Maternal Nursing

Lecturer: Grenland Hisu

Labor & Delivery
Stages of Labor:
Stage 1: from the start of Uterine contraction  full cervical dilatation
- Crowning – bulging of the perineum, surest sign that a fetus is about to
be delivered
Stage 2: full cervical dilatation  delivery of the baby
Stage 3: baby  delivery of placenta
Stage 4: delivery of placenta  1-4 hrs. post-partum (Recovery stage)
True labor:
1. Regular uterine contraction
2. Pain cannot be relieved by walking
3. Pink show that progresses to bloody show
4. Progressive cervical dilatation
*most significant – progressive cervical dilatation (cannot proceed in the
stage 2)
Phases of Labor: LAT
Cervical dx Uterine Contraction
Latent: 0-3 cm Frequency: 5-10 mins
Duration: 20-30 secs
Intensity: MILD

Active: 4-7 cm Frequency: 3-5 mins

Duration: 30-45 secs
Intensity: MODERATE

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Transitional: 8-10 cm Frequency: 2-3 mins
Duration: 45-60 secs
Intensity: STRONG
Stage 2 will occur (Transitional stage)
*CBQ: the nurse is caring for mrs. C who is on progress of labor, cephalic,
duration = 80 sec, LOA, 90% effacement, frequency = 2 mins, vertex
presentation, Cx. Dilatation = 8 cm, station = -2. What phase of labor?
Answer: Transitional
*CBQ: when is the time to minor bp & fhb
Answer: in between contraction

**Effacement: thinning of the cervix

Frequency of BP & Fetal heart rate
Done: In between contraction
L – every hour
A – every 30 mins
T – every 15 mins – best time to monitor BP & FHB

Breathing technique: LAT-CAP

Latent: Chest breathing
Active: Abdominal breathing
Transitional: Pant-blow breathing (if 8-9 cm cervical dilatation)
10 cm: fully dilated – instruct mother to push during contraction

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*CBQ: the nurse is caring for mrs. C who is on progress of labor, cephalic,
duration = 80 sec, LOA, 90% effacement, frequency = 2 mins, vertex
presentation, Cx. Dilatation = 8 cm, station = -2. what breathing technique?
Answer: pant-blow breathing
Station: Degree of the fetal descend to the level of the ischial spine
-5 floating (unengaged) MGT: 1. Bed rest
-4 2. Ambulate – to facilitate fetal descend
-3
-2
-1
0  engagement: the head is on the level of the ischial spine
+1  1 cm/finger breath
+2
+3 crowning – stage 2
+4 - transitional phase
+5
*CBQ: which of the following assessment indicates that the mother should
be transfer from labor room to delivery room?
A. 80% effacement
B. Cephalic
C. LOA
D. + 4 station  indicates crowning

*CBQ: Cervical dilatation = 8 cm Station = -2 station

Answer: Transitional yet unengaged

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Fetal Lie: relationship of fetal long axis to maternal long axis
a. Longitudinal lie: fetal long axis is directly proportional to the long
axis of the mother

b. Transverse lie: fetal long axis is perpendicular to the long axis

Fetal presentation: presenting parts

1. Cephalic – occiput (ideal presentation)
2. Breech – sacrum
3. Shoulder – scapula

Types of Cephalic presentation: fetal attitude:

1. Vertex (head) flexion
2. Brow slight extension
3. Chin/face presentation hyperextension

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Types of Breech presentation:
1. Complete: CS (C – complete & S – baby is squatting)

2. Frank: FB ( F – Frank & B – baby is in buttocks presentation)

3. Footling: 1 or both legs as presenting part

Complication of Breech:
1. Cord prolapse
2. Head injury
Leopold’s Maneuver:
Best position: Dorsal Recumbent – to relax the abdominal muscle
“Hi BEA”
Leopold’s 1: Head
Leopold’s 2: Back
Leopold’s 3: Engagement
Leopold’s 4: Attitude

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Characteristics of Uterine Contraction:
1. Duration (A-B/C-D) – Beginning – End of a single contraction)
2. Frequency (A-C) – beginning to beginning of next contraction
3. Interval (B-C) – end to beginning of next contraction

Effect of Uterine Contraction:

 Increment – increases U.C = decreases FHB – normal due to vagal

nerve stimulation
 Acme – peak
 Decrement – decreases U.C = increases FHB

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Stage 2: Full cervical dilatation to delivery of the baby
Focus of care:
1. Assess for crowning (bulging of the perineum)
2. Teach effective pushing
3. Cardinal movement of labor
Descend – crowning
Flexion
Internal
Rotation
Head Extension – first lung expansion, 1st cry – Priority: establish airway
(wipe nose)
- assess for cord coil
External
Rotation
Expulsion
Management for Cord coil
A. Check for normal FHB: (-) fetal distress MGT: insert 2 gloved finger
and lift the cord away from the head
B. (+) Fetal distress: MGT: clamp & cut the cord

Ritgen’s Maneuver – method of delivering the baby

- facilitates head delivery and prevent laceration
Stage 3: Delivery of the baby to delivery of placenta
Focus of care:
1. Check for the completeness
2. Cotyledons – 15-28 (average)
3. Schultze – smooth & shiny
4. Duncans – Rough & dirty

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 5. Placenta must be delivered w/in 3-10 mins (Max. 30 mins)
6. Signs of placental separation (GRL)
 Gushing of blood
 Rising of the fundus or abdomen becomes globular
 Calkin’s sign – rising of the fundus & abdomen becomes
globular
 Lengthening of the cord
After delivery of the placenta:
 Oxytocin – to prevent uterine atony
 Methergine – to prevent bleeding – hold if BP is high

Stage 4: delivery of placenta to 1-4 hrs post-partum (Recovery stage)

Focus of care:
1. Locate the fundus: Firm at the midline
- displacement to R and L: indicates full bladder
MGT: instruct to void
2. Assess for Lochial Discharges
Normal = not clotted
= not foul-smelling
 Rubra: 1-3 days (Bright Red)
 Serosa: 4-9 days (Brown)
 Alba: 10-21 days (White)

3. Assess for the post-partal bleeding

1ST 24 HRS:
Cause:
Atony: (+) bleeding with relaxed (Boggy uterus)
Perineal laceration: (+) bleeding with contracted uterus
MGT: ATONY
1. Massage the uterus
2. Ice pack over hypogastrium

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 3. Nipple stimulation
4. Oxytocin administration
MGT: PERINEAL LACERATION
1. Suturing (Episiorrhaphy)
2. Ice pack over perineum
3. Peri light – wound healing

AFTER 24 HRS:
Cause: Retained placental fragment
MGT:
1. D & C
2. Oxytocin after D & C

Prenatal care:
1. BP monitoring: every prenatal visit
Frequency of prenatal:
1-7 months: every month (4 weeks)
8-9 months: every 2 weeks
10 months (40 weeks) = EDD (Expected date of delivery) every week

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 Increase BP:
1st trimester = abnormal: indicates sign of h mole/molar pregnancy
2nd trimester & 3rd trimester = abnormal: PIH
Pre-eclampsia Ecclampsia
(-) seizure (+) seizure
Goal: to prevent seizure Goal: to treat seizure
- decrease DOC: MgSO4
environmental stimuli
Magnesium Toxicity
a. private room (BURP)
b. dim room BP – decrease
Urinary ouput – decrease
RR – decrease
Patellar reflex – negative

2. Weight Monitoring every pre-natal

 Edema of hands and face – 1st sign of PIH
Normal Weight gain:
1st trimester = 1.5 – 3 lbs (1lb per month)
2nd trimester:
3rd trimester: 10-12 lbs (1lb per week)
Full term: Average = 20-35 lbs
Ex:
140 – pre-pregnant
+20 = 160 – 175

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3.Decrease RBC: due to physiologic anemia
- increase in 30-50% of plasma volume
- 75% = plasma
- diluted blood
4. Urinalysis:
(+) proteinuria
(+) albuminuria indicates PIH
(+) glucosuria – indicates gestational diabetes
Slight glucosuria: normal due to high level of progesterone – excrete sugar
in the urine

5. Discomforts & Comfort Measures (Intervention)

a. Nausea & vomiting (morning sickness) – due to HCG
 best action: crackers & dry toast in the morning

b. Heart burns (pyrosis) – due to gastric reflux that increases HCL

(secondary to increasing pressure of enlarging uterus)
 best action: SFF (small frequent feedings)

c. constipation – due to compression of intestine by the enlarging uterus

 best action: High-fiber diet
d. urinary frequency – due to compression of bladder by the enlarging
uterus
 best action: kegel’s exercise
6. Leg Edema due decrease backflow of blood to the heart
Varicosities secondary to compression of uterus
 Best action: leg elevation

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 7. Supine hypotension – due to compression of vena cava by the
enlarging uterus
 Dizziness
 Lightheadedness
 Best action: left-side lying position

8. Leg cramps – due to imbalance between calcium & phosphorus that

causes hypocalcemia due to bone development
 Best action: perform dorsiflexion
Signs of Pregnancy:
Presumptive Probable Positive
1st tri: 1st tri: (+) FHB
Breast changes Hegar’s: softening of Doppler: 3 mos
(tenderness) uterus
Fetoscope: 4 mos
Amenorrhea Chadwicks: bluish
Stethoscope:5 mos
discoloration of vagina
Urinary frequency
(+) FHT: UTZ
Goodels: softening of
Nausea & vomiting
cervix (+) Fetal movement
(+) HCG (pregnancy (+) Fetal outline
test)
2nd tri:
Quickening 2nd tri:
Chloasma Ballottement: Passive
(melasma) movement of
unengaged fetus
Braxton-hick’s
contraction: painless,
irregular U.C

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