Maternal Newborn Ati

Front 1

Presumptive signs of pregnancy

Back 1

changes that are experienced by the woman that make her think that she may be pregnant.
Amenorrhea, Fatigue, Nausea and vomiting, Urinary frequency, Breast changes – Darkened areola, enlarged Montgomery’s tubules, Quickening – slight fluttering movements of the fetus felt by a woman, usually between 16 to 20 weeks of gestation.
Uterine enlargement, Linea nigra, Chloasma (mask of pregnancy), Striae gravidarum

Front 2

Probable signs of pregnancy

Back 2

changes that make the examiner suspect a woman is pregnant (primarily related to physical changes of the uterus).
Abdominal enlargement related to changes in uterine size, shape, and position
Cervical changes
Hegar’s sign – softening and compressibility of lower uterus
Chadwick’s sign – deepened violet-bluish color of vaginal mucosa secondary to increased vascularity of the area;
Goodell’s sign – softening of cervical tip
Ballottement – rebound of unengaged fetus
Braxton Hicks contractions – false contractions, painless, irregular, and usually relieved
by walking;
Positive pregnancy test, Fetal outline felt by examiner

Front 3

Positive signs of pregnancy

Back 3

– signs that can only be explained by pregnancy.
Fetal heart sounds, Visualization of fetus by ultrasound, Fetal movement palpated by an experienced examiner

Front 4

GTPAL acronym

Back 4

◯◯ Gravidity
◯◯ Term births (38 weeks or more)
◯◯ Preterm births (from viability up to 37 weeks)
◯◯ Abortions/miscarriages (prior to viability)
◯◯ Living children

Front 5

Chadwick’s sign

Back 5

Cervical changes are obvious because of the color change. The cervix becomes
a purplish-blue color that extends into the vagina and labia.

Front 6

Goodell’s sign.

Back 6

The cervix markedly softens in consistency

Front 7

Prenatal care

Back 7

begins with an initial assessment and then continues throughout pregnancy.
In an uneventful pregnancy, prenatal visits are scheduled every month for 7 months, every
2 weeks during the eighth month, and every week during the last month.

Front 8

One-hour glucose tolerance

Back 8

(Oral ingestion or IV administration of
concentrated glucose with venous sample
taken 1 hr later [fasting not necessary])
Identifies hyperglycemia; done at initial visit
for at-risk clients, and at 24 to 28 weeks of
gestation for all pregnant women (> 140 mg/
dL requires follow up).

Front 9

Three-hour glucose tolerance

Back 9

(Fasting overnight prior to oral ingestion or IV
administration of concentrated glucose with a
venous sample taken 1, 2, and 3 hr later)
Used in clients with elevated 1-hr glucose test
as a screening tool for diabetes mellitus. A
diagnosis of gestational diabetes requires two
elevated blood-glucose readings.

Front 10

Pregnancy fluid intake

Back 10

Consume at least 2 to 3 L of water each day from food and beverage sources.

Front 11

First Trimester RN teaching

Back 11

☐ Physical and psychosocial changes
☐ Common discomforts of pregnancy and measures to provide relief
☐ Lifestyle: exercise/stress/nutrition, sex, dental care, over-the-counter and prescription medications, tobacco, alcohol, substance abuse (discuss strategies to decrease or discontinue use), and STDs (encourage safe sexual practices)
☐ Possible complications and signs to report
☐ Fetal growth and development
☐ Prenatal exercise
☐ Expected laboratory testing

Front 12

Second Trimester RN teaching

Back 12

☐ Benefits of breastfeeding.
☐ Common discomforts and relief measures
☐ Lifestyle: sex and pregnancy, rest and relaxation, posture, body mechanics,
clothing, seat-belt safety, and travel
☐ Fetal movement
☐ Complications (preterm labor, gestational hypertension, gestational diabetes mellitus, premature rupture of membranes)
☐ Childbirth preparation

Front 13

Third Trimester RN teaching

Back 13

☐ Childbirth preparations
X Childbirth classes or birth plan.
X Breathing and relaxation techniques (deep cleansing breaths at one-half the usual respiratory rate during contractions can promote relaxation of the abdominal muscles, which lessens the iscomfort of uterine contractions)
X Discussion regarding pain management during labor and birth (natural childbirth, epidural)
X Signs and symptoms of preterm labor and labor
X Labor process
X Infant care
X Postpartum care
☐ Fetal movement/kick counts to ascertain fetal well-being. A client should be instructed to count and record fetal movements or kicks daily.
X It is recommended that mothers count fetal activity 2 or 3 times a day for 60 min each time. Fetal movements of less than 3 in/hr or movements that cease entirely for 12 hr indicate a need for further
evaluation.
☐ Diagnostic testing for fetal well-being (nonstress test, biophysical profile, ultrasound, and contraction stress test).

Front 14

Heartburn

Back 14

may occur during the second and third trimesters due to the stomach being
displaced by the enlarging uterus and a slowing of the gastrointestinal tract motility
and digestion brought about by increased progesterone levels. The client should eat
small frequent meals, not allow the stomach to get too empty or too full, sit up for 30
min after meals, and check with her primary care provider prior to using any over-thecounter
antacids.

Front 15

Danger Signs During Pregnancy

Back 15

Gush of fluid from the vagina (rupture of amniotic fluid) prior to 37 weeks of
gestation
■■ Vaginal bleeding (placental problems such as abruption or previa)
■■ Abdominal pain (premature labor, abruptio placenta, or ectopic pregnancy)
■■ Changes in fetal activity (decreased fetal movement may indicate fetal distress)
■■ Persistent vomiting (hyperemesis gravidarum)
■■ Severe headaches (pregnancy-induced hypertension)
■■ Elevated temperature (infection)
■■ Dysuria (urinary tract infection)
■■ Blurred vision (pregnancy-induced hypertension)
■■ Edema of face and hands (pregnancy-induced hypertension)
■■ Epigastric pain (pregnancy-induced hypertension)
■■ Concurrent occurrence of flushed dry skin, fruity breath, rapid breathing,
increased thirst and urination, and headache (hyperglycemia)
■■ Concurrent occurrence of clammy pale skin, weakness, tremors, irritability, and
lightheadedness (hypoglycemia)

Front 16

Dick-Read method

Back 16

refers to “childbirth without fear.” Uses controlled breathing and conscious and progressive relaxation of different muscle groups throughout the entire body. This method instructs a woman to relax completely between contractions and keep all muscles except the uterus relaxed during contractions.

Front 17

Leboyer

Back 17

is a method of childbirth that is based on the idea of “birth without
violence.” Environmental variables are stressed to ease the transition of the fetus from the uterus to the external environment (dim lights, soft voices, warm
birthing room). Water births are based on this method.

Front 18

Bradley

Back 18

stresses the partner’s involvement as the birthing coach. This method emphasizes increasing self-awareness and teaching the woman to deal with the
stress of labor by tuning into her own body. The mother is encouraged to trust her body and use natural breathing, relaxation, nutrition, exercise, and education throughout her pregnancy.

Front 19

Newborn bathing

Back 19

Bathing the NB every other day is appropriate. Daily bathing disrupts the skin integrity.

Front 20

Antepartum nursing care
Incompetent Cervix

Back 20

■■ An ultrasound showing a short cervix (less than 20 mm in length) indicates a
reduced cervical competence.
The painless dilation of the cervix in the absence of uterine contractions. The cervix is incapable of supporting the weight and pressure of the growing fetus and results in expulsion of the products of conception during the second trimester of pregnancy. This usually occurs around 20 weeks of gestation.

Front 21

Antepartum nursing care
Incompetent Cervix
S/S

Back 21

Subjective Data
◯◯ Increase in pelvic pressure

Objective Data
◯◯ Physical assessment findings
■■ Pink-stained vaginal discharge or bleeding
■■ Possible gush of fluid (rupture of membranes)
■■ Uterine contractions with the expulsion of the fetus
■■ Postoperative (cerclage) monitoring for uterine contractions, rupture of
membranes, and signs of infection

Front 22

Hyperemesis Gravidarum

Back 22

excessive nausea and vomiting (related to elevated hCG levels) that is prolonged past 12 weeks of gestation and results in a 5% weight loss from prepregnancy weight, electrolyte imbalance, acetonuria, and ketosis.
●● Hyperemesis gravidarum may be accompanied with liver dysfunction.
●● There is a risk to the fetus for intrauterine growth restriction (IUGR) or preterm birth if the condition persists.

Front 23

Nursing Care
Hyperemesis Gravidarum

Back 23

◯◯ Monitor the client’s I&O.
◯◯ Assess the client’s skin turgor and mucus membranes.
◯◯ Monitor the client’s vital signs.
◯◯ Monitor the client’s weight.
◯◯ Have the client remain NPO for 24 to 48 hr.
◯◯ Give the client IV fluids of lactated Ringer’s solution for hydration.

Front 24

Gestational Diabetes Mellitus

Back 24

The ideal blood glucose level during pregnancy should fall
between 70 and 110 mg/dL.
Subjective Data
◯◯ Hypoglycemia (nervousness, headache, weakness, irritability, hunger, blurred vision, tingling of mouth or extremities)
◯◯ Hyperglycemia (thirst, nausea, abdominal pain, frequent urination, flushed dry skin, fruity breath)

Front 25

Gestational Hypertension/Pregnancy -Induced Hypertension

Back 25

Hypertensive disease in pregnancy is divided into clinical subsets of the disease based on end-organ effects and progresses along a continuum from mild gestational hypertension, mild and severe preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome.
●● Vasospasm contributing to poor tissue perfusion is the underlying mechanism for the signs and symptoms of pregnancy hypertensive disorders.

Front 26

Gestational hypertension (GH)

Back 26

begins after the 20th week of pregnancy, describes
hypertensive disorders of pregnancy whereby the woman has an elevated blood pressure at:
140/90 mm Hg or greater,
or a systolic increase of 30 mm Hg
or a diastolic increase of 15 mm Hg from the prepregnancy baseline.
There is no proteinuria or edema. The client’s blood pressure returns to baseline by 12 weeks postpartum.

Front 27

Mild preeclampsia

Back 27

Mild preeclampsia is GH with the addition of proteinuria of 1 to 2+ and a weight gain of more than 2 kg (4.4 lb) per week in the second and third trimesters. Mild edema will also begin to appear in the upper extremities or face.

Front 28

Severe preeclampsia

Back 28

consists of blood pressure that is 160/100 mm Hg or greater, proteinuria 3 to 4+, oliguria, elevated serum creatinine greater than 1.2 mg/dL, cerebral or visual disturbances (headache and blurred vision), hyperreflexia with possible ankle clonus, pulmonary or cardiac involvement, extensive peripheral edema, hepatic dysfunction, epigastric and right upper-quadrant pain, and thrombocytopenia.

Front 29

Eclampsia

Back 29

is severe preeclampsia symptoms along with the onset of seizure activity or coma. Eclampsia is usually preceded by headache, severe epigastric pain, hyperreflexia, and hemoconcentrations, which are warning signs of probable convulsions.

Front 30

HELLP syndrome

Back 30

is a variant of GH in which hematologic conditions coexist with severe
preeclampsia involving hepatic dysfunction. HELLP syndrome is diagnosed by laboratory tests, not clinically.
◯◯ H – hemolysis resulting in anemia and jaundice
◯◯ EL – elevated liver enzymes resulting in elevated alanine aminotransferase (ALT) or aspartate transaminase (AST), epigastric pain, and nausea and vomiting
◯◯ LP – low platelets (< 100,000/mm3), resulting in thrombocytopenia, abnormal
bleeding and clotting time, bleeding gums, petechiae, and possibly DIC

Front 31

Gestational hypertensive diseases

Back 31

are associated with placental abruption, acute renal failure, hepatic rupture, preterm birth, and fetal and maternal death

Front 32

Gestational hypertensive diseases
S/S subjective

Back 32

●● Subjective Data
◯◯ Severe continuous headache
◯◯ Nausea
◯◯ Blurring of vision
◯◯ Flashes of lights or dots before the eyes

Front 33

Gestational hypertensive diseases
S/S objective

Back 33

■■ Hypertension
■■ Proteinuria
■■ Periorbital, facial, hand, and abdominal edema
■■ Pitting edema of lower extremities
■■ Vomiting
■■ Oliguria
■■ Hyperreflexia
■■ Scotoma - alteration in the field of vision
■■ Epigastric pain (indicates liver involvement)
■■ Right-upper quadrant pain
■■ Dyspnea
■■ Diminished breath sounds
■■ Seizures
■■ Jaundice
■■ Signs of progression of hypertensive disease with indications of worsening liver
involvement, renal failure, worsening hypertension, cerebral involvement, and
developing coagulopathies
■■ Rapid weight gain (2 kg [4.4 lb]) per week in the second and third trimesters

Front 34

Medications
Gestational hypertensive diseases

Back 34

◯◯ Magnesium sulfate
■■ Anticonvulsant
■■ Administer IV magnesium sulfate, which is the medication of choice for
prophylaxis or treatment. It will lower blood pressure and depress the CNS.

Front 35

◯◯ Nursing considerations
Magnesium Sulfate

Back 35

◯◯ Nursing considerations
■■ Use an infusion control device to maintain a regular flow rate.
■■ Inform the client that she may initially feel flushed, hot, and sedated with the
magnesium sulfate bolus.
■■ Monitor the client’s blood pressure, pulse, respiratory rate, deep-tendon reflexes,
level of consciousness, urinary output (indwelling urinary catheter for accuracy),
presence of headache, visual disturbances, epigastric pain, uterine contractions,
and FHR and activity.
■■ Place the client on fluid restriction of 100 to 125 mL/hr, and maintain a urinary
output of 30 mL/hr or greater.
■■ Monitor the client for signs of magnesium sulfate toxicity.

Front 36

Magnesium Sulfate Toxicity

Back 36

☐☐ Absence of patellar deep tendon reflexes
☐☐ Urine output less than 30 mL/hr
☐☐ Respirations less than 12/min
☐☐ Decreased level of consciousness
☐☐ Cardiac dysrhythmias
◯◯ If magnesium toxicity is suspected:
■■ Immediately discontinue infusion.
■■ Administer antidote calcium gluconate.
■■ Prepare for actions to prevent respiratory or cardiac arrest.

Front 37

Risk factors for hyperemesis gravidarum

Back 37

obesity, multifetal gestation, vitamin B
deficiencies, and maternal age less than 20

Front 38

5. A nurse is caring for a client who is diagnosed with mitral valve prolapse. The client’s ECG findings
reveal tachyarrhythmias. Which of the following medications should the nurse anticipate the primary
care provider will prescribe?
A. Propranolol (Inderal)
B. Gentamicin (Garamycin)
C. Digoxin (Lanoxin)
D. Nifedipine (Procardia)

Back 38

Propranolol is prescribed to treat arrhythmias. Gentamicin is an antibiotic prophylaxis prescribed to prevent endocarditis. Digoxin is used to increase cardiac output during pregnancy. Nifedipine is given late in pregnancy to control high blood pressure.

Front 39

Newborn urine/stools

Back 39

Newborns should have 6 to 8 wet diapers a day with adequate feedings and may have
3 to 4 stools per day.

Front 40

Newborn-Wellness Checkups

Back 40

◯◯ Parents should be advised that their newborn will require well-newborn checkups at 2
to 6 weeks of age, and then every 2 months until 6 months of age. Newborns who are
breastfed usually have a weight check around 2 days after discharge.
◯◯ The schedule for immunizations should be reviewed with the parents. The nurse
should stress the importance of receiving these immunizations on a schedule
for the newborn to be protected against diphtheria, tetanus, pertussis, hepatitis
B, Haemophilus influenzae, polio, measles, mumps, rubella, influenza, rotavirus,
pneumococcal, and varicella.

Front 41

Signs of Illness to Report
Newborn

Back 41

■■ A fever above 38° C (100.4° F) or a temperature below 36.6° C (97.9° F)
■■ Poor feeding or little interest in food
■■ Forceful vomiting or frequent vomiting
■■ Decreased urination
■■ Diarrhea or decreased bowel movements
■■ Labored breathing with flared nostrils or an absence of breathing for greater than
15 seconds
■■ Jaundice
■■ Cyanosis
■■ Lethargy
■■ Inconsolable crying
■■ Difficulty waking
■■ Bleeding or purulent drainage around umbilical cord or circumcision
■■ Drainage developing in eyes.
●● Parents should be instructed in relieving airway obstruction.

Front 42

The nurse will provide care for the newborn after
the circumcision and prior to discharge. Identify the priority nursing intervention that should be
included in the newborn’s postcircumcision care.

Back 42

Observe the newborn for bleeding by conducting checks every 15 min for 1 hr and then
every hour for at least 12 hr.

Front 43

A nurse is aware that which of the following is a contraindication for circumcising a male newborn?

Back 43

In hypospadias and epispadias, the urethra is located somewhere other than the tip of the
urethra, and the foreskin is needed for plastic surgery to repair the defect. Familiar history of
bleeding disorders, hypospadias, and epispadias are all contraindications for circumcision of
a newborn. Hydrocele and hyperbilirubinemia are not contraindications.

Front 44

A newborn has just been circumcised using a Gomco procedure. Which of the following nursing interventions is part of the initial care for this newborn?

Back 44

Petroleum gauze is applied to the site for 24 hr to prevent the skin edges from sticking to the diaper. Newborns should never be placed prone for any reason. Diapers are changed more frequently to inspect the site. Alcohol is contraindicated for circumcision care due to the fresh wound.

Front 45

PKU normal levels

Back 45

A normal result for PKU screening is 2 mg/dl. A result of 7 is a critical level and requires physician notification and the parents should be notified to bring infant in for further evaluation. Early intervention can prevent mental retardation.

Front 46

Ortolani's sign

Back 46

an audible click that occurs when the hip is moved reveals developmental dysplasia of the hip

Front 47

Calories during pregnancy

Back 47

◯◯ An increase of 340 calories/day is recommended during the second trimester. An increase of 452 calories/day is recommended during the third trimester.
◯◯ If the client is breastfeeding during the postpartum period, an additional intake of 330 calories/day is recommended during the first 6 months, and an additional intake of 400 calories/day is recommended during the second 6 months.

Front 48

folic acid

Back 48

increasing the intake of foods high in folic acid is crucial for neurological development and the prevention of neural tube defects. Foods high in folic acid include leafy vegetables, dried peas and beans, seeds, and orange juice. Breads, cereals, and other grains are fortified with folic acid. Increased intake of folic acid should be encouraged for clients who wish to
become pregnant and clients of childbearing age. It is recommended that 600 mcg of folic acid should be taken during pregnancy. Current recommendations for clients who are lactating include consuming 500 mcg of folic acid.

Front 49

Iron supplements

Back 49

Iron is best absorbed between meals and when given with a good source of vitamin C. Milk and caffeine interfere with the absorption of iron supplements. Good food sources of iron include beef liver, red meats, fish, poultry, dried peas and beans, and fortified cereals and breads. A stool softener may need to be added to decrease constipation experienced with iron supplements.

Front 50

Calcium

Back 50

involved in bone and teeth formation.
■■ Good sources of calcium include milk, calcium-fortified soy milk, fortified orange
juice, nuts, legumes, and dark green leafy vegetables. Daily recommendation is
1,000 mg/day for pregnant and nonpregnant women over the age of 19, and 1,300 mg/day for those under 19 years of age.

Front 51

fluids

Back 51

2 to 3 L of fluids is recommended daily. Fluids that are preferable include water, fruit juice, or milk.
◯◯ Caffeine intake should be limited to 300 mg/day. The equivalent of 500 to 750 mL/day of coffee may increase the risk of a spontaneous abortion or fetal intrauterine growth restriction.
◯◯ It is recommended that women abstain from alcohol consumption during pregnancy.

Front 52

For nausea

Back 52

tell the client to eat dry crackers or toast. Have her avoid alcohol, caffeine,
fats, and spices. Also avoid drinking fluids with meals, and DO NOT take a medication
to control nausea without first checking with the primary care provider.
◯◯ For constipation, increase fluid consumption and include extra fiber in the diet. Fruits, vegetables, and whole grains all contain fiber.

Front 53

Maternal phenylketonuria (PKU)

Back 53

high levels of phenylalanine pose danger to the fetus.
◯◯ It is important for the female client to resume the PKU diet for at least 3 months prior to pregnancy and continue the diet throughout pregnancy.
◯◯ The diet should include foods that are low in phenylalanine. Foods high in protein,
such as fish, poultry, meat, eggs, nuts, and dairy products, must be avoided due to
high phenylalanine levels.
avoids mental retardation

Front 54

Standard conversion factors

Back 54

◯◯ 1 mg = 1,000 mcg
◯◯ 1 g = 1,000 mg
◯◯ 1 kg = 1,000 g
◯◯ 1 oz = 30 mL
◯◯ 1 L = 1,000 mL
◯◯ 1 tsp = 5 mL
◯◯ 1 tbsp = 15 mL
◯◯ 1 tbsp = 3 tsp
◯◯ 1 kg = 2.2 lb
◯◯ 1 gr = 60 mg

Front 55

Paternal transition to fatherhood

Back 55

consists of a predictable three-stage process during the first few weeks of transition.
◯◯ Expectations – the father has preconceived ideas about what it will be like to be a father.
◯◯ Reality – the father discovers that his expectations may not be met. Commonly
expressed emotions include feeling sad, frustrated, and jealous. He embraces the need to be actively involved in parenting.
◯◯ Transition to mastery – the father decides to become actively involved in the care of the infant.

Front 56

Physiologic changes preceding labor (premonitory signs) include:

Back 56

◯◯ Backache – a constant low, dull backache, caused by pelvic muscle relaxation
◯◯ Weight loss – a 0.5 to 1 kg (1 to 3 lb) weight loss
◯◯ Lightening – fetal head descends into true pelvis about 14 days before labor; feeling that the fetus has “dropped;” easier breathing, but more pressure on bladder, resulting in urinary frequency; more pronounced in clients who are primigravida
◯◯ Contractions – begin with irregular uterine contractions (Braxton Hicks) that
eventually progress in strength and regularity
◯◯ Bloody show – brownish or blood-tinged mucus discharge caused by expulsion of the cervical mucus plug resulting from the onset of cervical dilation and effacement
◯◯ Energy burst – sometimes called “nesting” response
◯◯ Gastrointestinal changes – less common, include nausea, vomiting, and indigestion
◯◯ Rupture of membranes

Front 57

Rupture of membranes

Back 57

■■ Labor usually occurs within 24 hr of the rupture of membranes.
■■ Prolonged rupture of membranes greater than 24 hr before delivery of fetus may lead to an infection.
■■ Immediately following the rupture of membranes, a nurse should assess the FHR for abrupt decelerations, which are indicative of fetal distress to rule out umbilical cord prolapse.

Front 58

Assessment of amniotic fluid

Back 58

completed once the membranes rupture
■■ Color should be pale to straw yellow
■■ Odor should not be foul
■■ Clarity should appear watery and clear
■■ Volume is between 500 to 1,200 mL
■■ Nitrazine paper should be used by a nurse to test fluid to confirm that it is
amniotic.
☐☐ Nitrazine tests the pH of the amniotic fluid. Deep blue (6.5 to 7.5) indicates
fluid that is alkaline. If the fluid remains yellow, this indicates slight acidity
because the fluid is urine.

Front 59

There are five factors (the five “Ps”) that affect and define the labor and birth process:

Back 59

passenger, passageway, powers, position, and psychologic response.

Front 60

Passenger

Back 60

consists of the fetus and the placenta. The size of the fetal head, fetal
presentation, lie, position, and attitude affect the ability of the fetus to navigate the
birth canal. The placenta can be considered a passenger because it must also pass
through the canal.

Front 61

Lie

Back 61

the relationship of the maternal longitudinal axis (spine) to the fetal longitudinal axis (spine).
☐☐ Transverse – fetal long axis is horizontal and forms a right angle to maternal axis and will not accommodate vaginal birth. The shoulder is the presenting
part and may require delivery by cesarean birth if the fetus does not rotate
spontaneously.
☐☐ Parallel or longitudinal – fetal long axis is parallel to maternal long axis,
either a cephalic or breech presentation. Breech presentation may require a
cesarean birth.

Front 62

Attitude

Back 62

relationship of fetal body parts to one another.
☐☐ Fetal flexion – chin flexed to chest, extremities flexed into torso.
☐☐ Fetal extension – chin extended away from chest, extremities extended.

Front 63

Presentation

Back 63

the part of the fetus that is entering the pelvic inlet first. It can be the back of the head (occiput), chin (mentum), shoulder (scapula), or breech (sacrum or feet).

Front 64

Fetopelvic or fetal position

Back 64

the relationship of the presenting part of the
fetus (sacrum, mentum, or occiput) preferably the occiput, in reference to its
directional position as it relates to one of the four maternal pelvic quadrants. It is
labeled with three letters.
☐☐ The first letter references either the right (R) or left (L) side of the maternal
pelvis.
☐☐ The second letter references the presenting part of the fetus, either occiput
(O), sacrum (S), mentum (M), or scapula (Sc).
☐☐ The third letter references either the anterior (A), posterior (P), or transverse
(T) part of the maternal pelvis.

Front 65

Station

Back 65

measurement of fetal descent in centimeters with station 0 being at the level of an imaginary line at the level of the ischial spines, minus stations superior to the ischial spines, and plus stations inferior to the ischial spines.

Front 66

Passageway –

Back 66

the birth canal that is composed of the bony pelvis, cervix, pelvic floor, vagina, and introitus (vaginal opening). The size and shape of the bony pelvis must be adequate to allow the fetus to pass through it. The cervix must dilate and efface in
response to contractions and fetal descent.

Front 67

Powers –

Back 67

uterine contractions cause effacement and dilation of the cervix and descent of the fetus. Involuntary urge to push and voluntary bearing down in the second stage
of labor helps in the expulsion of the fetus.

Front 68

Position –

Back 68

of the woman who is in labor. The client should engage in frequent position
changes during labor to increase comfort, relieve fatigue, and promote circulation.
Position during the second stage is determined by maternal preference, primary care provider preference, and the condition of the mother and the fetus.
■■ Gravity can aid in the fetal descent in upright, sitting, kneeling, and squatting
positions.

Front 69

Psychological response –

Back 69

Psychological response – maternal stress, tension, and anxiety can produce
physiological changes that impair the progress of labor.

Front 70

Urinalysis

Back 70

clean-catch urine samples obtained to ascertain maternal:
☐☐ Hydration status via specific gravity.
☐☐ Nutritional status via ketones.
☐☐ Proteinuria, which is indicative of pregnancy-induced hypertension.
☐☐ Urinary tract infection via bacterial count.
☐☐ Beta-strep culture to check for streptococcus ß-hemolytic, Group B.

Front 71

■■ Blood tests

Back 71

☐☐ Hct level
☐☐ ABO typing and Rh-factor if not previously done

Front 72

Characteristics of True vs. False Labor
True Labor

Back 72

• Contractions
◯◯ May begin irregularly, but become
regular in frequency
◯◯ Stronger, last longer, and are more
frequent
◯◯ Felt in lower back, radiating to
abdomen
◯◯ Walking can increase contraction
intensity
◯◯ Continue despite comfort measures
• Cervix (assessed by vaginal exam)
◯◯ Progressive change in dilation and
effacement
◯◯ Moves to anterior position
◯◯ Bloody show
• Fetus
◯◯ Presenting part engages in pelvis

Front 73

Characteristics of True vs. False Labor
False Labor

Back 73

• Contractions
◯◯ Painless, irregular frequency, and
intermittent
◯◯ Decrease in frequency, duration, and
intensity with walking or position
changes
◯◯ Felt in lower back or abdomen above
umbilicus
◯◯ Often stop with sleep or comfort
measures such as oral hydration or
emptying of the bladder
• Cervix (assessed by vaginal exam)
◯◯ No significant change in dilation or
effacement
◯◯ Often remains in posterior position
◯◯ No significant bloody show
• Fetus
◯◯ Presenting part is not engaged in
pelvis

Front 74

Mechanism of labor

Back 74

☐☐ Engagement
☐☐ Descent
☐☐ Flexion – when the fetal head meets resistance of the cervix, pelvic wall, or
pelvic floor. The head flexes bringing the chin close to the chest, presenting
a smaller diameter to pass through the pelvis.
☐☐ Internal rotation – the fetal occiput ideally rotates to a lateral anterior
position as it progresses from the ischial spines to the lower pelvis in a
corkscrew motion to pass through the pelvis.
☐☐ Extension – the fetal occiput passes under the symphysis pubis and then the
head is deflected anteriorly and is born by extension of the chin away from
the fetal chest.
☐☐ Restitution and external rotation – after the head is born, it rotates to the
position it occupied as it entered the pelvic inlet (restitution) in alignment
with the fetal body and completes a quarter turn to face transverse as the
anterior shoulder passes under the symphysis.
☐☐ Expulsion – after birth of the head and shoulders the trunk of the neonate is
born by flexing it toward the symphysis pubis.

Front 75

Stages of labor

First stage:

Back 75

12 1/2 hr (average)
• Onset of labor
Begins With • Complete dilation
Ends With • Cervical dilation
Maternal Characteristics- 1 cm/hr for clients who are primigravida, and 1.5 cm/hr for clients who are multigravida, on average

Front 76

Stages of labor
Latent Phase:

Back 76

• Duration -Primigravida: 6 hr (approximately)
• Duration -Multigravida 4 hr
(approximately)
Begins With • Cervix 0 cm
• Irregular, mild to moderate contractions
• Frequency 5 to 30 min
• Duration 30 to 45 seconds

Ends With • Cervix 3 cm
Maternal Characteristics
• Some dilation and effacement
• Talkative and eager

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Stages of labor
Active Phase:

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• Duration
Primigravida: 3 hr (approximately)
Multigravida: 2 hr (approximately)
Begins With • Cervix 4 cm
• More regular, moderate to strong contractions
• Frequency 3 to 5 min
• Duration 40 to 70 seconds
Ends With • Cervix 7 cm dilate
Maternal Characteristics
• Rapid dilation and effacement
• Some fetal descent
• Feelings of helplessness
• Anxiety and restlessness increase as
contractions become stronger

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Stages of labor
Transition:

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• Duration: Approximately 20 to 40 min
Begins With • Cervix 8 cm
• Strong to very strong contractions
• Frequency 2 to 3 min
• Duration 45 to 90 seconds
Ends With • Complete dilation at 10 cm
Maternal Characteristics
• Tired, restless, and irritable
• Feeling out of control, client often states,
“cannot continue”
• May have nausea and vomiting
• Urge to push
• Increased rectal pressure and feelings of
needing to have a bowel movement
• Increased bloody show
• Most difficult part of labor

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Stages of labor
Second Stage:

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• Duration
Primigravida: 30 min to 2 hr
Multigravida: 5 to 30 min
Begins With • Full dilation
• Intense contractions every 1 to 2 min
Ends With • Birth
Maternal Characteristics
• Pushing results in birth of fetus

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Stages of labor
Third Stage:

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• Duration
Primigravida and Multigravida: 5 to 30 min
Begins With • Delivery of the neonate
Ends With • Delivery of placenta
Maternal Characteristics
• Placental separation and expulsion
• Schultze presentation: shiny fetal surface of placenta emerges first
• Duncan presentation: dull maternal surface of placenta emerges first

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Stages of labor
Fourth Stage:

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• Duration
Primigravida and Multigravida: 1 to 4 hr
Begins With • Delivery of placenta
Ends With • Maternal stabilization of vital signs
Maternal Characteristics
• Achievement of vital sign homeostasis
• Lochia scant to moderate rubra

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Nursing interventions during the fourth stage

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■■ Assess maternal vital signs every 15 min for the first hour and then according to
facility protocol.
■■ Assess fundus and lochia every 15 min for the first hour and then according to
facility protocol.
■■ Massage the uterine fundus and/or administer oxytocics as prescribed to maintain uterine tone to prevent hemorrhage.
■■ Assess the client’s perineum and provide comfort measures as indicated.
■■ Encourage voiding to prevent bladder distention.
■■ Promote an opportunity for maternal/newborn bonding.

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Sources of pain during the stages of labor

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First stage – labor pain is an internal visceral pain that may be felt as back and leg pain
Second stage – labor pain that is somatic and occurs with fetal descent and expulsion.
Third stage – labor pain with the expelling of the placenta is similar to the pain
experienced during the first stage.
Fourth stage – pain is caused by:
■■ Distention and stretching of the vagina and perineum incurred during the second
stage with a splitting, burning, and tearing sensation.

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Sedatives (barbiturates)

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such as secobarbital (Seconal), pentobarbital (Nembutal), and phenobarbital (Luminal) are not typically used during birth, but can be used
during the early or latent phase of labor to relieve anxiety and induce sleep.
☐☐ Adverse effects of sedatives
XX Neonate respiratory depression secondary to the medication crossing
the placenta and affecting the fetus
XX Unsteady ambulation of the client
XX Inhibition of the mother’s ability to cope with the pain of labor.
Sedatives should not be given if the client is experiencing pain, because apprehension can increase and cause the client to become hyperactive and disoriented.

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Opioid analgesics

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such as meperidine hydrochloride (Demerol), fentanyl (Sublimaze), butorphanol (Stadol), and nalbuphine (Nubain) act in the CNS to decrease the perception of pain without the loss of consciousness. The client may be given opioid analgesics IM or IV, but the IV route is recommended during labor because action is quicker.
☐☐ Butorphanol (Stadol) and nalbuphine (Nubain) provide pain relief without
causing significant respiratory depression in the mother or fetus. Both IM and IV routes are used.

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Adverse effects of opioid analgesics

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XX Crosses the placental barrier; if given to the mother too close to the time of delivery, opioid analgesics can cause respiratory depression in the neonate.
XX Reduces gastric emptying; increases the risk for nausea and emesis
XX Increases the risk for aspiration of food or fluids in the stomach
XX Sedation
XX Tachycardia
XX Hypotension
XX Decreased FHR variability
XX Allergic reaction

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Nursing actions
opioid analgesics

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XX Prior to administering analgesic or anesthetic pain relief, the nurse should verify that labor is well established by performing a vaginal exam that reveals a cervical dilation of at least 4 cm with a fetus that is engaged.
XX Have naloxone (Narcan) available to counteract the effects of respiratory depression in the newborn.
XX Administer antiemetics as prescribed.
XX Monitor maternal vital signs, uterine contraction pattern, and continuous FHR monitoring.

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Epidural and spinal regional analgesia

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consists of using analgesics such as
fentanyl (Sublimaze) and sufentanil (Sufenta), which are short-acting opioids that are administered as a motor block into the epidural or intrathecal space without
anesthesia. These opioids produce regional analgesia providing rapid pain relief while still allowing the client to sense contractions and maintain the ability to
bear down.

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Adverse effects of epidural and spinal analgesia

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XX Decreased gastric emptying resulting in nausea and vomiting
XX Inhibition of bowel and bladder elimination sensations
XX Bradycardia or tachycardia
XX Hypotension
XX Respiratory depression
XX Allergic reaction and pruritus

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Nursing actions
epidural block

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XX Administer a bolus of IV fluids to help offset maternal hypotension as
prescribed.
XX Help to position and steady the client into either a sitting or sidelying
modified Sims’ position with her back curved to widen the intervertebral space for insertion of the epidural catheter.
XX Encourage the client to remain in the side-lying position after insertion of the epidural catheter to avoid supine hypotension syndrome with
compression of the vena cava.
XX Coach the client in pushing efforts and request an evaluation of epidural pain management by anesthesia if pushing efforts are ineffective.
XX Monitor maternal blood pressure and pulse, observe for hypotension,
respiratory depression, and oxygen saturations.
XX Assess FHR patterns continuously.
XX Maintain the IV line and have oxygen and suction ready.
XX Assess for orthostatic hypotension. If present, be prepared to
administer an IV vasopressor such as ephedrine, position the client
laterally, increase IV fluids, and initiate oxygen.
XX Provide client safety such as raising the side rails of the bed. Do not
allow the client to ambulate unassisted until all motor control has
returned.
XX Assess the maternal bladder for distention at frequent intervals and
catheterize if necessary to assist with voiding.