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Introduction to Perinatal Nuring

Lecture 1 - September 7, 2022

Learning Outcomes:
- Describe the scope of perinatal nursing in Canada
- Describe current trends in perinatal health
- Consider how the social determinants of health influence the health of women and newborns
and discuss approaches needed to address health inequities in Canada

What is Perinatal Nursing?

- The provision of care to women and their families before, during and after childbirth
- Recognized as a nursing specialty in Canada
- Perinatal nurses work in many setting, including: hospitals, homes, ambulatory and
community care settings
Goals of Perinatal Nurses:
- To promote the physical, emotional, social and spiritual well-being of the whole family
- To work to address health inequities that influence health outcomes during the child bearing
years.

Guiding Principles for Perinatal Nursing in Canada

As perinatal nurses, we value the following:
- Caring
- Health and well-being
- Informed decision making
- Dignity
- Confidentially
- Justice
- Accountability
- Quality practice environments

Current Trends in Canada

- Still a very low % of women cared for by midwives
- Most perinatal care is provided by physicians
- Most perinatal care takes place in hospitals
- Home births account for a very small % of births in Canada
- Delay in childbearing
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- Multiple births
- Inequities in access to quality maternity care still exist in Canada, particularly in rural, remote,
inner-city, and First Nations, Metis and Inuit communities
- Increase in low birth weight and preterm births
- Breast feeding rates
- Inductions and caesarean delivers

The Social Determinants of Health

- Income and social status
- Social support networks
- Education and literacy
- Employment and working conditions
- Social environments
- Physical environments
- Personal health practices and coping skills
- Healthy child development
- Biology and genetic endowment
- Health services
- Gender
- Culture
- Currently, poverty is though to have the most significant influence on maternal/child health.
- Need to focus on provision of health promotions and preventive care to those experiencing
this condition of vulnerability

Quiz: What determinant of health is the most significant? Poverty

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The Normal Pregnancy

Lecture 2 - September 14, 2022

Learning Outcomes
- Describe the processes of fertilization and the development of the normal embryo and fetus
- Discuss the importance of preconception and prenatal care
- Describe expected maternal and family adaptations to pregnancy

Preconception Care
Goals of preconception care include:
• To optimize the health of all women PRIOR to entering into pregnancy
• To identify / modify risk factors (medical, behavioural, social) in order to improve health prior
to conception
Components of preconception care include
• Health Promotion
• Risk assessment and interventions

Conception & Implantation

- Conception (fertilization): the union of a single egg (ovum) and sperm (spermatozoon), which
marks the begging of pregnancy
- Fertilization usually oculars in the outer third portion of the fallopian tube (fertilized ovum is
called a “zygote”)
- An ovum is capable of fertilization for only 24 - 48 hours
- A spermatozoon’s function lifespan is 48 - 72 hours
- It takes 90 seconds for sperm to reach the cervical opening; 5 minutes to reach the fallopian
tube
- As the zygote migrates toward the uterus over the next 3 - 4 days it undergoes very rapid
mitotic cell division and eventually evolves into what is known as a “blastocyst”
- The blastocyst flats freely inside the uterine cavity before it eventually attaches itself to the
uterine endometrium within 8 - 10 days after fertilization
- Once the blastocyst is implanted successfully, it is referred to as an “embryo” for the next 8
weeks
- After 8 weeks, the embryo is then referred to as a “fetus”
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Health Promotion: Things to Avoid During Pregnancy

- Shellfish and some sea foods - Folic acid deficiency
- Undercooked meat, fish, poultry - Medications (including some vitamins, herbal
- Unpasteurized milk products / soft cheeses preparations, essential oils used in
aromatherapy
- Unwashed fruit / vegetables - Chemicals
- Excessive amounts of caffeine - Hot tubs, jacuzzis, saunas
- Herbal teas - Radiation
- Alcohol - Viruses (ie, rubella)

Embryonic and Fetal Structures

1. The placenta
2. The membranes
3. Amniotic fluid
4. Umbilical cord
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1. The Placenta
• Chorionic Villi attach placenta to uterine wall
• Serves as the lungs, kidney, and digestive tract
• Continues to grow throughout the pregnancy. At the end of 38 - 40 weeks, the placenta usually
is approximately 15 - 20 cm in diameter and 2 - 3 cm in depth. It covers about half of the
mineral uterine wall, and weighs approximately 400 - 600 gm (1 pound)
• Oxygen and nutrients osmose from the maternal blood to the embryo through the placenta
• Most substances (including alcohol and nicotine) are able to cross from maternal blood to the
fetal circulation through the placenta
• There is no direct enhance of blood between the embryo and the mother during pregnancy
• Blood flow through the placenta increases with gestation (i.e., is approximately 50ml/min at
10 weeks and approximately 500-600ml/min at 40 weeks)
• Uterine perfusion, and this placental circulation, is most efficient when the women lies on her
left side. This position takes pressure off the inferior vena cava, preventing blood from being
trapped in the woman’s lower extremities. When lying on her back, pregnant women may
begin to experience supine hypotension
• A healthy placenta usually weighs approximately 400-600gm (1lb) at birth

2. The Membranes
• The chorionic membrane develops from the chorionic villi. It
is the outermost fetal membrane that serves to form a sac that
contains amniotic fluid
• There is also a second membrane lining the chorionic
membrane, known as the amniotic membrane
• At birth, these membranes (both fused together as one) can be
seen covering the fetal surface of the placenta, giving this
surface a shiny appearance.
• There is no nerve supply in this membrane, therefore, when they eventually rupture, neither the
mother or the infant experience any pain
• The amniotic membrane is involved in the production of amniotic fluid

3. Amniotic Fluids
• Is constantly being newly formed and reabsorbed by the amniotic membrane, so it never
becomes stagnant.
• The major method of absorption of amniotic fluid occurs because the cutis continually
swallows the fluid. This fluid is then reabsorbed into the fetal blood stream from the fetal
intestine
• Most women will have approximately 80-1200 ml of amniotic fluid at term
• Polyhydramnios (more than 200ml of fluid) can sometimes occur when a fetus is unable to
swallow the amniotic fluid (i.e., with esophageal atresia or anencephaly). It is also commonly
seen in women who are diabetics (hyperglycaemia causes excessive fluid shifts into the
amniotic space)
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• When the fetal kidneys begin to function, fetal urge also adds to the quantity of the amniotic
fluid. A disturbance of fetal kidney function may result in oligohydramnios (a reduction in the
amount of amniotic fluid to less than 300ml)
• The main function of amniotic fluid is to:
• (a) shield the fetus against pressure or blow to the mother’s abdomen,
• (b) protect the fetus from temperature changes,
• (c) acid in muscular development because it allows the fetus freedom to move, and
• (d) protect the umbilical cord from pressure, which in turn protects fetal oxygen supply

4. The Umbilical Cord

• Is formed from fetal embraces (i.e., the amnion and chorion) and provides a circulatory
pathway that connects the embryo to the chorionic villi of the placenta
• Its function is to transport oxygen and nutrients to the fetus from the placenta and to return
waste products from the fetus in the placenta
• The umbilical cord is approximately 53 cm (21 inches) long at term and about 2 cm (3/4 in)
thick
• Most of the cord is gelatinous (Wharton’s jelly). This jelly gives the cord body and prevents
pressure on the one vein and two arteries that pass through it
• The umbilical vein carries oxygenated blood from the placenta to the fetus (the umbilical vein
is easy to identify at birth, once the umbilical cord has been cut, since it is much larger in
diameter than the umbilical arteries)
• Both umbilical arteries carry deoxygenated blood from the fetus back to the placenta
• At birth, the umbilical cord is always assessed to confirm the presence of one vein and two
arteries. The presence of only one vein and one artery is sometimes associated with
chromosomal disorders and/or congenital anomalies (particularly of the kidney and heart)
• In approximately 20% of all births, a loose loop of cord is found around the fetal neck at birth.
This loop of cord is usually removed before the shoulders are born, so that there is no traction
on the cord, preventing oxygen impairment
• Constriction of the smooth muscle of the umbilical cord arteries after birth contributes to
homeostasis and helps prevent haemorrhage of the newborn through the cord
• There is no never supply in the cord; hence, it can be cut at birth without pain to the mother or
the baby.

Fetal Circulation
- Fetal circulation differs from extrauterine circulation because the fetus derives oxygen and
excretes carbon dioxide not from gas exchange in the lung but from gas exchange in the
placenta
- Blood arriving from the placenta to the fetus is highly oxygenated (carried through the
umbilical vein). This vessel is called a vein rather than an artery even though it us carrying
oxygenated blood. This is because it is carrying blood toward the fetal heart
- Blood is then shunted through specialized structures (i.e., ductus venous, foramen oval, ductus
arteriosus) to ensure that blood flows to the most important organs of the body first (i.e., brain,
liver, heart, and kidneys.)
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Fetal Maturation

Respiratory system
Neurological System
- Development of alveoli - Spinal cord disorders
- Breathing practice
- Surfactant
Musculoskeletal System
- Age of viability - Bone ossification
- Lung maturity and betamethasone - Fetal movements
Gastrointestinal System
Integumentary System
- Meconium - Lanugo
- Vitamin K synthesis - Vernix caseosa
Renal System
Immune System
- Urine excretion - Maternal antibioses and passive immunity
- Oligohydramnios

Important Developmental Milestones

- 24th week - active production of ling surfactant begins
- 24th week - is the “age of viability”, (the earliest age at which fetuses could survive if born at
that time)
- 28th week - lung alveoli begin to mature and surfactant ca be demonstrated in amniotic fluid
- 28th week - blood vessels of the retina are formed but thin of the retina are formed but thin
and extremely susceptible to damage from high oxygen concentrations (this is an important
condition when caring for preterm infant who need oxygen)

Obstetrical Terms
• Gravida: a women who is pregnant
• Multigravida: a women who has had two or more pregnancies
• Multipara: a women who has completed two or more pregnancies to 20 weeks of gestation or
more
• Nulligravida: A women who has never been pregnant
• Nullipara: a women who has not completed a pregnancy with a fetus beyond 20 weeks
• Postterm: a pregnancy that goes beyond 41 weeks gestation
• Preterm: a pregnancy that has reached 20 weeks gestation, but before completion of 37 weeks
gestation
• Primapara: a women who has completed one pregnancy with a fetus who reach 20 weeks
gestation or more
• Fullterm: a pregnancy between 37 weeks - 41 weeks gestation
• Viability: The capacity to live outside the uterus occurring about 22 - 25 weeks gestation
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Human Chorionic Gonadotropin (hCG)

- Produced by the placenta, hCG is often referred to as the pregnancy hormone
- Prevents menstruation and causes the endometrium to thicken and become highly vascular
during pregnancy
- Ensure that the corpus luteum of the ovary continues to produce progesterone and estrogen
- If the corpus luteum fails, progesterone levels will fall, causing the endometrial lying of the
uterus to slough off, which will result in a loss of the pregnancy
- Also suppresses maternal immunological system, this preventing the immune system from
recognizing the placental tissue and rejecting it as a foreign substance
- Found in maternal blood and urine as early as the first missed menstrual period, through to
about the 100th day of pregnancy
- Because this is the hormone analyzed by pregnancy tests, a false-negative result from a
pregnancy test may be obtained before or after this period
- At about the 8th week of pregnancy, the outer layer of cells of the developing placenta begin
to produce progesterone on their own, making the corpus luteum, which was producing
progesterone, no longer necessary. Hence, the production of hCG begins to decrease at this
time
- hCG levels are usually completely negative within 1 or 2 weeks after birth. The presence of
hCG in the maternal blood after this time may indicate that retained placental tissue is still
present in the uterus

Presumptive (Subjective) signs of pregnancy:

- are those that are least indicative of pregnancy
- Taken as single entities, they could easily indicate other conditions
- Some presumptive sigs of pregnancy include: breast changes, nausea, vomiting, amenorrhea,
frequent urination, fatigue, uterine enlargement, quickening linea nigra, melasma, striae
gravidarum

Probable signs of Pregnancy

- are subjective signs that can be documented by an examiner
- Generally, these are more reliable than presumptive signs, however, they still are not positive
or true diagnostic findings
- Some probable signs of pregnancy include Serum laboratory tests, Chadwick’s sign (color
change of the vagina from pink to violet), Goodell’s sign (softening of the cervix), Hegar’s
sign (softening of the lower uterine segment), ballottement, Braxton hicks contractions, fetal
outline felt by examiner.

Positive Signs of Pregnancy

- Leave no doubt of pregnancy
- They include things like evidence on an ultrasound of a fetal outline, audible fetal heart rate,
fetal movement felt by examiner
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Physiological Changes of Pregnancy

Uterine changes:
- Palpable at symphysis pubis at 12 weeks
- Reaches level of umbilicus at 20 weeks
- Grows in a constant fashion at a rate of approximately 1cm / week
- Lightening occurs at approximately 38 weeks
- Hedgar’s sign
- Ballotment
- Braxton Hicks
- Amenorea
- Cervical changes
- Goodell’s sign
- Chadwick’s sign

Ovarian Changes:
- Ovulation ceases

Breast Changes:
- Breast tenderness

Muscle and Skin Changes:

- Diastasis
- Straie gravidarum
- Linea nigra
- Melasma (chloasma)

Cardiovascular Changes:
- Cardiac output, blood volume and heart rate
- Peripheral blood flow changes

Respiratory Changes:
- Nasal congestion
- Shortness of breath

Body Temperature:
- Slight decrease due to hormonal changes

GI Changes
- Nausea/vomiting
- Gastric reflux/heartburn
- Hypertrophy and bleeding of gums
- Increased saliva production
- Decreased pH of saliva
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Urinary Changes:
- Fluid retention
- Urinating frequently

Skeletal Changes:
- Change in center of gravity while ambulating leads to postural changes
- Back pain

Estimated Date of Birth (EDB)

• 38 - 42 weeks gestation is considered a normal gestational period
• Gestational age wheels or birthdate calculators are available
• Nagele’s Rule: Count backward 3 calendar months from the first day of the last menstrual
period and add 7 days (e.g., if the last menstrual period began May 15, count back 3 months
(February 15), and add 7 days, to arrive at a EDB of February 22).

Nutritional Health During Pregnancy

- When promoting nutritional health remember to stay positive… Comment on what is being
done correctly rather than criticizing what is being done wrong
- Offer lots of positive reinforcement
- Use words like “foods that are best for you during your pregnancy” instead of “your
pregnancy diet”
- Average weight gain during pregnancy is 11 – 16 kg (25 – 35 lb.)
- Normal weight gain occurs at approximately 0.4 kg (1 lb.) / month during the first
trimester, and then 0.4 kg (1 lb.) / week during the last two trimesters (i.e., 3 lb. – 12 lb. –
12 . lb.)
- If overweight, no dieting during pregnancy please!
- If underweight, will need to gain slightly more than the recommended 3 – 12 – 12.
- Multiple pregnancies: Weight gain is higher (approx. 40-45 lbs)
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The High Risk Pregnancy

Lecture 3 - September 31, 2022

High Risk Pregnancy: When the life or health of the mother and/or fetus is jeopardized during
pregnancy

- Although most pregnancies and births are considered low risk, there are still some births that
are categorized as high risk due to maternal or fetal complications
- To prevent morbidity and mortality, timely identification of these risks, along with timely
implementation of appropriate interventions, is required

Adenatal Care Recommendations

- Woman who are planning to conceive should visit a pre-conception clinic prior to becoming
pregnant
- Once pregnant, first antenatal visit should be done as soon as possible so risk factors that
adversely affect the pregnancy can be identified early
Prenatal Visits should be regular:
• 0-28 weeks (every 4 weeks)
• 28-36 weeks (every 2 weeks)
• 36 weeks (weekly, until delivery)
During each visit:
• Weight
• BP
• Fundal Height
• Fetal Heart Rate
• Urine for protein and glucose
• Review of any other problems/concerns woman and her family may have

The First Antenatal Visit

Health history interview
- First day of the last menstrual period
- Normal signs of pregnancy (ie nausea/vomiting, fatigue, breast tenderness, etc)
- Home pregnancy test results / serum HcG test results
- History of medical problems that may affect the pregnancy (i.e. sexually transmitted diseases,
hypertension, diabetes etc.)
- Nutritional Status
- Exercise patterns
- Smoking history
- Alcohol consumption
- Medication intake
- Pregnancy history (i.e G= number of times the woman become pregnant; P = number of living
children; history of spontaneous/therapeutic abortions, preterm births, etc.)
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Routine Laboratory Assessments

- Pap smear
- Complete Blood Count (CBC)
- White Blood Cell (WBC)
- Platelet count
- Blood grouping with Rh factor
- Serum alpha fetoprotein
- Antibody titters for rubella and hepatitis B
- Glucose tolerance test
- Urinalysis
- An early ultrasound may also be done to confirm the expected date of delivery

Antenatal testing for High risk Pregnancy

- The purpose of this testing is to monitor for complications that could result in any fetal
compromise
- There are many screening tests available (some of these are non-invasive and others are more
invasive)

Adenatal Testing for High Risk Pregnancy

First Trimester:
- Ultrasound between 11-14 weeks to examine Nuchal
Translucency (NT)
- Serum tests (I.e., pregnancy-associated plasma protein-A
(PAPP-A); Beta-hCG)
Second Trimester
- Ultrasound (18-22 weeks gestation): to asses gestational age,
fetal anatomy, fetal growth, screen for open neural tube
defects (NTD’s) and overall fetal well-being
- Serum Coombs Test (to screen for Rh incompatibility)
- PRN Amniocentesis after 14 weeks (I.e., to test for NTDs, R/O genetic disorders, assess fetal
lung maturity, diagnose fetal hemolytic disease, meconium)
- Percutaneous Umbilical Blood Sampling (PUBS)
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Third Trimester:
- Fetal movement routing
- Non-stress test (NST)
- Contraction Stress Test (CST)
- Biophysical Profile (BPP)

Gestational Conditions
- There are many disorders that can develop during pregnancy, which can place the woman and
her fetus at serious risk
- The next several slides will provide you with a brief overview of the disorders listed below
- Pre-eclampsia
- Gestational diabetes mellitus
- Hyperemesis Gravidarum
- Ectopic Pregnancy
- Placenta Priva
- Placental Abruption Rh incompatibility

Pre-eclampsia / Eclampsia
• A serious condition that affects about 5% of pregnant
women, and typically starts after 20 weeks gestation
• Elevated BP is the primary symptom, but there may be other
symptoms such as protein in the urine, liver or kidney
abnormalities, persistent headaches, or vision changes
• Pre-eclampsia causes blood vessels to constrict, which can
result in reduced blood flow / injury to the liver, kidneys, brain, and uterus.
• Decreased blood flow to the uterus can lead to poor growth of the fetus, too little amniotic
fluid, placental abruption, or premature birth.
• Changes in blood vessel endothelial cells also causes capillaries to “leak” fluid into the
interstitial spaces. This results in fluid retention, rapid weight gain, and excessive swelling of
the face, arms, hands, legs, and feet.
• The condition can progress slowly or rapidly from mild symptoms to severe, life-threatening
Eclampsia (a convulsive state), if not diagnosed and treated promptly.
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Pathophysiology of Pre-eclampsia
- The spiral arteries of the uterus (located in the endometrium) play an important role in
providing blood flow to the growing placenta and fetus.
- Normally, the spiral arteries widen during pregnancy to increase blood flow to the placenta.
This widening is thought to be influenced by how well the trophoblast burrowed into the
uterus during the time of implantation. If the
trophoblast failed to implant correctly, the spiral
arteries will fail to widen, and instead, stay
narrow as the pregnancy progresses.
- Over time, this causes the placenta to become
very oxygen deprived. In response, the placenta
releases substances (i.e., pro-inflammatory
proteins) into the maternal circulation in an
attempt to increase blood flow to it.
- However, these substances are very toxic to
maternal endothelial cells (cells that line the
inside of blood vessels throughout the body and
organs).
- When the maternal endothelial cells become
damaged, vasospasm of the blood vessel walls
results. This causes the blood vessel to become
rigid and much narrower than normal, which leads to maternal hypertension.
- Damaged endothelial cells also result in an increase in permeability of the blood vessel wall.
This allows fluid from the vascular system to leak into the interstitial spaces.
- This leads to fluid retention, rapid weight gain, and excessive swelling / pitting edema of the
face, arms, hands, legs, and feet.

Signs and Symptoms of Pre-Eclampsia

- Hypertension: caused by vasospasm of the blood vessel walls
- Proteinuria: due to renal damage caused by hypoxia (glomerulus of the kidney does not
normally filter large molecules like protein. However, when it becomes damaged, the
glomerulus starts to leak protein from the blood into the urine
- Increase in Uric acid and creatinine levels: also due to kidney damage
- Decrease in urine output
- Edema (eyes, face, extremities, pulmonary edema, increase weight gain, cerebral edema)
- Cerebral edema leads to leads to headache, vision changes, hyperflexia, clonus (ie. irritable
muscle cramps/twitching) if this is present there is a high risk for seizures due to CNS
irritability
- RUQ abdominal pain be present due to decreased perfusion and swelling of the liver
- Severe pre-eclampsia can lead to another consdione known as HELLP syndrome, eclampsia
(seizures), placental abruption, and fetal death
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Nursing Interventions for Pre-eclampsia / eclampsia

- Check urine protein at every prenatal visit
- Monitor deep tendon reflexes (patellar and bicep) for hyper-reflexia (4 + reflexes indicate that
the CNS is stressed out and at risk for seizures)
- Asses neurological status, vision changes, headaches, ankle clonus
- Administer Magnesium Sulfate as prescribed, to decrease the risk of seizure activity
- If receiving Magnesium Sulfate, watch for decreased or absent reflexes, as this could indicate
Magnesium Sulfate Toxicity (have Calcium gluconate on hand – antidote for magnesium
sulfate toxicity)
- Check blood pressure at every prenatal visit, and educate mother to monitor BP at home if
possible
- Monitor peripheral edema
- Monitor urinary output
- Assess lungs for pulmonary edema, shortness of breath
- Encourage mother to assume left side lying position to improve placental perfusion
- Monitor for seizure activity (eclampsia) for up to 48 hours after delivery
- Take seizure precautions (i.e., suction equipment at bedside, padded side rails, etc.)
- If seizure occurs: stay with the patient, call for help, don’t restrain the patient, position patient
on left side to prevent aspiration, administer oxygen 8 – 10 liters via mask, fetal monitoring
- Protein rich diet
- Strick Intake / output monitoring (may need a Foley catheter)
- Administer antihypertensive medications as prescribed (i.e., hydralazine)

Gestational Diabetes Mellitus

Pathophysiology:
• Gestational diabetes mellitus is a condition whereby a hormone made by the placenta prevents
the body from using insulin effectively.
• As a result, glucose accumulates in the blood instead of being utilized by the body’s cells.
• Unlike type 1 diabetes, gestational diabetes is not caused by a lack of insulin. Rather, it is
caused by other hormones produced by the placenta (i.e., estrogen, cortisol, human placental
Lactogen) during pregnancy that can make insulin less effective (i.e., causes an insulin
resistance).
• Normally, the maternal pancreas is able to make additional insulin to overcome this insulin
resistance, but when the production of insulin is not enough to overcome the effect of the
placental hormones, gestational diabetes results.
• Symptoms of diabetes usually begin to appear at about 20 – 24 weeks gestation, and will
continue to be present until the placenta is eventually delivered.
• Because gestational diabetes is caused by hormones that are only produced during pregnancy,
the diabetic symptoms will disappear very soon after delivery.
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Nursing Care and Possible Complications

• Keeping blood glucose levels within a normal range is the primary goal of care.
• This is accomplished by encouraging a diabetic diet, regular exercise, daily blood glucose
monitoring, and insulin injections.
Possible Complications for the Baby:
• Macrosomia: Refers to a baby who is considerably larger than normal for their gestational age
(LGA). In response to maternal hyperglycemia, the fetal pancreas goes into overproduction to
cope with the excess glucose. This excess glucose is then converted to fat by the fetus, which
causes the fetus to grow excessively large.
• Hypoglycemia: Refers to low blood sugar in the baby immediately after delivery. This problem
occurs if the mother’s blood sugar levels have been consistently high, causing the fetus to have a
high level of insulin in its circulation. After delivery, the baby continues to have a high insulin
level, but it no longer has the high level of sugar supply from the mother. This results in the
neonate’s blood sugar level becoming very low. If the neonate’s blood sugar level drops to low, it
may be necessary to administer glucose either as an oral solution or IV within the first few hours
after birth

Hyperemesis Gravidarum
Pathophysiology
• This is an extreme condition that causes long-lasting intense nausea, vomiting, and weight loss
during pregnancy.
• It is different than the usual morning sickness that occurs during pregnancy in that the
symptoms are intense and persistent, leading to weight loss, dehydration, and electrolyte
imbalances.
• Usually develops during the 4th – 6th weeks of pregnancy and may last throughout the majority
of the pregnancy. The nausea is continuous and women who are suffering from the illness are
frequently exhausted over time, which considerably influences their daily life.
• While the exact cause of this disorder is not fully understood, it is thought to be related to the
rapid rise in hCG levels.
• Complications that may arise from excessive vomiting include dehydration, renal impairment,
malnutrition, and electrolyte imbalance.

Signs and Symptoms

• Dehydration (dark urine,
dry skin)
• Dizziness /
Lightheadedness
• Weight loss
• Excess salivation
• Increased heart rate
• Jaundice
• Low blood pressure
• Depression / anxiety
Treatment:
◦ Keep NPO to give GI system a rest
•Constant nausea and
◦ Bed rest
vomiting
◦ IV fluids to restore hydration and
•Loss of appetite
•Sleep disturbances electrolytes
◦ Total parental Nutrition (TPN) if unable
•Hyper olfaction
•Dysgeusia (taste to tolerate food or fluids
◦ Prenatal vitamins (may help to decrease
disorder)
•Decreased gustatory nausea)
◦ When food is tolerated, eat small,
discernment (decreased
perception of taste) frequent, bland, and dry meals (i.e.,
crackers)
◦ Avoid things that may trigger nausea
(i.e., scents; tastes)
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Ectopic Pregnancy
• Is when implantation occurs outside of the uterine cavity (i.e., inside the fallopian tube, on the
surface of the ovary, inside the abdomen, or in the cervix)
• The most common site of an ectopic pregnancy is in a
fallopian tube.
• Often no symptoms at the time of implantation (i.e., there is
no menstrual flow, the woman may experience nausea and
vomiting, and a pregnancy test for HcG will be positive).
• However, at 6 – 8 weeks gestation, the embryo grows large
enough to rupture the slender fallopian tube, resulting in
tearing of blood vessels and severe intraperitoneal bleeding.
• When the fallopian tube ruptures, the woman may feel a
sharp, stabbing pain in one of her lower abdominal
quadrants at the time of rupture, followed by scant
vaginal spotting. The scant amount of vaginal bleeding can
be deceptive, as most blood may be expelled into the pelvic
cavity rather than into the uterus.
• The ectopic pregnancy may only be diagnosed once the woman begins to experience
hypovolemic shock (rapid thready pulse, rapid respirations, decreased blood pressure, pale,
cool clammy skin), hence why all ectopic pregnancies are considered an emergency.

Management of Ectopic Pregnancy

• Ectopic pregnancy is considered to be a life-threatening obstetrical emergency. If not
recognized and treated swiftly, the moment the woman arrives in the emergency department,
outcomes will be poor.
• Establishing IV access with a large bore needle is a priority, as the woman will most likely
require IV fluids to increase intravascular volume.
• Blood transfusions will also most likely be required, therefore, taking a blood sample on
admission for blood typing and cross-matching is also a priority. This blood sample would
also be used to assess the woman’s hemoglobin levels to determine her current anemia status.
• If the ectopic pregnancy has not yet ruptured the fallopian tube, medications such as
methotrexate and mifepristone may be given, as a way of avoiding surgical intervention that
would ultimately destroy the fallopian tube and potentially lead to permanent infertility for the
woman.
• Methotrexate (a chemotherapeutic agent), destroys rapidly growing cells such as the
trophoblast and the zygote. The medication is administered at intervals, until a negative HcG
titer is produced.
• Mifepristone causes sloughing off of the tubal implantation site.
• Both of these medications would leave the fallopian tube intact, with no surgical scarring.
• If medication therapy is not effective, and the fallopian tube eventually ruptures, surgical
intervention would be performed. In some cases, surgery can be done via laparoscopy,
whereby damaged blood vessels can be ligated, and the damaged fallopian tube can be
removed.
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Placenta Previa
• A condition when the placenta is implanted abnormally in the uterus. It is the most common
cause of PAINLESS BLEEDING in the third trimester of pregnancy.
• Occurs in various degrees:
• Low lying placenta (placenta is implanted in the lower portion of the uterus but does not
cover the cervical os)
• Marginal implantation (placenta edge approaches the cervical os)
• Partial placenta previa (placenta occludes a portion of the cervical os)
• Total placenta previa (i.e., totally obstructs the cervical os)

• Most often diagnosed early during the first fetal ultrasound. When diagnosed, the mother
should be advised to AVOID COITUS, to get adequate rest, and to call her health care
provider at any sign of vaginal bleeding.
• Bleeding usually starts to occur in the 30th week of gestation

Management of Placenta Previa

• This is an obstetrical emergency due to the high risk for maternal hemorrhage and reduced
fetal oxygen supply.
• Place on immediate bed rest in a side-lying position.
• Assess perineum for bleeding to estimate blood loss.
• Weigh perineal pads before and after use to determine vaginal blood loss.
• NEVER attempt a pelvic or rectal examination with painless bleeding (may agitate the cervix
and cause massive hemorrhage which can be fatal to mother / fetus
• Depending on the location of the placenta, and the degree of cervical os involvement, vaginal
birth may still be possible.
• If the cervical involvement is greater than 30%, and the fetus is mature, the safest birth method
is cesarean birth.
• If labour has begun, bleeding is continuing, or the fetus is being compromised, birth must be
accomplished regardless of gestational age.
• If the bleeding stops and mother / fetus are stable, and the fetus is not yet 36 weeks of age, may
be managed by expectant watching (i.e., hospitalized, placed on complete bed rest, and
observed continuously for any signs of bleeding).
 19

• Betamethasone (a steroid that hastens fetal lung maturity), may be prescribed if the fetus is less
than 34 weeks.
• Birth must occur as soon as possible when:
• (1) the fetus reaches 37 weeks of age,
• (2) An amniocentesis analysis for lung maturity shows a positive result (i.e., favorable
lecithin-sphingomyelin ration (L/S ratio),
• (3) bleeding occurs again,
• (4) labour begins, or
• (5) the fetus shows symptoms of distress.
• After birth, the mother monitored carefully for:
• (1) post-partum hemorrhage (because the lower segment of the uterus does not usually
contract as efficiently as the upper segment), and
• (2) endometritis (because the placental site is close to the cervix, the portal of entry for
pathogens.

Placental Abruption (Premature Separation of the Placenta

• Placental abruption occurs in about 10% of pregnancies and is the most frequent cause of
perinatal death.
• Separation of the placenta usually occurs late in pregnancy, as late as during the first or second
stage of labour.
• It is therefore, always important to be alert to the amount and kind of vaginal bleeding a
woman is having while in labour
• The primary cause of premature separation is unknown, but certain predisposing factors have
been identified, including:
• High parity
• Advanced maternal age
• A short umbilical cord
• Chronic hypertensive disease
• Pregnancy-induced hypertension (PIH)
• Direct trauma (i.e., car accident or intimate partner abuse)
• Vasoconstriction from cocaine or cigarette use
• Chorioamnionitis (an infection of the fetal membraned and fluid
• Rapid decrease in uterine volume as occurs with sudden release of amniotic fluid
• This is also considered an obstetrical emergency, when bleeding is severe, and/or when fetal
status is compromised
 20

Signs and Symptoms

• Vaginal bleeding: Varies in amount. Sometimes bleeding may be concealed behind the
placenta. Thus, THE ABSENCE OF VAGINAL BLEEDING SHOULD NOT BE USED TO
RULE OUT PLACENTAL ABRUPTION.
• Abdominal / uterine tenderness or rigidity and back pain (occurs suddenly and is sometimes
very severe. Pain is often described as being sharp, stabbing, and located at the top of the
uterus
• Hypertonic uterine contractions, usually continuous in nature with one contraction coming
after another, without any rest period in between contractions.

Nursing Care During Placental Abruption

• Assess the patient’s vital signs, O2 saturation, and skin colour
• Observe for signs of hypovolemic shock (anxiety, loss of consciousness, etc.)
• Continuous fetal heart rate monitoring
• Assess uterine tone and presence of contractions
• Assess for abdominal or low back pain (pain is often high on the uterine fundus, and described
as a sharp, stabbing pain)
• Assess vaginal bleeding (note that bleeding may not always be present)
• IV access with a large bore needle. Group and x-match and have blood available for
transfusion if needed
• Place the patient in a lateral of left-side lying position to prevent pressure on the vena cava
• Avoid vaginal exams or any procedures that may disturb the injured placenta (i.e., insertion of
speculums, etc. may cause profuse bleeding)
• Administer O2 via mask to maintain oxygenation of mother and baby
• Administer IV fluids and blood or blood products as prescribed
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Rh Incompatibility
• Rh incompatibility occurs when an Rh-negative mother carries a fetus with an Rh positive
blood type
• There is usually no connection between fetal blood and maternal blood during pregnancy, so
the mother should not be exposed to fetal blood.
• However, if a villus ruptures, small amounts of fetal blood can occasionally enter the maternal
circulation.
• When this happens, the mother will develop Rh + antibodies. These antibodies will then attack
the fetus as though the fetus was a foreign invasion.
• To reduce the number of maternal Rh antibodies being formed (which could negatively affect
all future pregnancies), the woman is given an Rh immune globulin shortly after birth (i.e.,
RhoGam)

RhoGram is routinely given as follows

• 1 dose at 26 – 28 weeks gestation (given to all Rh negative women)
• 1 dose within 72 hours post-partum if baby is Rh positive
• 1 does may also be given in the event of any abdominal trauma during pregnancy, that might
increase the risk for mixing of maternal fetal blood (i.e., amniocentesis, chorionic villi
sampling, umbilical blood sampling, ectopic pregnancy, placental abruption, threatened
abortion, etc.).
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Factors Affecting Labour “The Five P’s”

1. Passenger (fetus and placenta)
2. Passageway (birth cancel, including pelvis and surrounding maternal soft tissues)
3. Powers (uterine contractions and pushing efforts)
4. Position (material position during labour and birth)
5. Psychological Response (maternal psychological status)

(1) The Passenger: Movement of the passenger (I.e the fetus) is determined by several
interacting components including:

Size of the fetal head

- The fetal skull is composed of two parietal bones, two
temporal bones, the front bone and the occipital bone
- These bones are joined together by membraneous sutures
(sagittal, lambdoidal, coronal and frontal)
- Membrane filled spaces called fontanels are located where the
sutures intersect. The two most prominent frontages are: 1-
the anterior fontanel (diamond shaped; closes at around 18
months) 2- the posterior fontanel (triangle shaped; closes at
approximately 6-8 weeks of age)
- Sutures and fontanels make the skull flexible to accommodate
the infant brain, which continues to grow for some time after
birth
- Because the bones are not firmly united, slight overlapping of
the bones, or molding of the head, occurs during labour. Molding can be extensive, but the
head of most newborns will return to normal within approximately 3 days after birth

Fetal presentation
- The term presentation refers to the part of the fetus that enters the pelvic inlet first and leads
through the birth canal during labour
- The three main presentations are: 1- cephalic (head first) 2- breech (buttocks or feet first) and
3- transverse (shoulders first)
- The term presenting part refers to the part of the fetal body that is first felt by the examining
finger during a vaginal examination (I.e. cephalic presentation - presenting part is usually the
occiput; breech presentation - usually the sacrum; should presentation- scapula)
 23

Fetal lie
- This refers to the relation of the spine of the fetus to the spine of the mother
- There are 3 primary lies:
1. Longitudinal (vertical) (spine of the fetus is parallel with mother’s spine
2. Oblique (spine of fetus is diagonal to mother’s spine
3. Transverse (horizontal), or (spine of the fetus is either at a right angle to the mother’s
spine)
- Birth cannot occur if the fetus remains in a transverse lie

Fetal attitude
- Refers to the relation of the fetal body parts to one
another (posture)
- Normal attitude (general flexion): back of the
fetus is rounded, chin is flexed on the chest, thighs
are flexed on the abdomen, and legs are flexed at
the knees, arms are crossed over the thorax, and
the umbilical cord lies between the arms and the
legs
- Any deviation from the normal attitude can pose
problems during the labour / birth process

Fetal Position
- This refers to the relation of the presenting part to the
four quadrants of the mother’s pelvis
- The first letter of the abbreviation indicated location of
the presenting part in the right (R) or left (L) side of the
mother’s pelvis
- The second letter stands for the specific presenting part
of the fetus (O = occiput; S = sacrum; M = mentum; and
Sc = scapula)
- The third letter stands for the location of the presenting
part in relation to the anterior (A), posterior (P), or
transverse (T) portion of the paternal pelvis.
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(2) The passageway

- This refers to the birth canal. It is composed of the
mother’s rigid bony pelvis and the soft tissues of the
cervix, pelvic floor, and vaginal canal and vaginal
opening.
- The bony pelvis plays a major role in the labour process
because the fetus must successfully accommodate itself to
this relatively rigid passageway
- The pelvic cavity varies in size and shape in all women.
The most common types of pelvis’ are 1 - the gynecoid
pelvis (classic female type, most favourable shape for
birthing); 2 - android pelvis (resembling the male pelvis);
3 - Anthropoid (anthropoid apes), and 4 - Platypelloid
(flat pelvis)
- Soft tissues of the passageway include the lower uterine
segment, cervix, pelvic floor muscles, vagina, and introitus. Uterine contractions cause the
lower segment of the uterus to thin out gradually distended to accommodate the fetus.
Contractions originate in the upper portion of the uterus, exerting a downward force on the
fetus, pushing it against the cervix. As this happens, the cervix gradually thins (effaces) and
dilates (opens).

(3) The Powers

- Involuntary powers (primary powers) and voluntary powers (secondary powers) combine to
expel the fetus and the placenta from the uterus
- Uterine contractions (primary power) signal the beginning of labour. Contractions originate in
the upper uterine segment and move downward over the uterus in waves, separated by short
rest periods. Contractions are measured/described according to frequency, duration and
intensity.
- Once the cervix is completely dilated, bearing down efforts (voluntary power) by the woman
can help to augment the force of the involuntary contractions
 25

(4) Position of the Labouring Women

- Position affects the woman’s anatomical and physiological adaptions to labour
- Frequent changes in position receive fatigue, increase
comfort, and improve circulation
- A labouring woman should be encouraged to find positions
that are most comfortable to her
- An upright position is advantageous in that gravity can
promote the descent of the fetus
- Uterine contractions are generally stronger and more
efficient in effacing /dilating the cervix when upright,
resulting in a shorter labour.
- Upright positions also improve blood flow to the mother /
fetus, by preventing compression on the descending aorta
and ascending vena cava
- If a women which to lie down, the lateral position is
suggested
- An “all fours” position can sometimes help relieve back
pain
- Positioning for a second stage of labour may be determined by the woman’s preference

(5) Psychological Response

- The primary goal here is to preserve the family’s psychological outlook, so that labour is later
on viewed and remembered as a positive experience
- The term “psychological response” refers to the psychological state or feelings that a women
brings with her into labour. For most women, this is a feeling of apprehension, excitement and
fear
- Typically, women who do best tin labour are those who have a strong sense of self-esteem and
a meaningful support person with them (this helps them feel in control of circumstances)
- Post traumatic stress syndrome can develop in women as a result of having an extremely
frightening and stressful experience, with inadequate support throughout
- Encouraging women to ask questions at prenatal visits, and encouraging them to attend
preparation for childbirth classes can certainly help prepare them for labour
- As well, encouraging women to talk about their experience after labour helps to debrief,
which will facilitate them in being able to integrate the experience into their total life (rather
then trying their best to forget everything)

Mechanisms of Labour
- Passage of a fetus through the birth canal involves several different position changes, termed
the cardinal movements of labour, which include the following:
- Engagement & Descent (i.e., the downward movement of the biparietal diameter of the fetal
head to within the pelvic inlet),
- Flexion (i.e., when the head reaches the pelvic floor it bends forward onto the chest),
 26

- Internal Rotation (i.e., the head flexes as it touches the pelvic

floor, and the occiput rotates to bring the head into the best
relationship to the outlet of the pelvis),
- Extension (when the occiput is born, the back of the neck stops
beneath the pubic arch and acts as a pivot for the rest of the
head)
- External Rotation (after the head is born, the head rotates back to
the diagonal or transverse position) and
- Expulsion (once shoulders are born, the rest of the baby is born
easily and smoothly).

Preliminary Sings of Labour

- Lightening: Decent of the fetal presenting part into the pelvis occurs approximately 10 – 14
days before labour begins in primiparas. The fetal decent changes a woman’s abdominal
contour by positioning the uterus lower and more anterior in the abdomen. This gives relief
from diaphragmatic pressure and shortness of breath. Lightening occurs later in multiparas
(i.e., on the day of labour or even after labour has begun). Shooting leg pains from increased
pressure on the sciatic nerve, increased vaginal discharge, and urinary frequency from pressure
on the bladder are often associated with lightening.
- Increase in Level of Activity: Awaken full of energy instead of feeling chronically fatigued.
This is related to a hormone shift (i.e., an increase in epinephrine release caused by a decrease
in progesterone production from the placenta). Increased energy prepares the woman’s body
for the work of labor ahead.
- Slight Loss of Weight: Body fluid is more easily excreted with falling progesterone levels.
Weight loss between 1 – 3 lbs is not unusual.
- Braxton Hicks Contractions (False Labor): Extreme contractions experienced during the last
week or a few days before labor begins. It is often difficult to distinguish these between true
labour.
- Ripening of the Cervix: This is an internal sign that is seen only on pelvic examination. It is
an indicator that labor is very close at hand. Throughout pregnancy, the cervix feels softer
than normal to palpation, similar to the consistency of an earlobe (Goodell’s Sign). At term,
the cervix becomes still softer (i.e., butter soft), and begins to tip forward.

True Signs of Labour

- Uterine Contractions: Involuntary contractions that come without warning. They are first felt
in the lower back and then sweep around to the abdomen in a wave. Breathing exercises offer
some relief and a sense of well-being during the contraction.
- Show: Softening and ripening of the cervix leads to expulsion of the mucus plug that lled
the cervical canal during pregnancy.
- Rupture of the Membranes: Membranes sometimes rupture with the beginning of labour (but
not always). This is experienced as a sudden gush or as scanty, slow seeping of clear fluid
from the vagina. Early rupture of the membranes can actually shorten the duration of labour as
it helps the fetal head to descend into the pelvis and put pressure on the cervix (hence,
fi
 27

hastening the dilatation process). If membranes rupture before the fetal head is engaged in the
pelvis, prolapsed cord may result.

Stages of Labour: First Stage

First Stage of Labour (Latent Phase):
- Begins at the onset of regular contractions and ends when rapid cervical dilatation begins.
Contractions during this phase are mild and short (i.e., approx. 20 – 40 seconds). Cervical
effacement occurs and cervix may dilate from 0 to 3 cm. This phase usually lasts for
approximately 4 – 6 hours.
First Stage of Labour (Active Phase):
- Cervical dilatation occurs more rapidly, increasing from 4 to 7 cm. Contractions grow
stronger, lasting 40 – 60 seconds, and occur approx. every 3 – 5 minutes. This phase lasts
approximately 2 – 3 hours. This can be a difficult time during labour as contractions are more
frequent, intense and beginning to cause true discomfort. Much support is needed from others
during this phase. The woman should also be allowed to assume whatever position is most
comfortable for her during this time.
First Stage of Labour (Transition Phase):
- Contractions reach their peak of intensity, occurring every 2 – 3 minutes with duration of 60 –
90 seconds and cause maximum cervical dilatation of 8 to 10 cm. By the end of this phase,
both full dilatation and complete effacement have occurred.

Stages of Labour: Second Stage

- This stage takes about 1 hour. The woman begins to feel an overwhelming, uncontrollable
urge to push or bear down with each contraction. The woman often only barely hears the
conversation in the room around her, as all of her energy and thoughts are directed toward
giving birth.
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Stages of labour: Third Stage

- Third Stage of Labour: Two stages are involved: (1) placental separation, and (2) placental
expulsion.
- Placental Separation usually occurs approx. 5 minutes after birth. Signs that separation has
occurred include: Lengthening of the umbilical cord, sudden gush of vaginal blood, change in
the shape of the uterus, firm contraction of the uterus, and appearance of the placenta at the
vaginal opening.
- Placental expulsion can be either a “Shiny Schultze” or a “Dirty Duncan,” Normal blood loss
during the third stage of labor is approximately 300 – 500 ml.
 29

Stages of Labour: Fourth Stage

- Lasts about 1 or 2 hours after birth of the placenta. It is a period of immediate recovery, when
homeostasis is re established. It is an important period of observation for complications, such
as abnormal bleeding. The fourth stage of labour is also a time for bonding with the new baby
and initiation of breastfeeding.

Nursing Care During Labour

First Stage of Labour:

- Respect contraction time
- Promote change of positions
- Promote voiding and provide bladder care
- Offer support
- Respect and promote the support person
- Support woman’s pain management needs
- Amniotomy if warranted

Second Stage of Labour:

- Prepare the place of birth
- Positioning for birth
- Promoting effective second-stage pushing
- Perineal cleaning
- Assist with episiotomy if needed
- Assist during birth
- Cutting and clamping the cord
- Introducing the infant

Third & Fourth Stages of Labour:

- Placenta delivery
- Oxytocin administration
- Perineal repair
- Immediate post-partum assessment and nursing care of mother and neonate
- Aftercare

High Risk Labour and Birth

- Although labour often proceeds without any deviation from the normal, many potential
complications can occur.
- If a complication does arise, and assurances cannot be given freely, the family needs someone
who is knowledgeable about the deviation and its treatment.
- The family also needs a person (nurse) who understands their feelings of helplessness.
- Nurses play a key role in providing this type of skilled physical and emotional care.
 30

- Your textbook provides detailed information with regards to some of the more common
complications that you will see while working in a birthing center. Please review the
following in your text as there may be some questions on this in the future.
- Preterm Labour & Birth
- Post term Pregnancy, labour, and birth
- Induction of Labour
- Augmentation of Labour
- Caesarean Birth
- Vaginal Birth after Caesarean (VBAC)
31