Maternity Client: Antepartum Care

 This
lesson reviews the normal, expected
occurrences during the antepartum
(prenatal) period, which is the interval
between fertilization and the beginning of
labor. Nursing care during the antepartum
period is also reviewed.
Gestation
 Gestation lasts approximately 280 days.
 (For
Nagele's rule to be accurate, the woman must
have a regular 28-day menstrual cycle.
 Nagele’s Rule:
 First day of LMP: September 19, 2016
 Subtract 3 months: June 19, 2016
 Add 7 days: June 26, 2016
 Add 1 year: June 26, 2017
 EDD: June 26, 2017
SELF-CHECK
 A nurse in a prenatal clinic, performing an initial assessment
of a pregnant client, is using Nägele's rule to determine the
client's estimated date of delivery (EDD). The client tells the
nurse that her last menstrual period (LMP) began on February
10, 2016. What EDD does the nurse calculate with this
information?
 October 17, 2016
 November 17, 2016
 September 17, 2016
 December 17, 2017
Answer: 2
 Rationale:For Nägele's rule to be accurate, the
woman must have a regular 28-day menstrual cycle.
The nurse would subtract 3 months and then add 7
days to the first day of the LMP, then add 1 year to
that date. Subtracting 3 months from February 10,
2016 is November 10, 2015. Adding 7 days to
November 10, 2015 is November 17, 2015. Adding 1
year to November 17, 2015 yields the correct answer,
November 17, 2016.
Gravida and Parity
 Gravida is used to refer to the number of pregnancies or to
the pregnant woman herself.
 Gravidity is the state of being pregnant.
 A nulligravida is a woman who has never been pregnant.
 A primigravida is a woman who is pregnant for the first time.
 A multigravida is a woman in at least her second
pregnancy.
Parity
 Parity
is the number of births (not the number of
fetuses—e.g., twins) carried past 20 weeks’ gestation,
whether or not the fetuses were born alive.
Anullipara is a woman who has not had a birth at
more than 20 weeks of gestation.
A primipara is a woman who has had one birth that
occurred after the 20th week of gestation.
A multipara is a woman who has had two or more
pregnancies resulting in viable offspring.
 Pregnancy outcomes: use of the GTPAL acronym:
G the number of pregnancies, including the current one.
T term births, the number of children born at term (longer
than 37 weeks’ gestation).
Pis preterm births, the number of children born before 37
weeks’ gestation.
A abortions and miscarriages, the number of abortions
and/or miscarriages (included in gravida if before 20
weeks’ gestation; included in parity if past 20 weeks’
gestation).
· L stands for the number of current living children.
Example:
A woman is pregnant for the fifth time. She has
undergone two elective abortions, both in the first
trimester; gave birth to a daughter at 40 weeks’
gestation; and gave birth to a son at 35 weeks’
gestation.
 GTPAL = 5, 1, 1, 2, 2
 Therefore she is gravida (G) 5 and para 2; term (T) 1 (the daughter
born at 40 weeks); preterm (P), 1 (the son born at 35 weeks);
abortion (A), 2 (the abortions are counted in the gravidity but not
included in the parity because they were performed before 20
weeks’s gestation); and living children (L), 2.
SELF-CHECK
 A nurse is obtaining an obstetric history from a client who is
pregnant. The client tells the nurse that she gave birth to twins at
36 weeks' gestation and had a stillbirth at 24 weeks. The client
also reports that she experienced a spontaneous abortion at 12
weeks' gestation. How should the nurse document the woman's
pregnancies?
1. Gravida 2, para 4
2. Gravida 3, para 5
3. Gravida 4, para 2
4. Gravida 5, para 3
Answer: 2
 Rationale: Gravida refers to the number of pregnancies,
of any length, that the woman has had. Para (parity)
refers to the number of pregnancies that have
progressed past 20 weeks at delivery. Because the client
is pregnant and was pregnant with twins, pregnant
before the stillbirth at 24 weeks, and pregnant before
experiencing a spontaneous abortion at 12 weeks'
gestation, she is referred to as gravida 4. Because only
two of the pregnancies progressed past 20 weeks, she is
para 2. Therefore the client is gravida 4, para 2.
Signs of Pregnancy
 Presumptive Signs
 Amenorrhea
 Nausea and vomiting
 Increased size and feeling of fullness in breasts
 Pronounced nipples
 Urinary frequency
 Quickening- fetal movement between 16th-20th week of
pregnancy
 Fatigue
 Discoloration and thickening of the vaginal mucosa
Probable signs
 Uterine enlargement
 Hegarsign- softening of the lower uterine segment,
around 6 weeks of gestation
 Goodell sign- softening of the cervix- second month
of gestation
 Chadwick sign- violet discoloration of the mucous
membrane of the cervix, vagina, and vulva- 4 weeks
of pregnancy
 Ballottement- rebounding of the fetus
 Positive result on pregnancy test (hCG)
Positive signs
 Fetal
heart rate, detectable with an electronic device
(Doppler transducer) at 10 to 12 weeks and with a
nonelectronic device (fetoscope) at 20 weeks of
gestation
 Active fetal movements palpable by examiner
 Outline of fetus on ultrasound
SELF-CHECK
 A nurse reviewing the record of a client seen in the clinic
notes that the nurse-midwife documented the presence of
the Goodell sign during examination of the client. What
conclusion does the nurse make on the basis of this finding?
1. The client is definitely pregnant.
2. The nurse-midwife noted softening of the cervix.
3. The client exhibits a presumptive sign of pregnancy.
4. The nurse-midwife noted a violet coloration of the cervix.
Answer: 2
 Rationale: In the early weeks of pregnancy, the cervix softens as a
result of pelvic congestion (Goodell sign). Cervical softening is
noted on physical examination. The presence of the Goodell sign is
a probable indication of pregnancy. Another probable indication
of pregnancy is the Chadwick sign, in which the cervix changes
from pink to a violet color. Presumptive indications of pregnancy
are also termed subjective changes because they are
experienced and reported by the woman. Positive indications of
pregnancy include auscultation of fetal heart sounds, fetal
movement felt by the examiner, and visualization of the fetus on
ultrasonography.
Fundal Height
 The fundal height is measured to help gauge the fetus'
gestational age.
 During the second and third trimesters (weeks 18-30), fundal
height in centimeters approximately equals the fetus's age in
weeks, plus or minus 2 cm.
 At 16 weeks, the fundus can be found halfway between the
symphysis pubis and the umbilicus.
 At 20 to 22 weeks, the fundus is at the umbilicus.
 At 36 weeks, the fundus is at the xiphoid process.
 At 37-30 weeks= lower by 4 cm
Fundal Height
After delivery
1 hour- FH umbilicus- decrease 1 cm/day: 24
hours post I cm below the navel
 48 hours=2 cm below the navel
 7 days: symphysis pubis
 10 days: non-palpable
 6 weeks= pre-pregnancy site
Physiological Maternal Changes
 Circulating blood and plasma volumes increase.
 Physiological anemia occurs as the plasma increase
exceeds the increase in RBC production.
 Iron requirements are increased.
 The heart is elevated and moved to the left because of
displacement of the diaphragm as the uterus enlarges.
 Pulse may increase by about 10 beats per minute.
 Blood pressure may decline in the second trimester
 Retention of sodium and water may occur.
Integumentary System
 A dark streak, or linea nigra, may appear down the midline
of the abdomen.
 Chloasma (the "mask of pregnancy"), a blotchy brownish
hyperpigmentation, may appear over the forehead,
cheeks, and nose.
 Reddish-purple stretch marks (striae) may appear on the
abdomen, breasts, thighs, and upper arms.
 Vascular spider nevi may appear on the neck, chest, face,
arms, and legs.
 The rate of hair growth may slow.
Discomforts of Pregnancy
 Nausea and Vomiting
 Occur in the first trimester
 Result
from increased hCG level and changes in
carbohydrate metabolism
 Interventions
 Eating dry crackers before arising
 Eating small, frequent low-fat meals during the day
 Drinking liquids between meals rather than at meals
 Avoiding fried foods and spicy foods
 Accupressure (some types may require a
prescription)
 Herbalremedies, only if approved by health care
provider or nurse-midwife (click to learn more about
complementary therapies for nausea)
Heartburn
 Occurs in the second and third trimesters,
 From an increased progesterone level,
decreased gastrointestinal motility and
esophageal reflux, and displacement of the
stomach by the enlarging uterus.
Interventions
 Client should eat small, frequent meals.
 Advise client to sit upright for 30 minutes after a meal.
 Milk should be drunk between meals.
 Fatty and spicy foods should be avoided.
 Teach client to perform tailor-sitting exercises.
 Client
should take antacids only if they are
recommended by the health care provider or nurse-
midwife.
Syncope and Supine Hypotension

 Syncope usually occurs in the first trimester;

 Supine hypotension occurs particularly in the
second and third trimesters.
 These problems may be hormonally triggered or
caused by increased blood volume, anemia,
fatigue, sudden position changes, or lying supine
Interventions
 Sittingwith the feet elevated and changing
positions slowly helps prevent syncope.
 Changing the position to the lateral recumbent
(right or left side) to relieve the pressure of the uterus
on the inferior vena cava may help prevent supine
hypotension.
SELF-CHECK
Laboratory tests are performed on a woman in the first trimester
of pregnancy, and the results indicate that she is negative for Rh
factor. Which explanation of this finding should the nurse provide
to the woman?
1. The result of the Rh factor screen is normal.
2. Because the Rh factor is not present, no additional testing is
necessary.
3. Because the Rh factor is not present, the newborn infant will
need to receive immunization immediately after birth.
4. Because the Rh factor is not present, the client will need to
receive Rh immune globulin at about 28 weeks' gestation.
ANSWER: 4
 RATIONALE: If the client is Rh negative and the result
of an antibody screen is negative, she will need
repeat antibody screens and should receive Rh
immune globulin around 28 weeks' gestation to
prevent the formation of anti-Rh antibodies. An Rh-
negative woman should also receive Rh immune
globulin within 72 hours of delivery if her newborn is
Rh-positive. On the basis of the data provided in the
question, the other options are incorrect.
α-Fetoprotein (AFP) Screening

 Thisassay is used to assess the quantity of fetal serum

proteins; an increased level is associated with an
open neural tube (e.g., spina bifida) and abdominal
wall defects; it is also used to detect Down
syndrome.
Implementation
 Explain that the AFP level is determined with the use of
a single maternal blood sample drawn at 16 to 18
weeks' gestation.
 If the level is increased and the gestation is of less
than 18 weeks, a second sample is drawn.
 In the presence of an increased AFP level, ultrasound
is performed to rule out fetal abnormalities or multiple
gestation.
Amniocentesis
 Amniotic fluid is aspirated between 15 and 20
weeks of pregnancy to enable detection of
genetic disorders and metabolic defects and to
aid assessment of fetal lung maturity.
Implementation
 Obtain informed consent.
 If the client is less than 20 weeks pregnant, she should have a full bladder
to support the uterus; if amniocentesis is being performed after 20 weeks’
gestation, the client should have an empty bladder to minimize the
chance of puncture.
 Prepare the client for ultrasonography, which is performed to locate the
placenta and avoid puncture.
 Obtain baseline vital signs and fetal heart rate (FHR); monitor every 15
minutes.
 Position the client supine during the exam and on the left side after the
procedure. Instruct the client to notify the health care provider or nurse-
midwife if chills or fever develops, fluid leaks from the needle-insertion site,
fetal movement decreases, or uterine contractions occur.
 Rh-negative women may be given RhoGAM to counter risks related to
the procedure.
Fern Test
 This simple test is used to determine whether amniotic fluid is
leaking.
 Implementation
 Position the client in the dorsal LITHOTOMY position
 Instruct the client to cough, which will cause fluid to leak from
the uterus if the membranes have ruptured.
 Under sterile technique, a specimen is obtained from the
external portion of the cervix and vaginal pool, then
examined on a slide under a microscope.
 A fernlike pattern, caused by the salts in the amniotic fluid,
indicates the presence of amniotic fluid.
Nitrazine Test
 Detect the presence of amniotic fluid in vaginal secretions,
which have a pH of 4.5 to 5.5 and do not affect the yellow
Nitrazine strip or swab. Amniotic fluid has a pH of 7.0 to 7.5
and turns the yellow Nitrazine strip blue.
 Implementation
 Position the client in the dorsal lithotomy position.
 Touch the test tape to the fluid.
 Assess the test tape for a blue-green, blue-gray, or deep-blue
color, all of which indicate that the membranes have
probably ruptured.
Nonstress Test (NST)
 Assess placental function and oxygenation
 Used to determines fetal well-being
 Enables evaluation of FHR in response to fetal movement
 Implementation
 External ultrasound transducer and the tocodynamometer
(a.k.a. the "toco") are applied to the mother, and a
tracing of at least 20 minutes' duration is obtained so that
the FHR and the uterine activity may be observed.
Implementation
 Obtainbaseline blood pressure and recheck pressure
frequently.
 Position
mother in the lateral position to avoid vena
cava compression.
 Themother may be asked to press a button every
time she feels fetal movement; the monitor records
each point of fetal movement, and the record is
used as a reference against which to assess FHR
response.
REACTIVE
 Normal/negative
 Indicates a healthy fetus
 Two or more FHR accelerations of at least 15 beats
per minute, lasting at least 15 seconds from the
beginning of the acceleration to the end, in
association with fetal movement, during a 20-minute
period
 NON-REACTIVE
 Abnormal
 Noaccelerations or accelerations of less than
15 beats per minute or lasting less than 15
seconds during a 40-minute observation
Nutrition
 The average weight gain during pregnancy is 25 to 35 lbs (11
to 16 kg) for women of normal prepregnancy weight.
 An increase of about 300 calories per day is needed during
pregnancy.
 Caloric needs are greater in the last two trimesters than in the
first.
 An increase of about 500 calories per day is needed during
lactation.
 Theclient should be encouraged to consume a diet
high in folic acid and to take a folic acid supplement;
a diet rich in folic acid is necessary for all women of
childbearing age to prevent neural-tube defect in the
fetus during the first trimester of pregnancy.
 Theclient should drink at least eight to ten 8-oz (235ml)
glasses of fluid each day, four to six of them water.
 Sodium is not restricted unless specifically prescribed
by the health care provider or nurse-midwife.
Maternity Client: Intrapartum
Care
The Stages of Labor
 Stage 1
 Includes latent, active, and transition stages
 100% Effacement and dilation of the cervix occurs (0-10)
 LONGEST stage (primi)
 Latent= 1-4 cm , CONTRACTIONS= every 5-30 mins, 30-45 sec,
should stay at home or water breaks
 Active- 4-7 cm (1cm/hr) CONTRACTIONS= 3-5 mins, 45-60 secs
 Lasts 4-8 hrs, water may break= MECONIUM?= brown/yellow
green fluid, perform Nitrazine paper,
 Transition= 8-10cm , shortest phase, most painful, 30 mins to 2
hours, contractions= every 2-3 mins and 60-90 secs in length
 0= engage ischial spine,
The Stages of Labor
 Stage 2
 Full dilation and effaced= descending- intense pressure- station +1-+5
 Primi- 2-3 hours , multipara (20 mins)
 Expulsion of the fetus

 Stage 3
 5-15 mins, umbilical lengthens,
 Delivery mechanisms: Shiny “Schultze”: side of the baby, Dull/Dirty
Duncan: side of the mother: dull red and rough
 Full delivery of the baby
 Separation and expulsion of the placenta
 Pitocin after delivery of placenta
The Stages of Labor

 Stage 4
 Physical recovery; 1 to 4 hours after
 Monitor V/S
 Lochia- moderate to red no large clots, assess peri-
pad
 Fundus: firm, mid-line, near or at umbilicus
 Pericare (ice and witch of hazel)
The Process of Labor
 Attitude
 · Attitude is the relationship of the fetal body parts to one
another.
 · The normal intrauterine attitude is flexion, in which the fetal
back is rounded, the head is forward on the chest, and the
arms and legs are folded against the body.
 Lie
 Lie is the relationship of the spine of the fetus to the spine of
the mother.
Station
 Measurement of the progress of descent, in
centimeters, above or below the midplane from the
presenting part to the ischial spine
 Station 0: at ischial spine
 Minus station: above ischial spine
 Plus station: below ischial spine
Anesthesia
 Local Anesthesia
 Used to block pain during episiotomy
 Administered just before birth of baby
 No effect on fetus
 Pudendal Block
 Administered just before birth of baby
 Injection site at pudendal nerve by way of a transvaginal
route
 Blocks perineal area for episiotomy
 Effect lasts about 30 minutes
 No effect on contractions or fetus
 Lumbar Epidural Block
 Injection site in epidural space at L3-L4
 Administered after labor is established or just before a
scheduled cesarean birth
 Relieves pain of contractions and numbs vagina and
perineum
 May cause hypotension
 Does not cause headache, because the dura mater is not
penetrated
 Assess maternal BP Mother maintained in side-lying position or
with a rolled blanket beneath the right hip to displace the
uterus from the vena cava
 Subarachnoid (Spinal) Block
 Injection site in spinal subarachnoid space at L3-L5
 Administered just before birth
 Relieves uterine and perineal pain and numbs vagina,
perineum, and lower extremities
 May cause maternal hypotension
 May cause bladder distension and postpartum
headache
 Requires mother to lie flat for 8 to 12 hours after spinal
injection
 Administration of IV fluids as prescribed
 General Anesthesia
 May be used for some surgical interventions
 Mother not awake
 Presents the risk of respiratory depression and
vomiting
Amniotomy
 Artificial rupture of membranes (AROM)- performed by the health
care provider or nurse-midwife to stimulate labor if the fetus is at zero
or + station.
 Increases the risk of cord prolapse and infection.
 Monitor FHR before and after AROM.
 Record time of AROM, FHR, and characteristics of fluid.
 Meconium-stained amniotic fluid may be associated with fetal
distress.
 Bloody amniotic fluid may indicate abruptio placentae or fetal
trauma.
 An unpleasant odor to amniotic fluid is associated with infection.
 Expect more variable decelerations after rupture of the membranes
as a result of cord compression during contractions.
Episiotomy
 After Episiotomy
 Check episiotomy site.
 Institute measures to relieve pain.
 Provide ice pack for the 24 hours after procedure.
 Instruct the client in the use of sitz baths (immersion of the perineal or episiotomy area in the warm
water solution).
 Apply analgesic spray or ointment as prescribed.
 Provide perineal care, using clean technique; apply a peripad without touching the inside surface
of the pad.
 Instruct the client in proper care of incision.
 Instruct the client to dry perineal area from front to back and to blot area instead of wiping it.
 Instruct the client to shower rather than bathe in a tub to decrease the risk of infection at the
episiotomy site.
 Report any bleeding or discharge to the health care provider.
Maternity Client: Postpartum Care
Involution
 The weight of the uterus decreases from 2 lb to 2 oz (0.9kg to 57 gm) in 6
weeks.
 Immediately after delivery, the fundus can be palpated midway
between the symphysis pubis and umbilicus, after which it rises to a level
just above the umbilicus; next it sinks to the level of the umbilicus and
remains at this level for about 24 hours.
 After 24 hours, the fundus begins to descend by approximately 1 cm, or
one fingerbreadth, each day.
 By the 10th to 14th day after delivery, the fundus is in the pelvic cavity
and cannot be palpated abdominally.
 Note that a flaccid fundus indicates uterine atony and should be
massaged until firm; a tender fundus indicates infection.
Lochia
 Rubra is a bright-red discharge that appears from delivery day
to day 3.
 Serosa is a brownish-pink discharge that appears on days 4 to
10 after delivery.
 Alba is a white discharge that appears on days 10 to 14 after
delivery.
 Normally the discharge has a fleshy odor.
 Discharge diminishes daily but may increase with ambulation.
 Weigh perineal pad before and after use and identify the
amount of time between pad changes to most accurately
determine the amount of lochial flow.
Ovarian Function and Menstruation
 Ovarian function depends on the rapidity with which
pituitary function is restored.
 Menstrual flow resumes within 8 weeks in
nonbreastfeeding mothers.
 Menstrual flow usually resumes within 3 to 4 months in
breastfeeding mothers.
 Breastfeeding mothers may experience amenorrhea
during the entire period of lactation.
 Women may ovulate without menstruating, so
breastfeeding should not be considered a form of
birth control.
Breasts
 Breasts continue to secrete colostrum.
 A decrease in estrogen and progesterone levels after delivery
stimulates the secretion of prolactin, which promotes
production of breast milk.
 Breasts become distended with milk on the third day after
delivery.
 Engorgement occurs in 48 to 72 hours in nonbreastfeeding
mothers.
 Breastfeeding relieves engorgement.
Breastfeeding
 Put the baby to breast as soon as the mother and baby's
conditions are stable (on delivery table, if possible).
 · Stay with the mother each time she nurses until she feels
secure or confident with the baby and her feelings.
 · Uterine cramping may occur the first day after delivery while
the mother is nursing, when oxytocin stimulation causes the
uterus to contract.
 · Use general hygiene and wash the breasts once daily.
 · If engorgement occurs, the mother should breastfeed
frequently, apply warm packs before feeding, apply ice packs
after feedings, and massage the breasts.
Breastfeeding
 The mother should not use soap on the breasts, because it
tends to remove natural oils, increasing the likelihood of
cracked nipples.
 · If cracked nipples develop, they should be exposed to air
for 10 to 20 minutes after feeding, the baby's position should
be rotated for each feeding, and the mother should ensure
that the baby is latched onto the areola, not just the nipple.
 · The client’s bra should be well fitted and supportive.
 · The breasts may leak between feedings or during coitus;
place a breast pad in bra.
 · Medications should be avoided unless prescribed.
Breastfeeding
 Gas-producing foods and caffeine should be avoided.
· Hormonal contraceptives may cause a decrease in the
milk supply and are best avoided during the 6 weeks after
birth.
· Oral contraceptives containing estrogen are not
recommended for breastfeeding mothers; progestin-only
birth control pills are less likely to interfere with the milk
supply.
· The baby will develop his or her own feeding schedule.
Breastfeeding Procedure for Mother
 Wash hands and assume a comfortable position.
 Start with the breast that the last feeding ended with.
 Brush infant's lower lip with nipple.
 Tickle lips to have the infant open mouth wide.
 Guide nipple and areola into infant's mouth.
 After baby has nursed, release suction by depressing the infant's chin or
inserting a clean finger into the infant's mouth.
 Burp infant after first breast.
 Repeat procedure on the second breast until infant stops nursing.
 Burp infant again.
 Listen for audible sucking and swallowing during feeding.
Apgar Score
 Quick assessment tool to assess status of newborn after
birth
A= ppearance (skin color)
P= ulse (heart rate)
G= rimace (reflex irritability
A= ctivity (muscle tone)
R= espiratory effort

**Performed at: 1 minutes and 5 minutes after birth

***re-assess after 10 minutes if score 6 or less
 0 1 2
Appearance Pale/blue all Acrocyanosis Pink allover
over

Pulse Absent <100 bpm >100 bpm

Grimace No response to Grimace (no Cry and active

stimulation cry) movement

Activity None, flaccid Some flexion of Arms and leg

arms and legs flexed

Respiratory Absent Weak; irregular Strong, regular

cry vigorous cry
Interventions
Interventions:
7-10= routine post-delivery care
4-6= some resuscitation( oxygen,
suctions, stimulation, rub back
0-3= full resuscitation
Sample scenario
 You’re collecting the 1 minute APGAR on a
male newborn. You note that HR:140 bpm. The
baby’s cry is strong and regular and body is
pink with slight blue hands. There is some
flexion of arms and legs. While assessing the
newborn, he moved and cried. What is your
patient’s APGAR score?