fever
Infection
Hypoxia
Drug effects
Bradycardia (<110 bpm for 10+ min)
Actions:
Notify provider
Stop oxytocin
Turn mom side-lying
Give O2, increase IV fluids
Decelerations Types:
Early = Head compression → benign
Late = Uteroplacental insufficiency → dangerous
Actions: Side-lying, O2, fluids, stop oxytocin
Variable = Cord compression
Actions: Reposition, O2, amnioinfusion
Prolonged = Significant interruption of O2
Accelerations = Healthy Baby! 🥰
No treatment needed
Contraction Patterns:
Frequency: every 2–3 minutes
Duration: ~70 sec
Intensity: ~50 mmHg (IUPC)
Resting tone: 10–15 mmHg
Cervical dilation: ~1cm/hr
Stop oxytocin if:
5 contractions in 10 minutes
Contractions >2 minutes long
No relaxation between contractions
Maternity Ch. 14 – Pain Management
Pain During Labor and Birth
Neurologic Origins of Pain:
Visceral Pain: Comes from cervical changes, lower uterine segment stretching, and uterine ischemia. Felt in the lower abdomen.
Referred Pain: Starts in the uterus and radiates to areas like the back, abdomen, thighs, and gluteal region.
Somatic Pain: Sharp, intense, burning, and localized. Caused by stretching of perineal tissues, traction on peritoneum, uterocervical support, and tissue lacerations during birth.
Labor Stage Pain Types:
First Stage: Mainly visceral pain.
Second Stage: Somatic pain.
Third Stage: Similar to first stage (visceral pain).
Perception and Expression of Pain
Pain Threshold: Similar across all people, regardless of culture or background.
Pain Tolerance: Varies; it’s how much pain a person is willing to endure.
Expression of Pain: Includes anxiety, crying, groaning, writhing, hand-clenching, and more. Cultural norms may influence expression.
Factors Influencing Pain Response
Physiological Factors
Cultural Beliefs
Anxiety Levels
Previous Pain Experience
Gate-Control Theory (brain blocks pain signals)
Comfort Measures
Support System
Environment
Nonpharmacologic Pain Management
Effleurage: Light abdominal stroking during contractions.
Sacral Counterpressure: Fist or hand against the lower back to relieve pressure.
Breathing Techniques: Patterned breathing, cleansing breaths.
Other Techniques:
Hydrotherapy (baths/showers)
Acupressure/acupuncture
Movement/position changes
Imagery, music, hot/cold therapy
Biofeedback
Hypnosis
Pharmacologic Pain Management
Systemic Medications:
Opioids (e.g., meperidine): May cause respiratory depression in mother and baby, and ↓ FHR. Antidote: Naloxone.
Antiemetics (e.g., promethazine)
Benzodiazepines (e.g., diazepam)
Inhaled: Nitrous oxide (self-administered)
Regional Anesthesia and Analgesia
Local Infiltration: Lidocaine for local numbing (e.g., episiotomy).
Pudendal Nerve Block: Numbs lower vagina, vulva, perineum.
Nursing Care: Monitor FHR and maternal vitals, position mother on her side, administer IV fluids, ensure informed consent.
Epidural Block:
Given in epidural space (L3–L4).
Reduces pain below umbilicus.
Side effects: Maternal hypotension, fetal bradycardia.
Spinal Block:
Injected into CSF (subarachnoid space).
Used just before delivery (e.g., C-section).
Pain relief from T6 to feet.
Risks: Hypotension, fetal bradycardia, maternal headache, bladder and uterine atony.
General Anesthesia:
For emergency births only.
Chapter 16: Nursing Care of the Family During Labor and Birth
The Law – EMTALA
Federal regulation enacted to ensure that a woman receives emergency treatment or labor care
Stages of Cervical Dilation
Latent Phase: 0–5 cm
Active Phase: 6–10 cm
Assessment
Prenatal data
Interview
Admission data
Psychosocial factors
History of sexual abuse
Stress in labor
Cultural factors
Culture and father participation
Non-English speaking mother
Physical Examination
General systems assessment
Vital signs
Leopold maneuvers
Assessment of fetal heart rate (FHR) and pattern
Assessment of uterine contractions
Vaginal examination
Leopold’s Maneuver
Watch video here
Vaginal Exam
Cervical dilation: 0–10 cm
Cervical thinning (Effacement): 0–100%
Fetal station: Presenting fetal part in the birth canal in relation to the ischial spine
Laboratory and Diagnostic Tests
Analysis of urine specimen
Blood tests
Other tests
Assessment of amniotic membranes and fluid
Nursing Interventions
General hygiene
Nutrient and fluid intake
Oral intake
IV intake
Elimination
Voiding
Bowel
Catheterization
Ambulation and positioning
Supportive Care During Labor and Birth
Labor support by the nurse
Labor support by the father or partner
Labor support by doulas
Labor support by grandparents
Siblings during labor and birth
Emergency interventions
Second Stage of Labor
Begins with full cervical dilation (10 cm)
Complete effacement (100%)
Preparing for birth
Maternal position
Bearing-down efforts
FHR and pattern
Support of father or partner
Supplies, instruments, and equipment
Birth in delivery or birthing room
Mechanism of birth: Vertex presentation
Mechanism of Labor: Seven Cardinal Movements (Vertex Presentation)
Engagement
Descent
Flexion
Internal rotation
Extension
Restitution and external rotation
Expulsion (birth)
Second Stage of Labor (Continued)
BABY IS BORN
Immediate assessments and care of the newborn
Perineal trauma related to childbirth
Perineal lacerations: First, second, third, or fourth degree
Vaginal and urethral lacerations
Cervical injuries
Episiotomy
Third Stage of Labor
Care management
Placental separation and expulsion
Change in shape of uterus
Sudden gush of dark blood from introitus
Apparent lengthening of umbilical cord
Firmly contracting fundus
Pitocin bolus
Pitocin maintenance
Fourth Stage of Labor
Care management
Assessment
Post-anesthesia recovery
Nursing interventions
Care of the new mother
Care of the family
Family — Newborn relationships
CH. 17: LABOR AND BIRTH COMPLICATIONS
Labor and Birth at Risk
When complications arise, perinatal morbidity and mortality risks increase
Some complications are anticipated, particularly when mother is identified as high risk
Others are unexpected or unforeseen
LABOR AND BIRTH AT RISK (CONT.)
Crucial for nurses to:
Understand normal birth process
Prevent and detect deviations from normal labor and birth
Implement nursing measures if complications arise
Nurse and obstetric team must use knowledge and skills in a concerted effort to provide care in event of complications
PRETERM LABOR AND BIRTH
Preterm labor and birth
Preterm birth versus low birth weight
Spontaneous versus indicated preterm birth
Causes of spontaneous preterm labor and birth
Predicting spontaneous preterm labor and birth
Risk factors
Cervical length
Fetal fibronectin test:
Vaginal swab to detect fetal fibronectin
If negative: low risk of preterm birth in near future
If positive: increased risk of preterm delivery
PRETERM LABOR
What is it?
Uterine contractions AND cervical changes between 20–37 weeks gestation
Risk Factors
Infection, diabetes, hydramnios, multifetal pregnancy, previous preterm birth, smoking, substance abuse, hypertension, PROM, placenta previa
Signs/Symptoms
Cervical dilation, vaginal discharge, uterine contractions
Labs
Fetal fibronectin
Treatment
Nifedipine (suppresses contractions)
Magnesium sulfate (relaxes uterus)
Terbutaline
Indomethacin (suppresses labor)
Betamethasone
Nursing Care
Monitor for magnesium toxicity
Ensure maternal hydration
Client Education
Avoid intercourse
Modified bed rest
TERBUTALINE
Indications
Preterm labor (delays but doesn’t prevent labor)
Action
Relaxes the uterus
Side Effects
Tachycardia, angina, hypokalemia, dysrhythmias, restlessness, tremor
Nursing Considerations
Use in pregnancies <37 weeks
Short-term use only
PREMATURE RUPTURE OF MEMBRANES (PROM)
What is it?
Rupture of amniotic membranes before onset of true labor
Risk Factors
Maternal infection, incompetent cervix, previous preterm birth
Signs/Symptoms
Leakage of fluid from vagina
Diagnosis
pH test (nitrazine paper → turns blue with amniotic fluid)
Positive ferning test
Treatment
Ampicillin
Betamethasone
Preterm: hospital or home management
Near term: induce labor
Complications
Increased infection risk (esp. if rupture >24 hours before delivery)
Prolapsed cord
Nursing Care
Assess FHR
Avoid vaginal exams
Client Education (if home)
Modified bed rest
No intercourse
Take temp q4h
Report fever or foul discharge
PROM VS. PPROM
PPROM = Preterm premature rupture of membranes
Before 37 0/7 weeks
Infection is a major risk factor
Causes
Pathologic weakening of membranes
Inflammation
Uterine stress
CARE MANAGEMENT PROM
Depends on risk
Labor will likely be induced
PPROM
Managed conservatively
Usually hospitalized
Risk of:
Infection
Cord prolapse
Preterm labor & birth
Neonatal RDS
LABOR DYSTOCIA
What is it?
Prolonged, difficult labor
Risk Factors
Fetal macrosomia
Maternal fatigue
Uterine abnormalities
Cephalopelvic disproportion
Malpresentation (e.g., shoulder dystocia)
Analgesia
Signs/Symptoms
Prolonged latent phase
Arrest of dilation/effacement/descent
Nursing Care
Encourage ambulation, position changes (hands/ knees)
Prepare for assisted birth or C-section
OBSTETRIC PROCEDURES
Version
External cephalic version
Internal version
Induction of labor
Elective induction
Bishop score ≥39 weeks
BISHOP SCORE
What is it?
Measures cervical readiness for induction
Components
Cervical consistency
Dilation
Effacement
Position
Station
Scoring
Each scored 0–3 (position/station: 0–2)
Multiparous: >8 = ready
Nulliparous: >10 = ready
EXTERNAL VERSION
US-guided, at 37 weeks
Rotate fetus to vertex position
Risk: cord compression, placental abruption
Nursing Care
Monitor FHR
Monitor maternal vitals
INDUCTION OF LABOR
Cervical Ripening
Chemical agents: prostaglandins (misoprostol)
Mechanical: balloon catheter, dilators, membrane stripping
Nursing Care
Monitor for tachysystole
Monitor FHR and contractions
Dinoprostone (Cervidil)
INDUCTION OR AUGMENTATION
Oxytocin
From posterior pituitary
Stimulates contractions
High-alert medication
Risks
Placental abruption
Uterine rupture
Unnecessary C-section
Fetal hypoxemia
Nursing Care
Monitor FHR, contractions
Use tocolytics if needed
OBSTETRIC PROCEDURES (CONT.)
Forceps-assisted
Medical management
Nursing interventions
Vacuum-assisted
Medical management
Nursing interventions
ASSISTED DELIVERIES
Vacuum = Suction cup on fetal head
Forceps = Spoon-like tools
Indications
Prolonged 2nd stage
Fetal distress
Maternal exhaustion
Complications
Maternal/fetal lacerations
Subdural hematoma
Facial bruising
Cephalohematoma
Caput succedaneum
Nursing Care
Lithotomy position
Empty bladder
Confirm ROM and fetal engagement
PRECIPITOUS LABOR
What is it?
Labor <3 hours from onset to birth
Risk Factors
Hypertension
Oxytocin
Younger age
Low birth weight
Abruption
Signs/Symptoms
Abrupt, intense contractions
Complications
Maternal lacerations
Uterine rupture
PPH
Fetal hypoxia
Intracranial hemorrhage
Nursing Care
Side-lying position
Oxygen and IV fluids
D/C oxytocin
Assist emergency delivery
CESAREAN BIRTH
What is it?
Delivery via abdominal & uterine incision
Anesthesia: spinal/epidural/general
Types
Scheduled
Unplanned
Indications
Maternal, fetal, placental concerns
Risk Factors
Labor dystocia
Malpresentation
Fetal distress
Prior C-section
Complications
Hemorrhage, infection
Nursing Care
Prep site, IV, Foley
Medications
Post-op analgesics, dressing check
OBSTETRIC EMERGENCIES
Meconium-stained fluid
Fetus passed stool in utero
Sign of hypoxia
Risk of aspiration
Requires:
Neonatal resuscitation team
Intubation
OBSTETRIC EMERGENCIES (CONT.)
Shoulder dystocia
Head born, shoulder stuck
“Turtle sign”
Risks: brachial plexus injury, hemorrhage
Interventions
McRoberts maneuver
Suprapubic pressure
Gaskin maneuver
OBSTETRIC EMERGENCIES (CONT.)
Prolapsed cord
Cord precedes baby → compressed circulation
Risk Factors
ROM
Malpresentation
Unengaged presenting part
Signs/Symptoms
Visible/palpable cord
Variable/prolonged FHR decels
Nursing Care
Call for help
Insert fingers to lift fetus
Position: knee-chest or Trendelenburg
Warm, sterile saline towel
Oxygen
Prepare for birth
OBSTETRIC EMERGENCIES (CONT.)
Uterine rupture
Rupture of uterine wall
Risk Factors
Oxytocin overuse
Uterine distention
Multigravida
Surgery/trauma
Signs/Symptoms
“Tearing” pain
Non-reassuring FHR
Hypovolemic shock
Nursing Care
IV fluids, blood
Emergency C-section ± hysterectomy
Monitor for shock
OBSTETRIC EMERGENCIES (CONT.)
Amniotic fluid embolism (AKA: Anaphylactoid syndrome of pregnancy)
What is it?
Amniotic fluid → maternal circulation → blocks lungs
Risk Factors
Advanced maternal age
Diabetes
Multiparity
Meconium fluid
Uterine rupture
Signs/Symptoms
Sudden chest pain
Dyspnea, bleeding
Tachycardia, hypotension
Complications
Respiratory failure
DIC
Death
Nursing Care
Oxygen, IV, blood
CPR, intubation
Ventilation
CH. 18 – Postpartum Physiological Changes
Maternal Physiologic Changes
After birth period is the interval between birth and return of reproductive organs to their nonpregnant state.
Referred to as puerperium or fourth stage of pregnancy.
Traditionally lasts 6 weeks, although this varies among women.
Postpartum Physiological Changes
Consist of:
Uterine involution
Lochia flow
Cervical involution
Decrease in vaginal distention
Alteration in ovarian function and menstruation
Changes in cardiovascular, urinary tract, breast, and gastrointestinal tract
Greatest risks during postpartum:
Hemorrhage
Shock
Infection
Pitocin will continue to infuse to stimulate uterine contractions and prevent PPH.
Fundus descends 1–2 cm every day.
12 hours after delivery, fundus should be firm, midline, and approximately at the level of the umbilicus.
PP Assessment: BUBBLE
Breast and Breastfeeding
Colostrum and Milk:
Colostrum = rich in antibodies, protein, fat- soluble vitamins
Secreted during pregnancy and for 2–3 days after delivery
Milk produced 3–5 days after delivery
Breast Engorgement:
Empty breasts completely with each feeding
Apply warm compresses before feeding; cool compresses after
Suppression of Lactation:
Wear a supportive bra for 72 hours
Avoid breast stimulation and warm water
Engorgement resolves spontaneously within 24–36 hours
Breast Care
Wash hands prior to breastfeeding
Ensure proper latch
Apply breastmilk to sore nipples and air dry
Report signs of mastitis (cracked/sore nipples, erythema, flu-like symptoms)
Stay hydrated
Oxytocin from breastfeeding helps uterus contract and prevents hemorrhaging
Uterine cramps may occur during breastfeeding
Uterus Involution
Fundus = topmost part of the uterus
Assess and document:
Height
Location
Consistency
Administer medications after placenta delivery to promote contractions and prevent hemorrhage.
1 week PP: Fundus should be halfway between umbilicus and pubis symphysis
2 weeks PP: Fundus should not be palpable
Lochia
Uterine discharge after delivery: blood, mucus, uterine tissue
Abnormal findings:
Malodorous = infection
Lochia rubra beyond 1 week
Quantity: *Scant: < 5 cm stain
Light: < 10 cm stain
Moderate: < 15 cm stain
Heavy: > 15 cm stain or 1 pad saturated in 2 hours
Excessive: pad saturated in 15 minutes
Check for pooling of blood under buttocks
Cervix
Soft immediately after birth
Becomes firm within 12–18 hours
Regains prepregnancy form
Dilated to 10 cm during labor; closes gradually
Vagina and Perineum
Estrogen deprivation → thin vaginal mucosa, absence of rugae
Rugae reappear within 3 weeks
Mucosa thickens with return of ovarian function
Dyspareunia (painful intercourse) may persist
Care for episiotomy, if applicable
Perineum Care
Apply ice packs to reduce pain/edema, prevent hematomas
Use squeeze bottle with warm water after voiding, pat dry
Sitz baths 15–20 min, several times daily
Use topical anesthetics (e.g., benzocaine)
Witch hazel pads for hemorrhoid discomfort
↑ Fluid and fiber to prevent constipation
Postpartum Immunizations
Rubella: For clients with titer <1:8
Contraindicated if immunosuppressed
Avoid pregnancy for 28 days
Tdap: If not received in 3rd trimester
Varicella: Given if no immunity
Dose 1: before discharge
Dose 2: 6–8 weeks after
Avoid pregnancy for 28 days
Rhogam: Within 72 hours for Rh- mom with Rh+ baby
Endocrine System
Pituitary hormones and ovarian function differ
Nonlactating: 70% menstruate within 12 weeks
Ovulation as early as 27 days
Lactating: Return of ovulation depends on breastfeeding pattern
Urinary System
Within 12 hours → diuresis
Nighttime diaphoresis for 2–3 days
Full bladder → displaces uterus → ↑ bleeding risk
GI System
Appetite returns post-anesthesia
Bowel movement may not occur for 2–3 days
Cardiovascular Changes
Blood loss:
Vaginal: 500 mL
Cesarean: 1,000 mL
CO remains ↑ for 48 hrs; returns to baseline in ~12 weeks
Blood volume back to normal in ~4 weeks
Labs: *↑ Coagulation factors (~3 weeks) → ↑ DVT risk
↑ WBC (~1–2 weeks), up to 25,000
Nursing care:
Assess legs for DVT
Encourage early ambulation
Integumentary System
Chloasma fades after pregnancy (30% may persist)
Areola and linea nigra hyperpigmentation may not fully regress
Stretch marks fade, don’t disappear
Spider angiomas, palmar erythema regress with ↓ estrogen
Hair growth slows, possible hair loss
Chapter 19 – Nursing Care of the Family During the Postpartum Period
After Birth Woman – Nursing Care
Support rest and recovery
Assess physiologic and psychologic adaptations
Prevent complications
Educate on self-care and infant care
Support mother/partner transition to parenthood
Postanesthesia recovery required before discharge
Parental-Infant Bonding
Signs: holding, singing, smiling, recognizing features
Impaired signs: ignoring baby, apathy, disgust, disappointment
Nursing: encourage hands-on care, skin-to-skin, teach hunger cues
Planning for Discharge
Newborns’ and Mothers’ Health Protection Act of 1996:
Vaginal: 48 hrs
C-section: 96 hrs
Criteria based on AAP recommendations
Planning for Discharge (continued)
Ongoing assessments and labs
Prevent:
Excessive bleeding
Bladder distention
Infection
Promote comfort:
Nonpharmacologic and pharmacologic
Sibling Adaptation
Let siblings see the baby early
Gift from the baby
Give younger kids a doll to care for
Let older siblings help
Expect regression (toileting, sleeping, behavior)
Monitor behavior
Discharge Teaching
Self-care and warning signs
Sexual activity:
Wait until provider clears
Lochia should be white, episiotomy healed
Use lubricants if needed
Contraception:
Ovulation can start 1 month postpartum
Pregnancy possible during breastfeeding
Chapter 21 – Postpartum Complications
Postpartum Hemorrhage
Blood loss:
500 mL (vaginal)
1,000 mL (c-section)
4 Ts: Tone, Trauma, Tissue, Thrombin
Risk Factors
Uterine atony
Magnesium sulfate
Birth canal trauma
Precipitous delivery
Retained placenta
Uterine inversion/subinvolution
Macrosomia
S/s of PPH
Saturated pad ≤ 15 min
Boggy uterus
Large clots
Constant bleeding
Hypovolemic shock:
Tachycardia, hypotension, cold/clammy skin
↓ H&H
Medications
Oxytocin
Methylergonovine (Methergine) – CI: Hypertension
Misoprostol (Cytotec) – vaginal or rectal
Carboprost (Hemabate) – CI: Asthma, may cause diarrhea
Postpartum Infections
Fever > 38°C after 24 hrs or for 2 days in 10-day period
Endometritis:
Most common infection
RF: C-section, retained placenta, PROM, internal monitoring
S/s: Fever, suprapubic pain, malodorous lochia, ↑ WBC
Tx: IV/oral antibiotics, analgesics