maternal and

child notes

by SNurses_notes
 ABBREVIATIONS
IUP/IUFD ......Intrauterine pregnancy / intrauterine fetal demise MLE...............Midline episiotomy
SAB ...............Spontaneous abortion NST ...............Non-stress test
TAB................Therapeutic abortion CST................Contraction stress test
LMP...............Last menstrual period BPP................Biophysical profile
ROM..............Rupture of membranes VBAC.............Vaginal birth after cesarean
SROM............Spontaneous rupture of membranes AFI.................Amniotic fluid index
AROM ...........Artificial rupture of membranes BUFA.............Baby up for adoption
PROM............Prolonged rupture of membranes (>24 hours) NPNC............No prenatal care
PPROM .........Preterm premature rupture of membranes PTL ................Preterm labor
SVD ...............Spontaneous vaginal delivery BOA...............Born on arrival
FHR ...............Fetal heart rate BTL ................Bilateral tubal ligation
EFM...............Electronic fetal monitoring D&C / D&E ...Dilation & curettage / dilation & evacuation
US..................Ultrasound transducer (detects FHR) LPNC.............Late prenatal care
FSE................Fetal scalp electrode (precise reading of FHR) TIUP ..............Term intrauterine pregnancy
IUPC..............Intrauterine pressure catheter (strength of contractions) VMI / VFI ......Viable male infant / viable female infant
LTV ................Long term variability EDB ...............Estimated date of birth
SVE................Sterile vaginal exam EDC...............Estimated date of confinement
EDD...............Estimated date of deliver

40 WEEKS GESTATIONAL AGE

PREGNANCY DURATION 38 WEEKS FETAL AGE
40 weeks gestational age The This refers to the age of the TRIMESTERS
0-13 weeks
number of completed weeks developing baby, counting from the FIRST TRIMESTER
14-26 weeks
counting from the 1st day of estimated date of conception. The SECOND TRIMESTER
the last normal menstrual fetal age is usually 2 weeks less than THIRD TRIMESTER 27-40 weeks
cycle (LMP). the gestational age.

Gravida/Gravidity
PRENATAL TERMS
A woman who is pregnant / the number of PRETERM
pregnancies Pregnancies that have reached 20 weeks but ended
before 37 weeks

NULLIGRAVIDA PRIMIGRAVIDA MULTIGRAVIDA

Never been pregnant Pregnant for the first time A woman who has had 2+

Parity
pregnancies
TERM
Pregnancies that have lasted between week
37 and week 42
The number of pregnancies that have reach viability
(20 weeks of gestation) whether the fetus was born Early Term: 37 – 38 6/7
alive or not Full Term: 39 – 40 6/7
Late Term: 41 – 41 6/7

NULLIPARA PRIMIPARA MULTIPARA

0 1 2+
Zero pregnancies
beyond viability (20 weeks)
One pregnancy that has
reached viability (20 weeks)
Two or more pregnancies that
have reached viability (20 POSTDATE/POSTTERM
weeks) A pregnancy that goes beyond 42 weeks
 GTPAL
An acronym used to assess pregnancy outcomes.

G GRAVITY The number of pregnancies

Includes the present pregnancy
Includes miscarriages / abortions
Twins / triplets count as one

T TERM The number born at term

> 37th week of gestation
Includes alive or stillborn
Twins / triplets count as one

P
The number of pregnancies delivered
PRE-TERM beginning with the 20th - 36 6/7th
weeks of gestation
BIRTHS Includes alive or stillborn
Twins / triplets count as one

A ABORTIONS/ The number of pregnancies

delivered before 20 weeks
MISCARRIAGES gestation
Counts with gravidity
Twins / triplets count as one

L LIVING
The number of current living children
Twin / triplets count individually
 PREGNANCY SIGNS & SYMPTOMS
presumptive (subjective)
P PERIOD ABSENT (AMENORRHEA)
R REALLY TIRED
E ENLARGED BREASTS
S SORE BREASTS
U URINATION INCREASED (URINARY FRREQUENCY)
M MOVEMENT PERCEIVED (QUICKENING)
E EMESIS & NAUSEA

probable (objective)
P POSITIVE PREGNANCY TEST (HIGH LEVELS OF THE HORMONE: HCG)
R RETURNING OF THE FETUS WHEN UTERUS IS PUSHED W/ FINGERS (BALLOTTEMENT)
O OBJECTIVE
B BRAXTON HICKS CONTRACTIONS
A A SOFTENED CERVIX (GOODELL'S SIGN)
B BLUISH COLOR OF THE VULVA, VAGINA, OR CERVIX (CHADWICK'S SIGN)
L LOWER UTERINE SEGMENT SOFT (HEGAR'S SIGN)
E ENLARGED UTERUS

positive (objective)
F FETAL MOVEMENT PALPATED BY A DOCTOR OR NURSE
E ELECTRONIC DEVICE DETECTS HEART TONES
T THE DELIVERY OF THE BABY
U ULTRASOUND DETECTS BABY
S SEEING VISIBLE MOVEMENTS
PREGNANCY PHYSIOLOGY
 NAEGELE'S RULE
Used for estimating the expected date of delivery (EDD)
based on LMP (last menstrual period)

DATE OF LAST MENSTRUAL PERIOD - 3 CALENDAR MONTHS + 7 DAYS + 1 YEAR

EXAMPLE

Remember:
How many days are in each month?

30 days hath facts about NAEGELE'S rules

September, April, June &
November. All the rest have 31,
except February alone (28 days)
Bases calculation on a woman who has a 28-
day cycle (most women vary)
The typical gestation period is 280 days (40
weeks)
First-time mothers usually have a slightly
longer gestation period

WHAT TO AVOID DURING PREGNANCY

TERATOGENIC DRUGS TORCH INFECTIONS
TORCH infections are a group of infections
RE ME MB ER TH
E
TERA-TOWAS that cause fetal abnormalities. Pregnant
MN EM ON IC ! women should avoid these infections!

T THALIDOMIDE
RE ME MB ER TH
E
TORCH
E Epileptic medications
(valproic acid, phenytoin)
MN EM ON IC !

T Toxoplasmosis
R Retinoid (Vit A)

A Ace inhibitors,ARBS PARV O Virus - B19 (fifth disease)

T Third element(lithium)
R Rubella
O Oral Contraceptives

W Warfarin (coumadin) C Cytomegalovirus

A Alcohol
H Herpes Simplex Virus

S Sulfonamides & sulfones

 STAGES OF LABOR
1
STAGE CERVIX DILATES FROM 0-10 CM
INTERVENTIONS
Promote comfort
LATENT (EARLY) - LONGEST STAGE
Cervix dilates: 1-3 CM
Warm shower, massage, or epidural
Offer fluids & ice chips
Intensity: Mild
Contractions: 15-30 mins Provide a quiet environment
Encourage voiding every 1 - 2 hours
ACTIVE Encourage participation in care & keep informed
Cervix dilates: 4 - 7 cm Instruct partner in effleurage (light stroking of the abdomen)
Intensity: Moderate
Contractions: 3 -5 min (30-60 Encourage effective breathing patterns & rest between contractions
sec in duration)

TRANSITION RE ME MB ER TH
E
L abor
MN EM ON IC !
Actively
Cervix dilates: 8 - 10 cm
Intensity: Strong Transitioning
Contractions: Every 2-3
min (60-90 sec in duration)

STAGE STAGE
THE BABY IS DELIVERED.
2 THE
CERVIX
BABYDILATES
IS DELIVERED.
FROM 0-10 CM 3 The PLACENTA is delivered

Starts when cervix is fully dilated & effaced The PLACENTA is expelled (5-30 after birth)
Ends after the baby is delivered

SIGNS OF A PLACENTA DELIVERY DELIVERY MECHANICS

INTERVENTIONS Lengthening umbilical
cord
Gush of blood
"Shiny Shultz"
Side of baby delivered 1st

Provide ice chips & ointment for dry lips Uterus changes from "Dirty Duncan"
oval to globular shape Side of mother delivered 1st
Provide praise & encouragement to the mother
q
Monitor uterine contractions & mothers vital INTERVENTIONS
Assessing mothers vital signs
signs
Maintain privacy & encourage rest between Uterine status (fundal rubs every 15
contractions minutes)
Encourage effective breathing patterns & rest Provide warmth to the mother
between contractions Promote parental-neonatal attachment
Monitor for signs of birth (perineal bulging or Examine placenta & verify it's intact -
visualization of fetal head)
Should have 2 arteries & 1 vein

4
STAGE RECOVERY!
Firm
RECOVERY: first 1-4 hours after delivery of the placenta Midline
Assessing the fundus q Continue to monitor vital signs & temperature for
infection Soft
Administer IV fluids Boggy
Monitor lochia discharge (lochia may be moderate in amount & red). Displaced
Monitor for respiratory depression, vomiting, & aspiration if general
anesthesia was used
Great time to watch for complications such as bleeding (postpartum
hemorrhage)
 TRUE VS.FALSE LABOR
FALSE LABOR TRUE LABOR
Occur regularly
CONTRACTIONS

- Stronger
Irregular - Longer
Stops with walking / position - Closer together
change • More intense with walking
Felt in the back or the abdomen • Felt in lower back -> radiating to
above the umbilicus the lower portion of the abdomen
Often stops with comfort • Continue despite the use of
measures comfort measures

May be soft
NO significant change in.... Progressive change
- Softening
CERVIX

- Effacement
- Dilation - Effacement
No bloody show - Dilation signaled by the appearance of
In posterior position (baby's bloody show - Moves to an increasingly
head facing mom's front of anterior position (baby's head facing
belly mom's back

Presenting parts become engaged in

the pelvis
Presenting part is usually not Increased ease of breathing (more
FETUS

engaged in the pelvis room to breathe)

Presenting part presses downward &
compresses the bladder = urinary
frequency

SIGNS OF LABOR
LABOR SIGNS OF PRECEDING LABOR
Lightening
Moving the fetus, placenta, & the
Increased vaginal discharge (bloody show)
membranes out of the uterus Return of urinary frequency
through the birth canal Cervical ripening
Rupture of membranes "water breaking" • Persistent
backache
Stronger Braxton Hicks contractions
Days preceding labor
- Surge of energy
- Weight loss (1- 3.5 pounds) from a fluid shift
 FETAL HEART TONES
EARLY DECELERATIONS
"Mirror" image of mom's contractions
( They don't technically come early) NORMAL FETAL HEART RATE
120-160 BPM

Cause:
NORMAL

From head compression

Intervention:
Continue to monitor
No intervention needed

Literally comes late after mom's

LATE DECELERATIONS contraction

Cause:
Uteroplacental insufficiency
NON-REASSURING

Intervention:
D/C oxytocin
Position change
Oxygen (nonrebreather)
Hydration (IV fluids)
Elevate legs to correct the
hypotension

VARIABLE DECELERATIONS *Variable: Looks "V" shaped

Cause:
Cord compression
NON-REASSURING

Intervention: Side-lying or knee chest will

relieve pressure on cord
D/C Oxytocin
Amnioinfusion
position change
Breathing techniques
Oxygen (nonrebreather)
 PREECLAMPSIA OVERVIEW
Overview of Hypertensive disorders during pregnancy

HYPERTEN
1st trimester 2nd trimester 3rd trimester
IS

SIO
WHAT
SYSTOLIC > 140

N?
or
20 weeks DIASTOLIC > 90
CHRONIC HTN: Before
PREECLAMPSIA: HTN after 20 weeks gestation with
pregnancy or before 20 Hypertension may be
systemic features abbreviated "HTN"
weeks!
GESTATIONAL HTN: HTN after 20 weeks without
systemic features

SIGNS & SYMPTOMS PATHOLOGY RISK FACTORS

"PRE" eclampsia Pathology isn't completely known HX of preeclampsia in previous
P Proteinura pregnancies
PLACENTA is the root cause. Family history of preeclampsia
R Rising BP 1st pregnancy
E Edema Defective spiral artery Obesity
AMA (advanced
Severe headache remodeling Very young (<18) or very old (>35) maternal age)
RUQ or epigastric pain Systemic vasoconstriction & Medical conditions (Chronic HTN, renal
Visual disturbances disease, diabetes, autoimmune disease
endothelial dysfunction
↓ Urine output
Hyperreflexia
Rapid weight gain

HELLP SYNDROME ECLAMPSIA

(seizures activity or a coma)
VARIANT OF PREECLAMPSIA Immediate care:
LIFE-THREATENING Side-lying
Padded side rails with
pillows/blankets
H Hemolysis O2
EL Rising BP Suction if needed
Do not restrain
LP Low platelet count Do not leave

MAGNESIUM SULFATE TOXICITY!

RR <12
RX given to prevent seizures during & after labor. ↓ DTR's
UOP <30 mL/hr *Mag is excreted in urine
*Remember: magnesium acts like a depressant EKG Changes ↓ →↑
UOP Mag levels

THERAPEUTIC RANGE: 4 – 7 mg/dL ANTIDOTE: calcium gluconate *because magnesium

sulfate can cause respiratory depression
 VEAL CHOP
A TOOL TO HELP INTERPRET FETAL STRIPS

V VARIABILITY C CORD COMPRESSION

E EARLY DECELARATIONS
H HEAD COMPRESSION

A ACCELERATIONS O OK (NORMAL FETAL OXYGENATION)

L LATE DECELERATIONS P PLACENTAL INSUFFICIENCY

ASSESSMENT OF UTERINE CONTRACTIONS

BEGINNING of the Lasts 45 - 80 seconds

DURATION contraction to the END

of the same contraction
Should not exceed 90 second

Only measured through external monitoring

Number of contractions 2 - 5 contractions every 20 minutes

from the BEGINNING of Should not be more FREQUENT then every 2 minutes
FREQUENCY one contraction to the
Only measured through external monitoring
BEGINNING of the next

25 - 50 mm Hg Mild - nose
Should not exceed 80 mm HG Moderate - chin
Strength of a contraction
INTENSITY at its PEAK Can be palpated
Strong - forehead

TENSION in the uterine Average: 10 mm HG Soft = good

muscle between contractions Should not exceed 20 mm HG Firm = not resting

RESTING TONE (relaxation of the uterus =

fetal oxygenation between Can be palpated
enough

contractions)
 LABOR & BIRTH PROCESSES
A TOOL TO HELP INTERPRET FETAL STRIPS

5 factors that affect the process of labor & birth

PASSENGER - Fetus & Placenta
PASSAGEWAY - The Birth Canal
POSITION - Position of the Mother
POWERS - Contractions
PSYCHOLOGY - Emotional Response

PASSENGER - FETUS & PLACENTA

SIZE OF THE FETAL HEAD SIZE OF THE FETAL HEAD
FONTANELS Refers to the part of the fetus that enters the
Space between the bones of the skull pelvic inlet first through the birth canal
allows for molding during labor
Anterior (larger)
- Diamond-shaped
- Ossifies in 12-18 months CEPHALIC
Posterior Head first
- Triangle shaped Presenting part: Occipital (back of
- Closes 8 - 12 weeks head/skull)
MOLDING
Change in the shape of the fetal skull to SHOULDER
"mold" & fit through the birth canal Shoulders first
Presenting part: Scapula

FETAL LIE
Relation of the long axis (spine) of the fetus to the long axis (spine) of the mother
LONGITUDINAL OR VERTICAL
The long axis of the fetus is parallel with the long axis of the mother
Longitudinal: cephalic or breech
TRANSVERSE, HORIZONTAL, OR OBLIQUE
Long axis of the fetus is at a right angle to the long axis of the mother
Transverse: vaginal birth CANNOT occur in this position
Oblique: usually converts to a longitudinal or transverse lie during labor
 LABOR & BIRTH PROCESSES
A TOOL TO HELP INTERPRET FETAL STRIPS

PASSENGER
FETAL ATTITUDE
GENERAL FLEXION
Back of the fetus is rounded so that the chin is flexed on the
chest, thighs are flexed on the abdomen, legs are flexed at the
knees
BIPARIETAL DIAMETER
9.25 cm at term, the largest transverse diameter and an
important indicator of fetal head size
SUBOCCIPITOBREGMATIC DIAMETER
Most critical & smallest of the anteroposterior diameters

FETAL POSITION
FETAL STATION
Where the baby's presenting part is located in the pelvis
Presenting part?
- Head, foot, butt (closest to exit of uterus)
Measured in centimeters (cm)
- Find the ischial spine = zero
- Above the ischial spine is (-)
- Below the ischial spine is (+)
+4 / +5 = Birth is about to happen
- Documented
-5, -4, -3, -2, -1, 0, +1, +2, +3, +4, +5
ENGAGEMENT
Fetal station zero = baby is "engaged"
Presenting parts have entered down into the pelvis inlet & is at the
ischial spine line (0)
When does this happen?
- First-time moms: 38 weeks
- Already had babies: can happen when labor starts
 LABOR & BIRTH PROCESSES
PASSAGEWAY The Birth Canal: Rigid bony pelvis, soft tissue
of cervix, pelvic floor, vagina & introitus

TYPES OF PELVIS SOFT TISSUE

GYNECOID LOWER UTERINE SEGMENT
Classic female type • Stretchy
Most common CERVIX
ANDROID Effaces (thins) & dilates (opens)
Resembling the male pelvis After fetus descends into the
vagina, the cervix is drawn upward
ANTHROPOID
and over the first portion
Oval-shaped
PELVIC FLOOR MUSCLES
Wider anteroposterior diameter
Helps the fetus rotate anteriorly
PLATYPELLOID
VAGINA INTROITUS
The flat pelvis
External opening of the vagina
Least common

POSITION POSITION OF THE MOTHER DURING

UPRIGHT POSITION
Sitting on a birthing stool or cushion "

ALL FOURS" POSITION

On all fours: putting your weight on your hands & feet

LITHOTOMY POSITION " MOST COMMON "

Supine position with buttocks on the table
FREQUENT CHANGES IN
LATERAL POSITION POSITION HELP WITH:
RELIEVING FATIGUE
Laying on a side INCREASING COMFORT
IMPROVING CIRCULATION
 LABOR & BIRTH PROCESSES
POWERS Contractions: Primary & Secondary
PRIMARY POWERS SECONDARY POWERS
Does not affect cervical dilation but
DILATION
helps with expulsion of infant once the
Dilation of the cervix is the
cervix is fully dilated
enlargement or widening of the
Voluntary bearing-down efforts by
cervical opening & canal once
the women once the cervix has
labor has begun
dilated
Cervix: closed full dilation (10 cm)
When the presenting part reaches
pressure from amniotic fluid can
the pelvic floor, the contractions
also apply force to dilate
change in character & become
expulsive.
Laboring women start to feel an
EFFACEMENT involuntary urge to push & she uses
Shortening & thinning of the secondary powers to aid in the
cervix during the first stage of expulsion of the fetus
labor
Cervix normally: 2 -3 cm long 1 cm
thick
The cervix is "pulled back /
thinned out" by a shortening of
PSYCHOLOGY
the uterine muscles EMOTIONAL RESPONSE
EFFACEMENT Anxiety can increase pain perception
Shortening & thinning of the & the need for more medications
cervix during the first stage of (analgesia & anesthesia)
labor
Cervix normally: 2 -3 cm long 1 cm
thick THINGS TO CONSIDER:
The cervix is "pulled back / SOCIAL SUPPORT
thinned out" by a shortening of
the uterine muscles
PAST EXPERIENCE
KNOWLEDGE
 NEW BORN ASSESSMENT
IT AL GOA
APGAR
7-10 supportive care

LS
4-6 moderate depression

I NI
1ST PRI OR ITY = AIR WA
Y
Suc tion wit h bul b syri
< 4 aggressive resuscitation suc tion
nge / dee p

*Ne wb orn s are obl iga

tor y nos e

APGAR SCORING bre ath ers

2ND PRI OR ITY = WA RM

SCORE 0 POINTS 1 POINT 2 POINTS

TH
Dry wit h a bla nke t or
pla ce in wa rme r

APPERANCE cyanotic /pale Peripheral cyanosis

Pink
(SKIN COLOR all over only

PULSE
(HEART RATE)
0 < 100 >100 CIRCULATORY SYSTEM
Blood flow from umbilical vessels &
GRIMACE placenta stop at birth
No response to Grimace or weak cry Acrocyanosis: - Blueness of hands &
(REFLEX Cry when stimulated
stimulation when stimulated feet (normal during the first 24 hours of
IRRITABILITY
life)
Well flexed & resisting Closure of
ACTIVITY (TONE) Floppy Some flexion
extension - Ductus arteriosus
-Foramen ovale
Slow, irregular -Ductus venosus
RESPIRATION Apneic Strong cry Transient murmurs are normal
breathing

Breathing pattern is IRREGULAR.

VITAL SIGNS Newborns are abdominal breather
Respiratory Rate: To count breaths, place Count for a
30 - 60 breaths/min your hand on their full minute!
abdomen
Heart Rate:
110 - 160 BPM HEAD
Can be 180 if crying Caput Succendeum:
Cephahemtaoma:
Can be 100 if sleeping Take apical Edema (collection of fluid)
Crosses the suture lines
pulse for 1 full min (Like a baseball cap)
Birth trauma (collection of blood)
Does not cross the suture lines
Temperature (auxillary):
97.7° - 99.5° F Molding: abnormal head shape that results from pressure (normal)
36.5° - 37.5° C Fontanelles:
Bulging = increase ICP or hydrocephalus
Blood Pressure: Fontanelles may be bulging
Sunken = dehydration when the newborn cries,
Not done routinely vomits, or is lying down.
Systolic 60 – 80 mm Hg This is normal.
Diastolic 40 – 50 mm Hg
MAP
Equal to the # of weeks gestation UMBILICAL CORD
or higher
Should have A A Should be dry, no
GENERAL CHARACTERISTICS 2 arteries odor, & no drainage
& 1 Vein V
HEAD & CHEST CIRCUMFERENCE
LENGTH & WEIGHT
HEAD CIRCUMFERENCE
Expected Length
32 - 39 cm
14 - 15 inches
*measure above eyebrows
44 - 55 TEMP HEAT LOSS DUE TO:
cm 17 - 22 in
CHEST CIRCUMFERENCE
Evaporation: Moisture from skin & lungs
Expected Weight Convection: Body heat to cooler air
30 - 36 cm
2,500 - 400 g
Conduction: Body heat to a cooler surface in direct contact
12 - 14 inches
Radiation: Body heat to a cooler object nearby
*measure above nipple line
5 lb, 8 oz - 8 lb, 14 oz
POST PARTUM ASSESSMENT: "BUBBLES"
BREASTS
B
MASTITITIS
May be sore after breastfeeding Infection & Inflammation of beast tissue
Breastfeed every 2 - 3 hours (15 - 20
minutes each breast) Continue breastfeeding Rest
Warm compress Analgesics
Position newborn "tummy to mummy"
Hydration Wash hands!
Latch should be completey around the
areola

U UTERUS
UTERINE ATONY
RISK FACTORS
SYMPTOMS
Enlarged
Soft
Boggy
Poorly contracted uterus
Retained placenta Not midline
Chorioamnionitis (infection)
Uterine fatigue INTERVENTIONS
Full bladder Fundal massage
Assist to void or use in-and-out catheter

B BOWELS HEMORRHOIDS
May see blood in the stool
Should begin to shrink following birth
Constipation is common after INTERVENTIONS
birth. Increasing FLUIDS & Tucks / witch hazel
FIBER may help! Ice pack
Squeeze bottle
Sitz Bath

B BLADDER
Postpartum urinary retention is common
- In-and-out caterization may be needed
- Bladder distention can cause a displaced & boggy
utuerus!
SIGNS OF INFECTION
Foul smelling or purulent
lochia
Fever (>100.4 F )

LOCHIA
Abodminal tenderness

L
Tachycardia

"REALLY SORE AFTER"

RUBRA
RUBRA bright red
SEROSA
SEROSA pinkish/brown
ALBA
RUBRA
whitish-yellow
1-3 days 4-10 days 0 - 14 days *Can last up to 6
weeks

EMOTIONAL STATUS
E Postpartum depression (PPD) is common for women following childbirth
As the nurse ask about feelings of... depression
hopelessness
self-harm
harm to the newborn
Crying
Irritable
Sleep disturbances
Anxiety
Feelings of guilt

SECTION
S
( C-section incisions) / Episiotomy
Promote proper wound healing
Report to the health care provider: pain
inflammation • surrounding skin is warm to touch
POST PARTUM ASSESSMENT
 TERMS & CONDITIONS
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