In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of antepartal, intrapartal, postpartum, and newborn care in order to:

  • Assess client's psychosocial response to pregnancy (e.g., support systems, perception of pregnancy, coping mechanisms)
  • Assess client for symptoms of postpartum complications (e.g., hemorrhage, infection)
  • Recognize cultural differences in childbearing practices
  • Calculate expected delivery date
  • Check fetal heart rate during routine prenatal exams
  • Assist client with performing/learning newborn care (e.g., feeding)
  • Provide prenatal care and education
  • Provide care to client in labor
  • Provide post-partum care and education
  • Provide discharge instructions (e.g., post-partum and newborn care)
  • Evaluate client's ability to care for the newborn

Introduction to the Female Reproductive System

The internal organs and structures of the female reproductive system are the:

Uterus

Anatomically, the uterus is comprised of the endometrium which is the most inner layer of the uterus, the second layer of the uterus which is the myometrium and the perimetrium which encases the entire organ; and two major sections which are the body or corpus of the uterus and the cervix which is the lower part of it.

The uterus is an internal organ of female reproduction, however, it enlarges to the point that it becomes an abdominal organ at about the 12th week of gestation so that the growth of the fetus is accommodated.

In pregnancy and non pregnancy states, the cervix protects the internal environment of female reproduction from the exterior environment; during pregnancy, the cervix additionally protects the fetus. For example, during early pregnancy, a mucous plug is formed in the cervix to protect the developing fetus from the external environment.

Vagina

This internal organ of reproduction connects the exterior female reproductive system structures to the internal female reproductive organs and structures. It serves as a protection against infection during pregnancy because it produces high acidity; and the vaginal also becomes more vascular during pregnancy.

Fallopian Tubes

The fallopian tubes are the site of fertilization; after about 4 days after fertilization, the fertilized ovum moves from the trumpet like ampulla of the fallopian tube to the uterus, with the exception of ectopic pregnancies which abnormally maintain the fertilized ovum in the fallopian tube.

Ovaries

Unlike other organs of reproduction, the ovaries serve as both an endocrine organ and a reproductive organ.

Anatomically, the ovaries are comprised of the three distinct layers which from the outer most to the innermost layer, are:

  • The tunica albuginea
  • The medulla that contains ovarian circulation
  • The cortex which contains the corpora lutea, the ova and the follicles

The ovaries, as an endocrine organ, produce hormones such as progesterone and estrogen. These hormones play an integral part in the female's menstrual cycle, breast development, and the retention of a developing fetus during pregnancy.

Bony Pelvis

The bony pelvis which consists of two innominate bones which are the sacrum and the coccyx, and that, unlike other parts of the human's skeletal system, become more pliable and able to change in order to facilitate the movement of the fetus to the external world during labor and a vaginal delivery.

The external organs and structures of the female reproductive system are the:

  • Mons pubis
  • Urethral meatus
  • Vaginal vestibule
  • Labia minora
  • Labia majora
  • Clitoris and the
  • Perineal body

Conception

Conception and fertilization are complex processes that entail cellular division, gametogenesis, and chromosomal arrangement. A singular cell is formed at the time of fertilization with mitosis and meiosis; gametogenesis is the production of a single male sperm or a single female ova each of which has 23 pairs of chromosomes and, that, after fertilization form the zygote of 46 pairs of chromosomes. Females and males have a total of 23 pairs of chromosomes, two of which are sexually assigned autosomes and the remaining are not. Females have XX female chromosomal arrangements and males have XY chromosomal arrangements.

Maternal Physical Changes During Pregnancy

Some of the physical changes that occur during pregnancy include the presumptive, probable and positive signs of pregnancy, urinary system changes, circulatory system changes, endocrine system changes, gastrointestinal system changes, skin changes, respiratory system changes, skeletal changes, central nervous system changes, metabolic changes, and vital sign changes.

The presumptive signs of pregnancy are:

  • Urinary frequency
  • Fatigue
  • Amenorrhea
  • Nausea and vomiting which is referred to as morning sickness
  • Breast soreness
  • Darkened areolae
  • Large Montgomery glands
  • Uterine enlargement
  • Vaginal discoloration
  • Skin pigmentation changes and
  • Fetal movement which is referred to as quickening

The probable signs of pregnancy include:

  • Hegar's sign which is changes to the lower portion of the uterus
  • Abdominal enlargement
  • A positive human chorionic gonadotropin or HCG test
  • Braxton Hicks contractions
  • Chadwick's sign which is a blue tinge to the vagina and cervix
  • Gooddell's sign which is the softening of the cervix
  • The ability to palpate the fetus which is referred to as fetal ballottement and
  • Cervical and uterine changes in terms of consistency, size and shape

And, lastly, the positive signs and symptoms of pregnancy are:

  • Fetal heart tones
  • Ultrasound evidence of a fetus and
  • The objective assessment of fetal movement

Assessing the Client's Psychosocial Responses to Pregnancy

In addition to assessing the client's physiological changes and responses to pregnancy, the registered nurse also assesses the client's psychosocial responses to pregnancy including those relating to the mother's response to and perceptions of the pregnancy, the father's response to and perceptions of the pregnancy, the coping mechanisms used by the mother and father as they cope with this developmental and maturation change, the emotional preparedness of the parents for the pregnancy, and the support systems, including the mother's and father's familial support systems and their utilization of appropriate and available support systems in the community.

Many emotions and different perceptions can occur as a response to pregnancy. Some of these emotions include joy, fear, mood swings, anxiety, financial concerns, depression, and adverse emotional reactions to the bodily changes of pregnancy. The father may also have similar reactions. The emotions and perceptions can vary among clients and they can also vary according to the particular clients' specific situation.

It is believed that about 50% of all pregnancies are unplanned and it is known that single mothers, including teenage mothers, often become pregnant. Some mothers and fathers can successfully adapt to and welcome an unwanted pregnancy and others cannot. Stressful decisions such as those relating to abortion and adoption have to be supported by the nurse.

Social support systems are highly beneficial in terms of normal and abnormal coping with a pregnancy. Some women may have a lot of social supports during this maturational milestone in terms of family members and their spouse or partner and others may have little or no support. This is particularly true when the partner is absent and/or not welcoming of an unwanted pregnancy.

Assessing the Maternal Client For Antepartal Complications

Although most pregnancies are without complications, there are many pregnancies that are adversely affected with antepartal, intrapartal and postpartum complications. These antepartal complications will now be discussed.

As you will learn in this section maternal antepartal complications during the antepartal periods include:

Infections

All infections pose antepartal dangers and risks for the pregnant woman and the developing fetus.

Some examples of these infections are briefly discussed below:

HIV/AIDS

The mother's immunosuppression can lead to the development of other infections and this virus can infect the neonate perinatally as well as during breast feedings. The mother's treatment of HIV/AIDS continues as it did prior to the pregnancy and all procedures during pregnancy that can increase the risk of infection to the fetus are avoided whenever possible. Some of the invasive procedures and interventions that are avoided include episiotomy, amniocentesis, internal fetal heart monitoring, forceps deliveries, and vacuum extractions

Salpingitis and Endometritis

Salpingitis is an inflammation or infection of the fallopian tubes; this infection most often occurs as the result of untreated endometritis and it can lead to life threatening pelvic inflammatory disease, massive sepsis, tubo-ovarian abscesses and infertility.

Endometritis, an inflammation or infection of the uterine endometrium, most often occurs after a miscarriage, spontaneous abortion, after a planned abortion and as the result of another infection in the postpartum period of time.

Diminished bowel sounds, tachycardia, elevated white cells, a fever, abdominal tenderness and pain and foul smelling lochia are some of the signs and symptoms associated with endometritis and salpingitis.

Interventions, in addition to the administration of antimicrobial drugs such as clindamycin or gentamycin, can include fluid rehydration, and the symptomatic relief of the fever and abdominal pain.

Tubo-Ovarian Abscesses

Tubo-ovarian abscesses, often the result of acute salpingitis, can also occur as the result of other infections such as pelvic inflammatory disease after a delivery, abortions and spontaneous abortions. It, too, can lead to massive sepsis and death when left untreated.

Tubo-ovarian abscesses can be signaled with foul smelling lochia, a high fever, and the signs of peritonitis including abdominal and pelvic pain.

Intravenous broad scope antibiotics, fluid replacement, and electrolyte replacements, and hospitalization are typically indicated.

Gonorrhea

Gonorrhea can also be transmitted to the fetus in utero and also with delivery. The signs and symptoms of this sexually transmitted disease can include a yellowish - greenish vaginal discharge, dysmenorrhea, abdominal discomfort and dysuria. This infection can also be asymptomatic. Medications used for the treatment of gonorrhea include broad scope antibiotics such as ceftriaxone and azithromycin.

Chlamydia

Chlamydia, the most frequently occurring sexually transmitted disease, when symptomatic, can present with vaginal spotting, perineal itching and dysuria. During pregnancy, the woman is treated with amoxicillin or azithromycin for chlamydia.

Candida Albicans

This fungal infection most frequently occurs as the result of diabetes, the use of oral contraceptives and a recent course of antibiotic therapy. Candida albicans can also be transmitted to the neonate upon delivery.

Oral candida albicans is characterized with white-gray patches on the tongue and other oral surfaces; and vaginal candida albicans is characterized with a white vaginal discharge and genital redness. This infection is treated with over the counter clotrimazole or fluconazole.

Chorioamnionitis

Choriomnionitis results from a bacterial infection of the chorionic membranes and the fetal amnion. Choriomnionitis can occur as the result of a premature rupture of the membranes.

Choriomnionitis is associated with complications such as bacteremia, potentially life threatening sepsis, pelvic abscesses, fetal complications and postpartum hemorrhage.

Choriomnionitis can be signaled with signs and symptoms such as a maternal fever, maternal leukocytosis of > 15000 to 18000 cells/μL, maternal tachycardia, uterine tenderness and a purulent vaginal discharge. The fetal heart rate typically exceeds 160 beats per minute.

When immediate and intense intravenous antibiotic therapy is not successful, an emergency cesarean section may be necessary.

TORCH Infections

TORCH is an acronym for:

  • Toxoplasmosis
  • Other infections
  • Rubella
  • Cytomegalovirus
  • Herpes

The infections included in TORCH are clustered in this manner because all of these infections cross the normally protective placental barrier and as such, not only threaten the health and wellbeing of the pregnant woman, but they also serious threaten and jeopardize the growth and development of the developing fetus with the adverse teratogenic effects that all of these infections have. Because these infections pose such great dangers, immunological TORCH screening is often done to detect the presence of all of these offending infections among pregnant women.

The risk factors and the treatments of these TORCH infection vary according to the specific infection and the severity of each infection.

Toxoplasmosis can be contracted by handling of contaminated feline feces and from consuming meat that is not cooked enough; rubella is transmitted with contacts with someone with the disease when the host is not immunized against it; cytomegalovirus is spread via contact with bodily fluids, such as vaginal secretions, semen, blood, placental tissue, breast milk, and other bodily fluids; and, lastly, maternal herpes simplex infections occur as the result of direct contact with infectious genital or oral lesions, and the neonate is exposed to this infection during a vaginal delivery when the pregnant woman has infectious and active herpes simplex lesions on the genitalia at the time of delivery.

Group B Streptococcus B-Hemolytic Infection

Group B streptococcus B-hemolytic infections can also be transmitted to the fetus during the processes of labor and delivery.

Some of the risk factors associated with group B streptococcus B-hemolytic infections are a premature delivery, a low birth weight infant, a maternal history of group B streptococcus B-hemolytic infections, a premature rupture of the membranes, a maternal age of less than 20 years of age, and also secondary to invasive intrauterine fetal monitoring.

Intravenous amoxicillin and penicillin G are used for the treatment of group B streptococcus B-hemolytic infections and, at times, for the prophylaxis of these infections during pregnancy.

Toxic Shock Syndrome

Toxic shock syndrome, a staphylococcus aureus or streptococcal infection, can occur as the result burns, childbirth, surgical procedures, and other forms of trauma. Streptococcal toxic shock syndrome is typically more serious and life threatening than staphylococcus toxic shock syndrome and the former is often associated with systemic collapse.

The signs and symptoms of toxic shock syndrome include hypotension, skin desquamation of the palms of the hands, an erythematous skin rash, a high fever, altered levels of consciousness, nausea, vomiting and elevated nitrogen and creatinine levels.

The antimicrobial drugs of choice are a first generation cephalosporin or penicillin; however, those with a sensitivity to or allergy to these antimicrobials, can receive vancomycin or clindamycin. Additionally, hospitalization for treatments and closer monitoring of the pregnant woman may be indicated to prevent the high morbidity and mortality rates associated with toxic shock syndrome during pregnancy.

Urinary Tract Infections (UTI)

The greatest risk period for a urinary tract infection during pregnancy is from the 6th to the 24th week of pregnancy. The risk of urinary tract infections among pregnant women is greater than other populations because of the normal anatomical changes associated with pregnancy such as the increased size and weight of the uterus which can block the free flow of urine through the urinary tract.

The classical signs and symptoms of urinary tract infections, such as a fever, dark or grossly bloody colored urine, and pain occur.

The complications of urinary tract infections during pregnancy can affect the mother and the developing fetus. Some of these complications can include maternal hypertension, a low birth weight, preterm labor and possible renal damage. Levofloxacin, ampicillin and ciprofloxacin are typically the drugs of choice to treat these urinary tract infections when their effectiveness is confirmed with a urine culture and sensitivity.

Pyelonephritis

Pyelonephritis, most likely caused by E. coli, is a risk for the pregnant woman particularly when the woman is a diabetic and when they have a urinary tract infection, a urinary tract obstruction, bacteriuria, and/or chronic kidney disease.

Although some clients with acute or chronic pyelonephritis may be asymptomatic, most present with an elevated blood urea nitrogen level, malaise, dysuria, foul smelling urine, hematuria, increased white blood cells, a fever and decreased creatinine clearance.

Cardiac Disease

Cardiac diseases and disorders during pregnancy, similar to those in a non-pregnancy state, are associated with significant elevations in terms of morbidity and mortality rates. Even though cardiac diseases can preexist prior to pregnancy, some mothers develop cardiac disease during the course of their pregnancy since pregnancy increases the mother's cardiovascular demands because of the pregnancy.

Some examples of cardiac disorders that complicate pregnancy, in addition to preexisting and gestational hypertension, are:

  • All maternal, preexisting congenital heart disorders
  • Cardiomyopathy associated with left ventricular dysfunction
  • Pulmonary hypertension secondary to Eisenmengger syndrome which is left to right cardiac shunting
  • Rheumatic heart disease
  • Marfan syndrome, a genetic disorder that places the mother at risk for aortic dissection or rupture
  • Mitral valve prolapse

Although the symptoms may vary among pregnant clients, among the different cardiac disorders, and according to the severity of the cardiac disorder, some of the most common signs and symptoms experienced by the pregnant woman include fatigue, shortness of breath and dyspnea, chest pain, palpitations, and abnormal and adventitious breath sounds like rales.

Cardiac disease in classified according to its level of severity from Class I cardiac disease to Class IV cardiac disease with Class I cardiac disease as the least severe and Class IV cardiac disease as the most severe of all. Class I and Class II are associated with no limitations of symptoms with physical activity and symptoms with exertion. These classifications do not typically lead to maternal complications, however, Class III and Class IV cardiac disease may, particularly if left untreated, lead to maternal and fetal complications and even death. Class III cardiac disease is characterized with maternal cardiac symptoms with normal exertion and Class IV cardiac disease is characterized with maternal cardiac symptoms with rest and during periods of time without any physical activity.

Diabetes

Some pregnant women have diabetes prior to their pregnancy and other pregnant women develop gestational diabetes during the course of their pregnancy, but regardless of etiology diabetes during pregnancy is a complication for pregnant woman because all diabetes adversely affects glucose. The ideal blood glucose level is between 70 and 110 mg/dL during pregnancy.

As you should know, the commonly occurring risk factors associated with diabetes mellitus include obesity, a family history of diabetes and a high body mass index. Additional risk factors that place pregnant women at risk for gestational diabetes are an age at pregnancy of more than 25 years of age and a history of a stillborn or an infant who was large for gestational age. Research indicates that almost half of the women who develop gestational diabetes during pregnancy will have type 2 diabetes in the future.

Although many women with gestational diabetes may have the classical signs and symptoms of diabetes mellitus, such as urinary frequency and thirst, many others are asymptomatic. For this reason, all pregnant women are screened for the presence of diabetes.

The maternal complications of diabetes during pregnancy include:

  • Hypertension
  • Ketoacidosis
  • Infections resulting from elevated urinary glucose such as urinary tract and vaginal infections
  • Preeclampsia
  • Eclampsia

The fetal complications of diabetes, when not effectively treated, include:

  • Hydramnios
  • Hypoglycemia
  • Jaundice
  • Respiratory distress syndrome
  • Macrosomia which is excessive birth weight
  • Spontaneous abortion
  • Pre-term birth
  • Hypertension
  • Preeclampsia and eclampsia
  • Preterm Labor/Post term Pregnancy

Hypertension

Like diabetes, pregnant women can be adversely affected by hypertension that they have had prior to the pregnancy and they can also develop gestational hypertension during the course of their pregnancy, typically with its onset at or about the 20th week of pregnancy. Pregnant women less than 20 years of age and older than 40 years of age are more at risk for gestational hypertension than other women of other ages. Additional risk factors associated with gestational hypertension are diabetes, renal disease, a family history and/or a personal history of gestational hypertension, pregnancy with multiples, the mother's first pregnancy, and a molar pregnancy.

In terms of its severity, hypertension during pregnancy is classified as mild hypertension, mild preeclampsia, severe preeclampsia, and HELLP.

HELLP stands for:

  • H: Hemolysis which can lead to anemia
  • EL: Elevated liver enzymes
  • LP: Low platelet count which can lead to disseminated intravascular coagulopathy (DIC), thrombocytopenia and abnormal clotting

The treatment includes close medical monitoring and control including maternal life style choices such as diet and exercise. When indicated, antihypertensive medications, such as methyldopa, hydralazine, labetalol, and nifedipine, are used. Angiotensin II receptor blockers and ACE inhibitors are contraindicated in most cases.

Fetal complications associated with maternal hypertension include, among other things, premature delivery, a low birth weight and the complications that can result from maternal preeclampsia and eclampsia, as discussed immediately below.

Preeclampsia

Most often preeclampsia precedes eclampsia but this is not always the case. Preeclampsia typically has an onset after the 20th week of gestation and it is typically initially identified and assessed with the presence proteinuria and hypertension. The severity of preeclampsia and eclampsia and associated fetal and material complications are greatest when the preeclampsia, or eclampsia, emerge before the 35th week of gestation. Untreated and unmanaged, it may progress to life threatening eclampsia.

The risk factors associated with preeclampsia and the progression of preeclampsia to eclampsia are:

  • Diabetes
  • Obesity
  • Hypertension
  • Multiple gestations
  • Pregnancy after the age of 35 years of age
  • African American descent

In addition to proteinuria and hypertension, the signs and symptoms of preeclampsia can impact on virtually all bodily systems. These signs and symptoms are:

  • Gastrointestinal alterations such as vomiting and nausea
  • Hyperreflexia, headache, clonus and dizziness which indicate neurological alterations
  • Elevated serum transaminase and elevated liver enzymes which indicate altered hepatic functioning
  • Oligura, a creatinine level more than 90 µmol/L and proteinuria, as afore mentioned, indicate altered renal functioning
  • The emergence of hemolysis, a low platelet count, disseminated intravascular coagulation, thrombocytopenia and HELLP which indicate alterations in the mother's circulatory system
  • Other circulatory system changes such as edema
  • Right upper quadrant and epigastric pain
  • Respiratory changes as the result of pulmonary edema

Eclampsia

Of all the many possible complications of pregnancy, eclampsia is the leading cause of maternal death and poor fetal outcomes.

In addition to the signs and symptoms of preeclampsia, as listed immediately above, eclampsia is characterized with seizure activity that is not attributable or correlated with another cause such as hypoglycemia, central venous sinus thrombosis and/or an amniotic fluid embolus.

Some of the maternal complications associated with eclampsia are:

  • Seizures
  • Cerebral, hepatic and renal damage
  • Cerebral hemorrhage
  • Coma
  • Death

The possible fetal complications of eclampsia include:

  • Placenta abruption
  • Fetal demise
  • Abnormal fetal growth and development
  • Low birth weight
  • A premature delivery
  • Damage to organs such as the brain, liver and kidneys

Because of these serious fetal complications, the mother and the fetus are monitored on a frequent basis and, when the need arises, the preservation of fetal life may depend on an immediate delivery. Some of the interventions that can be indicated, as based on the current status and condition of the mother and the fetus, include monitoring the urinary output and expecting it to be at least 30 mL per hour, monitoring the maternal vital signs, assessing the mother's level of consciousness, checking maternal reflexes such as the deep tendon reflex.

The treatments for eclampsia, and some cases of preeclampsia, can include:

  • The administration of magnesium sulfate which is an anticonvulsant medication
  • The administration of corticosteroids which facilitates lung development for the fetus and better hepatic and platelet functioning
  • The administration of antihypertensive medications to control maternal hypertension and to prevent the complications associated with this hypertension
  • The restriction of fluid intake
  • Maintaining urinary output at 30 mL per hour
  • Bed rest as indicated
  • Labor induction or a planned delivery as indicated

Clients who are taking magnesium sulfate must be carefully monitored for the signs and symptoms of life threatening magnesium sulfate toxicity including a diminished level of consciousness, cardiac arrhythmias, respiratory depression, a urinary output of less than 30 mL per hour and neurological deficits such as an absent patellar deep tendon reflex response.

Magnesium sulfate toxicity is treated with the immediate cessation of the magnesium sulfate IV, and the administration of calcium gluconate which is the antidote for magnesium sulfate.

Preterm Labor

Preterm labor, technically defined, is the occurrence of true uterine contractions and the emergence of cervical changes characteristic of the full term changes with a full term delivery, between the 20th and 37th weeks of gestation.

Some of the risk factors associated with preterm labor including, but not limited to:

  • A lack of adequate prenatal care
  • Diabetes
  • Hypertension
  • Multiple gestations
  • Substance use and abuse
  • Maternal age < 17 years of age or > 35 years of age
  • Uterine abnormalities
  • Hydramnios
  • Infections, such as chorioamnionitis and others, that adversely affect amniotic fluid
  • Multiple pregnancies in rapid succession
  • A previous history of spontaneous abortions, preterm births or miscarriages

The signs and symptoms of preterm labor are the same as those of true, full term labor, as will be discussed in a subsequent section of the NCLEX-RN review.

The goals of the treatments for preterm uterine contractions and cervical changes are to cease preterm labor and maintain the pregnancy for as long as possible. Some of the treatments and interventions for preterm labor include:

  • Activity restriction
  • Positioning on the left lateral position to decrease uterine activity
  • Insuring hydration to prevent oxytocin release which stimulates contractions
  • The administration of medications such as nifedipine or indomethacin to suppress contractions, and magnesium sulfate to relax smooth muscle and to suppress contractions
  • The administration of betamethasone to stimulate fetal lung surfactant production and to enhance fetal lung maturation

Post Term Pregnancy

A post term pregnancy is defined as a pregnancy that lasts more than 294 days and WITHOUT any miscalculations of the due date of delivery. Post term pregnancies can result from a number of different factors and forces including, but not limited to, fetal anencephaly, a placental sulfatase deficiency, and maternal primiparity.

The fetal complications associated with a post term pregnancy are oligohydramnios, the aspiration of meconium, umbilical cord compression, a higher than normal mortality rate, birth trauma, and shoulder dystocia.

Post term pregnancy does not typically lead to any maternal complications other than a more difficult labor and delivery because of the typically large size and weight of a post term baby.

Subchorionic Hematoma

A subchorionic hematoma occurs when there is a blood clot between the membranes of pregnancy and the wall of the uterus that separates and leads to maternal bleeding.

Although a rare complication of pregnancy, the signs and symptoms of a subchorionic hematoma include vaginal bleeding and abdominal cramps. At times, the pregnant woman may be asymptomatic.

Hydatidform Moles

A hydatidform mole occurs as the result of a paternal chromosomal aberration. A hydatidform mole can be a complete or a partial molar pregnancy. There is no fetus with a complete hydatidform mole.

The classic sign of a hydatidform mole is the formation of grape like clusters that can even be seen in the vagina. Other signs and symptoms include pelvic pressure, maternal hypertension, vaginal bleeding during the first trimester, an abnormally rapid growth of the uterus, anemia, and maternal nausea and vomiting.

Hyperemesis Gravidarum

Hyperemesis gravidarum, affectionately known as morning sickness, is a persistent and excessive amount of maternal nausea and vomiting.

Hyperemesis gravidarum often occurs during the first trimester of pregnancy but some pregnant women may be affected with hyperemesis gravidarum throughout the course of the entire pregnancy. It is medically defined as nausea for the majority of the day and vomiting three or more times per day.

Other signs and symptoms include hypotension, tachycardia, dizziness, dehydration, and maternal weight loss.

Incompetent Cervix

Simply defined, an incompetent cervix, or cervical insufficiency, is a cervix that effaces and dilates too early during the pregnancy. An incompetent cervix is diagnosed typically as early as the fourth month of gestation. This premature effacement and dilation can lead to the rupture of the membranes and a miscarriage unless it is successfully treated.

The signs and symptoms of an incompetent uterus include back, pelvic, and abdominal cramping, vaginal spotting or bleeding, and other changes in the vaginal discharge.

Anemias

Iron deficiency anemia and folic acid deficiency anemia are also complications of pregnancy during the antepartal period of time. Both of these anemias can have adverse effects on both the pregnant mother and the developing fetus.

The risk factors associated with a folic acid deficiency include some medications that deplete folic acid, a history of a neural tube defect pregnancy in the past, an abnormal excessive excretion of folic acid, gastrointestinal malabsorption syndrome, and a less than adequate dietary intake of foods high in folic acid, coupled with the need for increased folic acid during pregnancy. Some of the signs and symptoms of folic acid deficiency anemia include diarrhea, depression, confusion, and glossitis.

Folic acid deficiency anemia, which can be simply prevented with the administration of folic acid supplementation during the prenatal period, can lead to fetal brain abnormalities and other neural tube abnormalities.

Iron deficiency anemia during pregnancy, like folic acid deficiency anemia, can result from a number of factors and forces such as the increased need for iron during pregnancy, a lack of maternal iron stores to meet the demands of pregnancy, an inadequate dietary intake of iron, and the fact that the maternal volume of plasma expands without a proportionate increase in the mother's hemoglobin, thus creating an iron deficit. The greatest need for iron occurs during the second trimester of pregnancy.

Some of the signs and symptoms suggestive of iron deficiency anemia include pallor, headache, irritability, pica, shortness of breath with moderate exertion, fatigue, brittle finger and toe nails, irritability, and palpitations.

A confirmative diagnosis is made when the laboratory diagnostic tests show a Hgb < 11 mg/dL during the 1st and 3rd trimester, a Hgb < 10.5 mg/dL during the 2nd trimester and a Hct < 33%. The treatment of iron deficiency anemia includes ferrous sulfate 325 mg bid or, when oral iron supplementation cannot be tolerated, iron dextran can be used.

The effects of iron deficiency anemia in terms of the fetus can prematurity, a low birth weight, and fetal demise; the mother, on the other hand, can be adversely affected with infections, postpartum hemorrhage and preeclampsia, for example.

Cardiopulmonary Maternal Collapse

Cardiopulmonary maternal collapse is a severe antepartal complication that can be a life threatening medical emergency for both the pregnant woman and the developing fetus.

The risk factors associated cardiopulmonary maternal collapse are:

  • Hemorrhage including an intracranial bleed
  • Heart disease
  • Genitourinary tract infections
  • Major trauma
  • Eclampsia
  • Thromboembolism
  • A ruptured ectopic pregnancy
  • An amniotic fluid emboli

The signs and symptoms of cardiopulmonary maternal collapse are INCREASED:

  • Pulmonary capillary wedge pressure
  • Systemic vascular resistance
  • Clotting factors
  • Tidal volume
  • Volume of erythrocytes
  • Sequestration of blood to the uterus
  • Plasma volume by 40% to 50%
  • Cardiac rate by 15 to 20 beats per minute
  • Cardiac output by 40%
  • Oxygen consumption by 20%
  • Arterial blood pressure by 10 to 15 mm Hg
  • Functional residual capacity by 25%

According to the physical status of the pregnant woman and the fetus, some of the life saving interventions for the correction and treatment of cardiopulmonary maternal collapse include cardiopulmonary resuscitation and advanced cardiac life support, an immediate caesarean section to preserve the lives of both the pregnant woman and the baby, and a post mortem caesarean section to save the baby after the mother has died.

Disseminated Intravascular Coagulation

Disseminated intravascular coagulation, also referred to as DIC, is an acquired clotting factor abnormality that can occur during pregnancy, particularly when the pregnant woman is affected with another disorder such as an amniotic fluid embolism, eclampsia, an incomplete abortion, a retained dead fetus, or the retention of the placenta.

The signs and symptoms of disseminated intravascular coagulation include the signs and symptoms of blood clotting and the signs and symptoms of bleeding. Other signs and symptoms include possible decreases in the level of consciousness, cyanosis, hypotension, hypothermia, tachycardia, behavioral and mood changes. Without treatment, disseminated intravascular coagulation can lead to death.

Ectopic Pregnancy

Ectopic pregnancy is another complication of pregnancy. Ectopic pregnancy occurs when the fertilized egg is implanted anywhere other than the uterus. Most ectopic pregnancies occur when the fertilized egg is implanted in the fallopian tube. Unilateral pain, nausea, vomiting, a brown vaginal discharge, and faintness are some of the signs and symptoms that can occur with an ectopic pregnancy.

Substance Use and Abuse

Substances both illicit and legal can adversely affect a pregnancy. For example, legal alcohol, prescription drugs, over the counter drugs, cigarettes, other legal tobacco products pose risks in terms of the pregnancy. For example, placental abruption, spontaneous abortions, a small for gestational age infant, as well as sudden infant death syndrome after birth and attention deficit hyperactivity disorder as the infant matures can result from tobacco use; fetal alcohol syndrome, impaired intrauterine fetal growth, mental retardation, microcephaly and cardiac anomalies can result from alcohol use and abuse; and tobacco use can lead to placental abruption, spontaneous abortions,

Prescription medications such as tranquilizers can cause fetal drug withdrawal, hypotonia, hypothermia, a low APGAR score upon birth, cleft palate and/or lip, and respiratory compromise.

Medications are categorized according to five categories in terms of their degree of risk in terms of fetal development and growth. Categories A and B are generally considered safe for pregnant women; and medications classified as category C, D, and X are not considered safe, therefore, category C, D, and X medications are not given to pregnant women unless they are absolutely necessary and the benefits associated with the particular medication greatly outweigh the fetal complications associated with their maternal use.

Additionally, the use of these illicit and illegal products and substances can lead to antepartal complications for both the fetus and the pregnant woman. The substances and the potential complications associated with each are listed below.

  • Marijuana: Intrauterine growth restriction, neonatal withdrawal, and developmental and behavioral abnormalities as the infant matures.
  • Heroin: Impaired respiratory functioning, tremors, convulsions, and neonatal irritability and withdrawal.
  • Methadone: Preterm labor, placenta abruptio, meconium aspiration, and fetal withdrawal
  • Barbiturates: Intrauterine fetal growth restrictions and fetal withdrawal
  • Methylenedioxymethamphetaime (MDMA or Ecstasy): Memory and learning deficits
  • Lysergic acid diethylamide (LSD): Chromosomal aberrations
  • Crack/cocaine: Microcephaly, genitourinary abnormalities, cardiac abnormalities, central nervous system depression and sudden infant death syndrome after birth.

Spontaneous Abortions

Spontaneous abortions, also referred to, as unintended abortions or miscarriages, most often occur during the first trimester of the pregnancy. Spontaneous abortion is defined as all losses of the fetus with the exception of an elective abortion to end an unwanted pregnancy.

Spontaneous abortions occur as the result of one or more factors including chemical and/or radiation exposures, abnormalities of the mother's anatomical structures such as the uterus, and maternal diseases and disorders such as infections, diabetes, and thyroid conditions.

Spontaneous abortions are classified into a number of different types of spontaneous abortions. An inevitable abortion is accompanied with bleeding, abdominal cramping, cervical dilation, and perhaps the rupture of the membranes. Threatened spontaneous abortions can be signaled with bleeding, abdominal, and back pain that is not accompanied with any cervical dilation or the rupture of the membranes.

An incomplete abortion also has the signs and symptoms of abdominal and back cramping as well as bleeding, but only part of the membranes is lost. A complete spontaneous abortion presents with severe bleeding, severe cramping, and the complete loss of the membranes well before the expected date of delivery.

Ultrasound and a speculum examination confirm the diagnosis of a spontaneous abortion.

Some of the complications associated with spontaneous abortions include disseminated intravascular coagulation (DIC), increases in terms of the maternal thromboplastin levels and fetal autolysis.

Dilation and curettage (D and C) is typically done to remove the products of the pregnancy; additionally, misoprostol may be required in order to remove any remaining contents.

Other interventions after a spontaneous abortion, as based on the client's condition, intravenous fluid replacement, blood or blood products, and a suction evacuation or dilatation and curettage (D & C) when the products of conception are not expelled spontaneously.

Premature Rupture of the Membranes

Premature rupture of the membranes occurs when the amniotic membranes break and rupture 1 hour or more prior to the onset of labor. Premature rupture of the membranes, a serious complication of pregnancy, can lead to infection as a result of the premature loss of the protective amniotic sac and its fluids. For example, an infection of the remaining amniotic membranes, referred to as chorioamnionitis, can occur as the result of a premature rupture of the membranes.

In addition to infection, another serious complication of premature rupture of the membranes is a prolapsed umbilical cord, accompanied with prolonged or variable deceleration, which can endanger the fetus prior to delivery. This complication is confirmed with a direct inspection of the introitus and with fetal heart monitoring that reveals prolonged or variable deceleration.

The signs and symptoms of a premature rupture of the membranes, referred to by many clients as "breaking the water", may include:

  • Pyrexia
  • Leakage or gushing of the fluid from the vagina
  • Foul smelling vaginal discharge
  • Maternal tachycardia
  • Increased fetal heart rate
  • Positive findings with the ferning test
  • Positive findings with a nitrazine paper test

The treatment of premature rupture of the membranes includes antibiotics to prevent infections, betamethasone to facilitate fetal lung maturity and surfactant production, and to prepare for childbirth.

Multiple Gestations

Multiple gestations is defined as a pregnancy with two or more fetuses. Even though multiple gestations is considered a risk, the risks associated with it are significantly decreased with good prenatal care.

In addition to the signs of pregnancy, multiple gestations are suspected during the first trimester when the mother's has a greater than normally expected weight gain, fatigue, abdominal expansion, and/or nausea and vomiting and when the fetal movements are felt sooner than normally. Multiples are confirmed with an ultrasound examination.

Maternal complications can include a number of different disorders and complications such as anemia, hydramnios, hyperammonemia, hypoglycemia, hypertension, preeclampsia and eclampsia, gestational diabetes, pulmonary embolism, coagulopathy, and a premature rupture of the membranes.

The fetal complications related to multiple gestations during the first trimester include infections and the complications of infection, spontaneous abortion, chromosomal anomalies, fetal growth restriction, an incompetent cervix, spontaneous abortion and the "vanishing twin" phenomena which threaten the second trimester of pregnancy with multiples. The "vanishing twin" phenomena occurs when one or more of the multiple fetuses is reabsorbed.

Fetal Growth Restriction

Fetal growth restriction and a small for gestational age fetus can occur as the result of both genetic and non genetic causes. Some of the maternal risk factors associated with restricted uterine growth are placental insufficiency, kidney disease, some infections like cytomegalovirus, diabetes, hypertension, and substance abuse.

The fetal complications of fetal growth restriction include perinatal asphyxia, polycythemia which gives the neonate a ruddy complexion, tachypnea, lethargy, meconium aspiration, and hypoglycemia, of which the most serious and life threatening is perinatal asphyxia which can occur during labor with each uterine contraction at which time the maternal placental perfusion decreases. An immediate delivery is indicated when fetal distress is present.

Oligohydramnios

Oligohydramnios is defined as an insufficient amount of amniotic fluid; the normal volume of amniotic fluid is from 5 to 25 and values less than 5 are considered oligohydramnios.

Oligohydramnios can result from a number of causes including medications like NSAIDs and ACE inhibitors, abruptio placentae, premature rupture of the membranes, restricted fetal growth, a post term pregnancy, hypertension, preeclampsia, eclampsia, chromosomal abnormalities of the fetus, and a maternal thrombolytic disorder.

The complications of oligohydramnios can include restricted fetal growth, impaired fetal lung development, and fetal demise. Ongoing monitoring with biophysical profiles, ultrasonography, and nonstress testing is done, and when necessary, induced labor or the immediate delivery of the fetus are done.

Polyhydramnios

Polyhydramnios is an excessive amount of amniotic fluid with a value of > 25.

Some of the factors that impact development of polyhydramnios are Rh incompatibility, hemolytic anemia, multiple gestations, infection and genetic fetal abnormalities. Some of the signs and symptoms of polyhydramnios are maternal respiratory distress and pre term labor contractions. The complications associated with polyhydramnios are premature rupture of the membranes, life threatening umbilical cord compression, preterm labor, abruption placentae, fetal distress and fetal death.

Continuous monitoring and the manual withdrawal of excessive amniotic fluid, may be indicated. This withdrawal of amniotic fluid is referred to as an amnioreduction.

Assessing the Client For the Symptoms of Postpartum Complications

Maternal assessment and management continues after the delivery of the neonate. These assessments are done with the knowledge that infections and hemorrhage are the most frequently occurring postpartum complications.

During the immediate postpartum period the acronym BUBBLE is a good way to remember the essential components of the postpartum assessment in addition to the assessment of the client's vital signs, the level of pain and discomfort, and other assessments.

The acronym BUBBLE stands for the assessment of the mother's:

  • The B of BUBBLE is the breasts
  • The U of BUBBLE is the uterine fundus height, consistency and placement
  • The B of BUBBLE is the bowel and other gastrointestinal functioning
  • The second B of BUBBLE is bladder functioning
  • The L of BUBBLE is lochia amount, consistency, color and odor
  • The E of BUBBLE is episiotomy edema and redness

Vaginal discharge progresses from bloody vaginal drainage with some small clots for about 10 days after which the vaginal drainage is brown and may continue for up to about 6 weeks. The breasts will be normally engorged, particularly when the mother is breast feeding; urinary output may increase during the first day or two of the postpartum period of time; about 12 or 13 pounds is lost by the new mother; and hormonal shifts may lead to depression for about two weeks, after which this depression may be serious and a sign of postpartum psychosis, rather than the "baby blues".

All the vital signs should return to their normal levels in about 24 hours after delivery. Infection and postpartum hemorrhage must be ruled out when the signs of infection or hemorrhage present. The local signs of infection are site pain, redness, heat, swelling and some bodily part dysfunction; and the systemic signs and symptoms of infection include fatigue, chills, hyperthermia, prodromal malaise, tachypnea, tachycardia, nausea, vomiting, anorexia, confusion, incontinence, abdominal cramping and diarrhea, among other signs and symptoms as based on the type of infection.

Recognizing Cultural Differences in Childbearing Practices

Culture, cultural practices and cultural beliefs can impact on the childbearing practices of many clients. For example, some cultures, more than others, promote the importance of large families, while others such as the Chinese limit the size of the family. Some cultures also differ in terms of their beliefs relating to single parenthood, pregnancies among unmarried couples, prenatal care, gender preference, breast feeding and places where the delivery of the infant should take place.

These practices and beliefs can impact on the importance of having children, health practices during pregnancy, beliefs about pregnancy and infant feeding.

Calculating the Expected Date of Delivery

The expected date of delivery is calculated using Nagle's rule which is:

  • The first day of last menstrual period - 3 months + 7 days = the estimated date of delivery

For example, when the first day of the last menstrual period is 9/20/2015 you would:

  1. Subtract three months from 9/20/2015 and then get 6/20/2015 and then
  2. Add seven days to 6/20/2015 and then get 6/27/2015, after which you would
  3. Add one year to 6/27/2015 to get the estimated date of delivery for 6/27 of the following year which is 2016.

Checking and Monitoring the Fetal Heart during Routine Prenatal Exams and During Labor

Now we will discuss monitoring the fetal heart rate during the antepartum period of time. Some of the terms used in respect to fetal heart rate monitoring will be defined now.

  • The baseline fetal heart rate is the average fetal heart rate per minute during a 10 minute period of time WITHOUT any periods of significant variability or any period when the rate varies by more than 25 beats per minute.
  • A wandering baseline fetal heart rate is a fluctuating fetal heart rate from the baseline. This abnormal fetal heart rate pattern can indicate disorders like a congenital abnormality or metabolic acidosis.
  • An acceleration is defined as an increased fetal heart rate over the fetal heart rate baseline with a less than 30 second duration from the onset to the peak. Accelerations can be prolonged, episodic, or periodic.
  • A prolonged acceleration is an acceleration of the fetal heart rate that lasts more than 2 minutes.
  • An episodic acceleration is defined as an assuring fetal heart rate pattern that normally occurs with fetal movements.
  • Periodic acceleration is an acceleration that occurs with contractions. They are normal.
  • A deceleration is a fetal heart rate that is less than the baseline. Decelerations can be early, late, variable or prolonged.
  • The onset of deceleration is the point where the fetal heart rate falls below the baseline.
  • The nadir of deceleration is the lowest point of the deceleration.
  • The descent of deceleration is the time between the onset and the nadir of deceleration.
  • The depth of deceleration is the number of beats per minute that occur during a deceleration until it reaches its nadir.
  • The duration of a deceleration is the time elapsed from the onset of the deceleration to the fetus' baseline fetal heart rate.
  • The recovery of the deceleration is the time elapsed from nadir to the fetus' baseline fetal heart rate.
  • A late deceleration is a gradual decrease of the fetal heart rate heart rate below baseline during contraction.
  • An early deceleration is a gradual increase of the fetal heart rate below the baseline during contraction which occurs during the peak of the contraction.
  • Variable decelerations occur when the fetal heart rate suddenly decreases by at least 15 beats per minute that lasts at least 15 seconds before it returns to the baseline.
  • A prolonged deceleration is defined as a decrease in the fetal heart rate of 15 or more beats per minute that persists more than 2 minutes from its onset to its return to the baseline.
  • Variability is classified as with minimal variation when it varies by less than 5 beats per minute; moderate variability occurs fetal heart rate varies by 6 to 25 beats per minute; and with marked and severe variability the fetal heart rate varies by more than 25 beats per minute.

Nonreassuring fetal heart rates and heart rate patterns include the absence of any variability, late decelerations, variable decelerations, fetal tachycardia, and fetal bradycardia. Noninvasive fetal heart rates are monitored on a continuous or an intermittent basis. The necessity of fetal heart monitoring is underscored when the mother has complications such as abnormal uterine contractions, hypertension, diabetes, a post term pregnancy, and renal disease and/or the fetus is at risk as the result of one or more factors such as fetal distress, meconium stained amniotic fluid, multiple gestations, placenta previa, abruptio placentae, an abnormal contraction stress test, an abnormal nonstress test, bradycardia and intrauterine growth restriction.

Noninvasive external fetal monitoring is advantageous over invasive internal fetal heart monitoring because there is less risk of infection, and there is no need for the rupture of the membranes or the dilation of the cervix at 2 or more centimeters, and there is no need for the fetus to have a descended presenting part.

Invasive internal fetal monitoring, when compared and contrasted to external fetal monitoring, is advantageous because it provides a higher quality and more accurate reading that is also not impaired with factors such as maternal obesity, fetal positioning and maternal positioning.

Normally, fetal heart rate baselines are from 110 and 160 beats per minute excluding any decelerations, accelerations, or episodes of variability over a 10 minute period of time. Fetal heart rates less than 100 indicate fetal bradycardia; and rates greater than 160 beats per minute indicate fetal tachycardia.

Assisting the Client with Performing/Learning Newborn Care

Mothers, particularly new mothers and significant others, need some assistance and support in terms of newborn care and infant feeding. They must know the nutritional needs of the baby, how to breast feed or bottle feed, how to provide cord care and circumcision care, diapering, bonding, attachment, preventing accidents, such as placing the infant on their back to prevent suffocation, and how to respond to the baby's crying.

Nutritional Needs and Feeding the Infant

The nutritional needs of the neonate include about 110 kcals per kilogram a day for the first 3 months of life and then 100 kcals per kilogram a day until the infant is about 6 months of age. Neonates and infants also need 2 ¼ to 4 grams of protein each day, and 140 to 160 mLs of fluid per day.

Human milk is considered the best form of nutrition for infants up to at least 6 months of age. Breast milk is produced in the breast as the result of the hormone prolactin. Prolactin, in addition to oxytocin, both of which are endocrine hormones that are secreted by the pituitary, regulate milk production. Breast milk is more readily and easily absorbed and digested than formula milk.

The decision to breastfeed or formula feed is a personal decision that should be made by the mother after a full discussion about the advantages and disadvantages of each type of infant feeding. Some of the factors and forces that impact on this decision include cultural practices and beliefs, the mother's employment, life style choices and socioeconomic status. For example, some cultures have the belief that breastfeeding is the natural and preferable choice and other cultures may not share this same belief; life style choices like a desire to drink alcoholic beverages after the delivery of the baby prevent the mother from breast feeding; and some places of employment may not accommodate the needs of the breast feeding woman with breaks for pumping and/or feeding the infant.

A healthy diet for the lactating breast feeding mother should include small amounts of fats, protein, whole grains, dairy products, fresh fruits and vegetables. Special foods are not needed to produce milk or to maintain an ample milk supply.

The normal breastfeeding process includes the proper positioning of the infant and mother, latch on and the sucking and swallowing sequence.

Positioning and holding the neonate for breast feeding will become a personal preference, however, there a number of positions that the mother should be instructed about including the football clutch hold position, the cradle position, the modified cradle position, and the side lying position.

Latch on is placing the areola and a large portion of the breast into the baby's mouth. The infant's rooting reflex promotes their latching on and it can be stimulated by stroking the baby's cheek when the nipple is in the baby's mouth. The suck and swallow sequence starts when the infant starts to suck, the milk is then moved with the infant's tongue to the back of the mouth and then the infant swallows.

Mothers who choose to bottle feed should be instructed about the safe and proper way to feed their infant. They should be instructed to hold the baby and NOT prop the bottle up for automatic feeding.

Cord Care

The umbilical cord stump should be gently handled and kept clean in order to prevent an infection. The umbilical cord stump typically dries up and falls off at about two to three weeks after birth.

Cleansing entails the use of plain water and NOT alcohol as was done in the past. After cleansing with water, the stump should be permitted to air dry or dried with an absorbent pad. Sponge bathing, rather than tub baths, is encouraged and the stump should be exposed to circulating air and not covered with a diaper in order to promote its drying out and falling off.

The mother should also be instructed how to identify any signs or symptoms of umbilical cord stump infection such as swelling, pus and redness.

Circumcision Care

The circumcision site is kept clean and inspected for any complications such as infection, bleeding and an alteration in urinary output.

The penis is cleansed, coated with a bit of petroleum jelly, and then covered with a sterile dressing until it is healed which typically occurs in about one week.

Diapering

New mothers also make choices in terms of what kind of diapers they will use for their infant until they are toilet trained. Some choose cloth diapers and other new mothers choose disposable diapers. Some of the factors that may come into play in terms of this decision include socioeconomic factors, the accessibility of a washer and dryer and personal preferences in terms of convenience. For example, based on the fact that many neonates and infants need 10 or more daily diaper changes, some parents choose cloth diapers because the cost associated with disposable diapers is prohibitive; and some choose disposable diapers rather than cloth diapers because they do not have access to a washer and dryer, and they prefer the convenience of disposable diapers.

Diapering techniques are relatively simple for the new parents to learn, however, diapering safety has to be emphasized. NO infant should ever be left unattended on a changing table or bed. These types of falls occur far more frequently than you can imagine.

Bonding and Attachment

Bonding and attachment to the parents is critically important to the healthy growth and development of the new baby. Bonding and attachments give the neonate and infant positive feelings of trust and intimacy.

Poor and absent bonding and attachments can lead to lifelong consequences such as mistrust, a lack of intimacy, and impairments in terms of cognitive and psychological development.

Nurses can promote bonding and attachments by encouraging both parents, and siblings, to hold the infant, to feed the infant and to communicate with the infant with touch, rocking and soothing cooing sounds.

Accident Prevention

The greatest safety risks among neonates and infants include suffocation, falls and strangulation. Suffocation can be prevented by keeping all objects out of the crib and always positioning the infant on their back and not on their stomach.

Providing Prenatal Care and Education

Prenatal care consists of a complete and thorough assessment of the mother, including a complete past medical history and physical assessment, client education, and ongoing care.

The initial client assessment during the first contact with a woman that may be pregnant should minimally consist of a complete health history and a complete physical assessment.

The components of this maternal health history, in addition to the data that is typically collected with other health histories, include the mother's gynecological history, the number of living children, the number of full term births, the number of preterm births, the number of spontaneous and elective abortions, any complications experienced in prior pregnancies, any current medical concerns related to the pregnancy or otherwise, the first day of the last menstrual period, the parents' genetic history, and the woman's psychological and emotional responses to the current pregnancy.

Some of the maternal routine diagnostic tests that are done during the prenatal period of time include:

  • Urinary or blood human chorionic gonadotropin to diagnose a pregnancy
  • One hour glucose tolerance test and a possible three hour glucose tolerance test
  • Tests for HIV, hepatitis B, gonorrhea, tuberculosis, Group B streptococcus, chlamydia, streptococcus, and syphilis
  • TORCH infections screening
  • Blood type including the Rh factor
  • Papanicolaou (PAP)
  • Hgb electrophoresis to detect conditions like sickle cell anemia
  • CBC with differential
  • Hgb and Hct
  • Rubella titer
  • Serum alpha-fetoprotein

Some of the fetal diagnostic tests that are done during the prenatal period of time include:

  • Biophysical Profile: This test measures and assesses fetal breathing, fetal movement, fetal tone, the fetal heart rate acceleration and the volume of the amniotic fluid.
  • Diagnostic Ultrasound: Transabdominal and transvaginal ultrasound, according to the American College of Obstetricians and Gynecologists, is used for a wide variety of normal and abnormal conditions such as fetal presentation, gestational age, fetal growth, an ectopic pregnancy, abruptio placentae and placenta previa.
  • Lung Maturity Studies: Lung maturation studies include the lecithin/sphingomyelin or L/S ratio, the lung profile and the phosphatidylglycerol (PG) level.

The lecithin/sphingomyelin or L/S ratio is the ratio of lecithin to the amount of sphingomyelin in the amniotic fluid that comprises the fetus' lung surfactant. A ratio < 2:1 is abnormal and suggestive of the fact that the newborn may be affected with respiratory distress syndrome and a ratio of < 1:5 indicate that the fetus is a high risk for infant respiratory distress syndrome.

The presence of phosphatidylglycerol prior to the 36th week of gestation indicates the possibility of neonatal respiratory distress syndrome; and the lack of phosphatidylglycerol indicates a significant risk of respiratory distress syndrome.

A lung profile consists of the lecithin/sphingomyelin ratio and the phosphatidylglycerol (PG).

  • Nonstress Test: This noninvasive, nonstress test monitors and measures the fetal heart rate and fetal movements. The results of this test is considered normal and reactive when the fetus' heart rate increases by at least 15 beats per minute over 15 seconds when the fetus moves; and the results of nonstress test are considered abnormal and nonreactive when the fetus' heart rate does NOT increase by at least 15 beats per minute over 15 seconds when the fetus moves.
  • Contraction Stress Test: This noninvasive test measures fetal responses to contractions that are stimulated with intravenous oxytocin or the mother's manual stimulation of her nipples. A normal contraction stress test occurs when there are no late or variable decelerations during at least three uterine contractions. This normal test is referred to as a negative contraction stress test. An abnormal, positive contraction stress test occurs when there are late or variable decelerations during contractions.
  • Amniocentesis: According to the American College of Obstetricians and Gynecologists, amniocentesis is indicated when the pregnant woman is at risk for complications, is older than 35 years of age and when there is a personal or family history of chromosomal aberrations and/or neural tube abnormalities.

Withdrawn amniotic fluid is laboratory tested to identify fetal abnormalities including fetal distress, for example, when it is brown, red or green in terms of color.

  • Chorionic Villus Sampling: Chorionic villus sampling, like amniocentesis, is beneficial for the assessment of the fetus for fetal abnormalities.
  • Percutaneous Umbilical Blood Sampling: Percutaneous umbilical blood sampling is effective for the assessment of the fetus in terms of the presence of any infections and chromosomal abnormalities in addition to the determination of the fetus' blood type and Rh factor.
  • Alpha-Fetoprotein: Maternal alpha-fetoprotein, also referred to as α-fetoprotein, can identify genetic disorders. Elevations of α-fetoprotein is suggestive of disorders such as anencephaly and spina bifida; and lower than normal maternal alpha-fetoprotein levels can indicate the possibility that the fetus is affected with Down's syndrome, hydatidiform mole and other abnormalities.
  • Triple Screens: The maternal blood test includes the laboratory testing of maternal alpha-fetoprotein,

human chorionic gonadotropin and estriol to determine the presence of fetal abnormalities. For example, elevated levels of human chorionic gonadotropin can indicate trisomy 21; and low levels of unconjugated estriol can also indicate the presence of trisomy 21.

  • Amniotic Fluid Index: The amniotic fluid index is used to assess fetal wellbeing. An amniotic fluid index of < 5 indicates the need for further assessments and determinations.

Prenatal Education

Ideally, prenatal education should be provided to the client even before they plan a pregnancy. For example, the client should be instructed about methods of birth control, the signs of pregnancy, and ways to prepare for pregnancy.

Upon initial contact, the pregnant woman and their partner should be taught about a wide variety of things that they will have to consider and make choices about. For example, they should be taught about their choices in terms of the care provider that will care for the mother during pregnancy and delivery, the possible birth settings, childbirth preparation classes, the birthing plan, who will be with the mother during labor and delivery, newborn care classes, sibling preparation classes, breast feeding and bottle feeding and:

  • Normal gestational growth and development
  • Normal physiological changes that occur during pregnancy
  • The presumptive, probable, and positive signs of pregnancy.
  • The signs and symptoms of complications during pregnancy
  • Nutrition during pregnancy
  • Exercise during pregnancy
  • The stages of labor and delivery
  • The postpartum period

Some of the settings for childbirth include a hospital, a community based birthing center and the home of the pregnant woman. All of these settings have their advantages and disadvantages. For example, a home delivery may be a disadvantage when the mother and/or the neonate are in need for emergency care and treatments and a hospital delivery may be perceived by the parents as impersonal and unnatural.

Choices in terms of the care provider that will care for the mother during pregnancy and delivery include an obstetrician, a nurse midwife and a non nursing midwife. Possible support people during the labor and delivery processes can include family members, spouses, a professional doula, friends, siblings and nursing students.

Pregnant women also should make knowledgeable decisions about childbirth methods and childbirth preparation classes should they elect to take advantage of them. The most common childbirth preparation classes are the Lamaze method, the Kitzinger method, the Bradley method, the Alexander method and the Hypno Birthing method.

The Lamaze method supports the fact that childbirth is a normal and natural process about which the mother has instinctive knowledge about. The Lamaze method childbirth preparation classes include information and education relating to pain management choices, methods of feeding the infant, the labor process, the postpartum period, and relaxation and breathing techniques for each stage of labor.

The Bradley method childbirth preparation classes include deep abdominopelvic controlled breathing to use during labor, good nutrition during pregnancy, breastfeeding, exercise during pregnancy, relaxation techniques, and the stages of labor. The Bradley method is a partner coached birth that supports the fact that participation in the labor and delivery processes is a satisfying and rewarding experience.

The Alexander method childbirth preparation classes include comfort measures to use during pregnancy and labor, pushing during delivery, and ways to promote the pregnant woman's flexibility, movement, balance, and coordination.

The Kitzinger method, a home delivery childbirth preparation method, consists of educational classes that include the home delivery method that clients without the risk for complications can decide upon. These classes include antepartum care, breast feeding, therapeutic touch during labor, chest breathing, abdominal relaxation and the use of sensory memory to facilitate the mother's understanding of her body and its functioning during pregnancy and the birth process.

Hypno Birthing childbirth preparation includes instruction on self hypnosis and how self hypnosis promotes the release of endorphins which is considered a natural anesthetic. In addition to self hypnosis, the pregnant woman is also taught about relaxation techniques and pushing techniques.

Providing Care to the Client in Labor

Labor is the natural process or induced process that consists of involuntary, rhythmic uterine contractions that increase in terms of frequency and intensity. Labor leads to the necessary effacement and dilation of the cervix that is needed for the vaginal delivery of the baby after pregnancy.

Effacement is the thinning and shortening of the cervix and dilation is the opening of the cervix. Labor usually begins about two weeks prior to the expected delivery date; labor usually lasts from twelve to eighteen hours.

The stages of labor and delivery include the first, second, third and fourth stages of labor.

The first stage of labor consists of the latent, active and transition phases. The latent phase of the first stage of labor typically lasts for several hours and the contractions are mild. During the active phase of the first stage of labor, the contractions become more frequent and severe, the cervix dilates up to seven centimeters and the fetus begins to descend in the birth canal. The transition phase of the first stage of labor is characterized with the increased frequency, intensity and duration of the contractions. The cervix dilates up to 10 cm.

The second stage of labor begins when the cervix is dilated 10 cm and it ends with the birth of the infant. The third stage of labor begins with the vaginal delivery of the baby and it ends when the products of conception, that is the placenta, are expelled. The fourth stage occurs during the first several hours after delivery.

During the latent phase of the first stage of labor, the mother should be encouraged to rest, walk, perform relaxation techniques and take deep breaths. Food and fluids are limited and restricted during this phase of the first stage of labor. They should also be encouraged to urinate every hour.

During the active phase of the first stage of labor, the client should be encouraged to continue voiding every hour and also to continue with ambulation, rest and relaxation exercises. At times, such as with prolonged labor, intravenous fluids may be used to prevent and treat dehydration. Nurses promote comfort and provide basic nursing are with things like massages, oral care and frequent positioning for comfort. The spouse or significant other should also be encouraged to care for their partner during this and all the other stages of labor.

Contractions and maternal vital signs are checked and monitored every 15 minutes; and the fetal heart rate is also monitored at least every 15 minutes. Fetal assessments include assessing and monitoring the fetal heart rate at least every 15 minutes as well and much more often and even continuously when the fetus is at risk. The mother must be reminded to pant rather than push in spite of the fact that the woman in labor has a strong urge to push.

The fetal lie, presentation, attitude, station and position are also monitored and assessed during labor.

Fetal lie is defined as the relationship of the fetus's spine to the mother's spine. Fetal lie can a longitudinal, transverse or oblique life. Longitudinal lie, the most common and normal lie, occurs when the fetus' spine is aligned with the mother's spine in an up and down manner; a transverse lie occurs when the fetus' spine is at a right ninety degree angle with the maternal spine; and, lastly, an oblique lie occurs when the fetus' spine is diagonal to the mother's spine.

Fetal presentation is defined by where the fetus' presenting part is within the birth canal during labor. The possible fetal presentations are the cephalic presentation, the cephalic vertex presentation, the cephalic sinciput presentation, the cephalic face presentation, the cephalic brow presentation, the breech presentation, the complete breech presentation, the frank breech presentation, the shoulder breech presentation, and the footling presentation.

The cephalic head presentation, the most common and normal presentation, is the fetus' head as the presenting part. The cephalic presentation can be further classified and categorized as the cephalic vertex presentation where the fetus' head is on its chest, the cephalic sinciput presentation where the head is partly flexed, the cephalic face presentation where the face is the presenting part of the head because the fetus' head is hyperextended, and the cephalic brow presentation which occurs when the fetus' head is extended.

A breech presentation occurs when a fetal body part, other than the head, is the presenting part. The breech presentation can be further classified and categorized as the complete breech presentation when the fetus' buttocks are the presenting part, the frank breech presentation that occurs when the buttocks present and the legs are straight up, the shoulder breech presentation when the shoulder presents, and the footling presentation were one or both of the feet presents.

Fetal attitude is the positioning of the fetus's body parts in relationship to each other. The normal attitude is general flexion in the "fetal position". All attitudes, other than the normal attitude, can lead to a more intense and prolonged labor.

Fetal station is level of the fetus' presenting part in relationship to the mother's ischial spines. Fetal station is measured in terms of the number of centimeters above or below the mother's ischial spines. Fetal station is -1 to -5 when the fetus is from 1 to 5 centimeters above the ischial spines and it is from +1 to +5 when the fetus is from 1 to 5 centimeters below the level of the maternal ischial spines.

Fetal position, simply stated, is the relationship of the fetus' presenting part to the anterior, posterior, right or left side of the mother's pelvis. The relationship of the fetus's presenting body part, such as left anterior, left posterior, right posterior and right anterior, in relationship to the maternal pelvis which is called the anterior, posterior, right and left pelvis which are noted and documented as A, P, R or L. The presenting part of the fetus is referred to as mentum, occiput, sacrum, and acromion. These presenting parts are noted and documented as M, O, S, and A respectively. The only normal positions are the left and right occiput anterior fetal position which is the ROA and the ROL, respectively.

Face presentation positions are noted and documented as:

  • RMA for the right mentum anterior position
    RMT for the right mentum transverse position
    RMP for the right mentum posterior position
    LMA for the left mentum anterior position
    LMT for the left mentum transverse position
    LMP for the left mentum posterior positionVertex presentation positions are noted and documented as:
  • ROA for the right occiput anterior position
  • ROT for the right occiput transverse position
  • ROP for the right occiput posterior position
  • LOA for the left occiput anterior position
  • LOT for the left occiput transverse position
  • LOP for the left occiput posterior position

Breech presentation positions are noted and documented as:

  • RSA for the right sacrum anterior position
    RST for the right sacrum transverse position
    RSP for the right sacrum posterior position
    LSA for the left sacrum anterior position
    LST for the left sacrum transverse position
    LSP for the left sacrum posterior position

Acromian presentation positions are noted and documented as:

  • RAA for the right acromian anterior position
    RAT for the right acromian transverse position
    RAP for the right acromian posterior position
    LAA for the left acromian anterior position
    LAT for the left acromian transverse position
    LAP for the left acromian posterior position

There are several types of delivery including:

  • Vaginal deliveries
  • Operative deliveries such as a forceps delivery, a vacuum delivery and a Caesarean and a
  • Vaginal Birth After a Caesarean Section

Vaginal deliveries are the most common form of delivery. Vaginal deliveries can be done with or without an episiotomy. An episiotomy may be indicated when the baby is excessively large, when there is shoulder dystocia, and/or maternal and/or fetal stress are present.

Forceps facilitate the delivery of the baby by providing traction and they can also facilitate the rotation of the fetus' head to the vertex position. All forceps except Piper forceps are applied to the sides of the head and only when the fetus' presentation is presenting downward. Piper forceps are used for breech presentations after the fetus' head is reachable after the delivery of the rest of the body.

The complications of forceps deliveries include maternal trauma, lacerations, pelvic floor damage, bleeding and an inadvertent extension of the episiotomy to the anus. Neonate complications include a low Apgar score, neurological trauma and damage, a fractured clavicle and Erb's palsy.

Vacuum deliveries are done with the application of suction to the occipital part of fetal head to assist in the delivery when the second stage of labor is extensively long and/or there is a nonreassuring fetal heart rate pattern. Attempted vacuum deliveries are ceased when there is no success after about one half hour.

Cesarean births are indicated with placenta abruptio, placental previa, cephalopelvic disproportion, a nonreassuring fetal heart pattern, and a cord prolapse. The incision can be a skin incision with can be vertical or transverse and a uterine incision which is done into the uterus.

Some of the maternal complications associated with Cesarean births are infection, hemorrhage, shock, emboli and adverse reactions to anesthetic agents.

Trial labor and a vaginal delivery can be attempted after the mother has had a Cesarean section in the past except under some circumstances such as an inadequate pelvis.

Providing Post-Partum Care and Education Including Discharge Instructions

As previously detailed with the section entitled "Assessing the Client For the Symptoms of Postpartum Complications", postpartum care and monitoring focuses on BUBBLE, and for the signs of infection and/or hemorrhage, which are the two most frequently occurring postpartum complications.

Mothers, particularly new mothers and significant others, need some assistance and support in terms of newborn care and infant feeding. Details about this necessary education were previously discussed with the section entitled "Assisting the Client with Performing/Learning Newborn Care".

Evaluating the Client's Ability to Care for the Newborn

Again, new mothers are monitored in terms of their abilities to provide care to the infant. Teaching and the reinforcement of teaching are necessary when a learning need is assessed.

The essentials of newborn care include bathing, feeding, quieting strategies, swaddling, diapering, cord care, and circumcision care.

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