Maternity & Newborn Nursing
Antepartum
Conception & Fetal Development
- Fertilization occurs in the ampulla of the fallopian tube within 24 hours of ovulation.
- The zygote undergoes cleavage as it travels to the uterus, becoming a morula (16-cell stage) then a blastocyst.
- Implantation into the endometrium occurs approximately 6–10 days after fertilization.
- Gestational age is calculated from the first day of the LMP (Naegele's Rule: LMP − 3 months + 7 days).
- Trimesters: First (0–13w), Second (14–26w), Third (27–40w).
Clinical Pearl: Quick EDD formula: First day of LMP, subtract 3 months, add 7 days, add 1 year. Example: LMP Jan 1 → Oct 8.
Prenatal Care
| Visit | Schedule | Key Assessments |
|---|
| Initial | 8–12 weeks | H&P, blood type/Rh, CBC, rubella, HIV, syphilis, hepatitis B, UA, Pap, dating ultrasound |
| Follow-up | Q4w to 28w, Q2w to 36w, Q1w to delivery | BP, weight, urine dip (glucose/protein), fundal height, FHR, edema assessment |
| 1-hour GCT | 24–28 weeks | Screening for gestational diabetes (normal < 140 mg/dL; if elevated, proceed to 3-hour OGTT) |
Physiological Changes of Pregnancy — "The Pregnant Body"
| System | Change | NCLEX Significance |
|---|
| Cardiovascular | ↑ Blood volume 40–50%; ↑ CO 30–50%; ↓ SVR; supine hypotension syndrome (vena cava compression) | Position in left-lateral tilt after 20w; avoid supine |
| Respiratory | ↑ Tidal volume; ↑ RR slightly; diaphragm elevated; decreased functional residual capacity | Dyspnea of pregnancy is normal; assess for pathologic causes |
| Renal | ↑ GFR ~50%; dilation of ureters; glycosuria may occur | Urine dip may show glucose — not always abnormal in pregnancy |
| GI | Decreased peristalsis → constipation; relaxed esophageal sphincter → heartburn; prolonged gastric emptying | Small frequent meals; avoid lying flat after eating |
| Hematologic | Physiologic anemia of pregnancy (plasma ↑ more than RBCs); ↑ WBC; hypercoagulable state | Hgb ≥ 11 g/dL is normal; ↑ risk of DVT |
| Integumentary | Linea nigra, chloasma (melasma gravidarum), striae gravidarum, palmar erythema | Reassure — most resolve postpartum |
| Musculoskeletal | Lordosis, relaxed pelvic ligaments (relaxin hormone), widened/tipped uterus | Teach body mechanics; may cause back pain |
Danger Signs of Pregnancy
Teach patients to report promptly:
- Vaginal bleeding (any amount)
- Severe, persistent headache (possible preeclampsia)
- Visual disturbances (blurring, spots — preeclampsia)
- Rupture of membranes (gush or trickle of fluid)
- Decreased or absent fetal movement (< 10 kicks in 2 hours after 28w)
- Severe abdominal pain or persistent cramping
- Temperature ≥ 101.3°F (38.5°C) or chills
- Dysuria, oliguria, or burning on urination
- Persistent vomiting (risk of hyperemesis/dehydration)
- Sudden edema of face or hands
Antepartum Complications
Hyperemesis Gravidarum
- Severe, persistent vomiting beyond 12 weeks; weight loss ≥ 5% of pre-pregnancy weight
- May cause dehydration, electrolyte imbalance, ketosis, vitamin deficiency (thiamine)
- Management: IV fluids, antiemetics (ondansetron, promethazine), thiamine and folic acid supplementation, small frequent bland meals
Preeclampsia
- New-onset hypertension ≥ 140/90 after 20 weeks + proteinuria or end-organ dysfunction
- Severe features: BP ≥ 160/110, thrombocytopenia, impaired liver function, pulmonary edema, cerebral/visual symptoms
- Eclampsia: seizure activity not attributable to other causes
- Management: Magnesium sulfate seizure prophylaxis; antihypertensives (labetalol, nifedipine, hydralazine); delivery is the definitive cure
Clinical Pearl: Magnesium sulfate therapeutic level is 4–8 mEq/L. Assess DTRs, respiratory rate (≥ 12/min), urine output (≥ 30 mL/hr). Antidote: Calcium gluconate. Signs of toxicity: loss of DTRs (10 mEq/L), respiratory depression (12+), cardiac arrest (15+).
Gestational Diabetes Mellitus (GDM)
- Glucose intolerance first recognized during pregnancy
- Screen at 24–28 weeks; risk factors: obesity, family history, previous GDM or macrosomic infant
- Management: Medical nutrition therapy, blood glucose monitoring, insulin (preferred) or metformin (alternative)
- Increased risk for: macrosomia, shoulder dystocia, neonatal hypoglycemia, preterm birth
Placenta Previa vs. Abruptio Placentae
| Feature | Placenta Previa | Abruptio Placentae |
|---|
| Definition | Placenta covers internal cervical os | Premature separation of normally implanted placenta |
| Bleeding | Painless, bright red, sudden onset | Painful, dark red (may be concealed) |
| Uterus | Soft, relaxed, normal tone | Tense, board-like, tender (Couvelaire uterus) |
| FHR | Usually reassuring initially | Often non-reassuring (fetal distress common) |
| Risk factors | Previous previa, multiple gestation, prior C/S, advanced maternal age | HTN, trauma, cocaine use, smoking, short cord, previous abruption |
| Management | NO vaginal exam! C-section; RhoGAM if Rh-negative | Emergency C-section if fetal distress; replace volume/blood |
Ectopic Pregnancy
- Implantation outside the uterus (95% in fallopian tube)
- Triad: amenorrhea + abdominal/pelvic pain + vaginal bleeding
- Rupture: sudden severe pain, syncope, hypovolemic shock, peritoneal irritation
- Management: methotrexate (early, unruptured) or salpingectomy/salpingostomy
Spontaneous Abortion (Miscarriage)
- Loss of pregnancy before 20 weeks' gestation
- Types: threatened, inevitable, incomplete, complete, missed, septic
- Management: RhIg if Rh-negative; D&C for incomplete; emotional support and grief counseling
Intrapartum
Stages of Labor
| Stage | Description | Duration | Nursing Care |
|---|
| Stage 1 — Latent phase | Cervical dilation 0–3 cm; contractions mild, irregular | Primip 6–12 h; Multip 4–8 h | Encourage rest, hydration, position changes |
| Stage 1 — Active phase | 4–7 cm; contractions moderate–strong, regular q3–5min | ~4–6 cm/hr primip; faster in multip | Monitor FHR & contraction pattern; pain management; assess progress |
| Stage 1 — Transition phase | 8–10 cm; strong contractions q2–3min lasting 60–90s | ~1–3 h | Short term; intense support; encourage effective pushing after complete dilation |
| Stage 2 | Full dilation to delivery of baby | Primip ≤ 3 h; Multip ≤ 2 h (with epidural: +1 h) | Coach pushing; perineal support; deliver baby; crowning |
| Stage 3 | Delivery of placenta (up to 30 min) | 5–30 min | Signs of separation: cord lengthens, gush of blood, uterus globular; administer oxytocin as ordered |
| Stage 4 | Immediate recovery (first 1–2 hours) | 1–2 h | Monitor VS, fundus, lochia, urine output; assess for hemorrhage |
Fetal Monitoring
VEAL CHOP Mnemonic
| VEAL | CHOP | Meaning |
|---|
| Variable decelerations | Cord compression | Umbilical cord compression ⇔ variable shape, abrupt drop/return |
| Early decelerations | Head compression | Benign; mirror uterine contraction; shape mirrors contraction |
| Accelerations | OK (reassuring) | FHR increase ≥ 15 bpm × ≥ 15 s = fetal well-being (reactive) |
| Late decelerations | Placental insufficiency | Uteroplacental insufficiency; onset after peak of contraction, returns to baseline after contraction ends |
NICHD FHR Category System
| Category | Definition | Action |
|---|
| I — Normal | Baseline 110–160; moderate variability; no late/variable decels; accelerations present/absent | Routine; continue monitoring |
| II — Indeterminate | All tracings not Category I or III (e.g., minimal variability, recurrent variable decels, prolonged decel) | Evaluate and intervene as indicated; reposition O₂, increase IV fluids, consider amnioinfusion or tocolysis |
| III — Abnormal | Absent variability + recurrent late/variable decels, sinusoidal pattern, or bradycardia | Immediate intervention; prepare for urgent delivery if not resolved |
Clinical Pearl: For non-reassuring FHR pattern, remember OIL: Oxygen (8–10 L/min non-rebreather), IV fluids (bolus), Lateral position (left preferred), and call for help.
Pain Management
| Method | Details | Nursing Considerations |
|---|
| Epidural | Local anesthetic + opioid (bupivacaine + fentanyl); placed during active labor | Monitor BP (hypotension common); assess bladder (Foley usually placed); no pushing until feeling urge; maintain IV access |
| IV Meds | Opioids: fentanyl, morphine, butorphanol (Stadol), nalbuphine (Nubain) | May cause respiratory depression in mother and neonate; avoid within 1–2 hours of delivery; monitor sedation level |
| Non-pharmacologic | Lamaze breathing, hydrotherapy, massage, positioning, acupressure, birth ball, hypnobirthing | Encourage; effective as adjunct; no side effects; support partner participation |
| Nitrous oxide | 50% N₂O/50% O₂; patient self-administered | Often used in early labor; rapid onset/offset; does not affect neonatal outcomes |
Induction & Augmentation
- Induction: artificial initiation of labor (for postdates, PROM, preeclampsia, etc.)
- Augmentation: stimulation of inadequate contractions after spontaneous onset
- Methods: oxytocin (Pitocin) IV, cervical ripening agents (misoprostol/Cytotec, dinoprostone/Cervidil), membrane stripping, amniotomy, Foley bulb
Clinical Pearl: Oxytocin infusion requires an IV pump and continuous FHR monitoring. Titrate to achieve 3–5 contractions per 10 minutes. Maximum dose: typically 20–40 mU/min. Watch for hyperstimulation — turn off oxytocin if > 5 contractions in 10 min or non-reassuring FHR.
Labor Dystocia
- Slow or arrested labor (protracted or arrest disorders)
- 4 Ps of labor can cause dystocia: Powers (contractions), Passenger (fetal size/position), Passageway (pelvis), Psyche (maternal)
- Most common: occiput posterior position ("sunny-side up") which causes prolonged back labor
- Management: position changes, amniotomy, oxytocin augmentation, vacuum/forceps, C-section if failed progress
C-Section (Cesarean Birth)
- Incidence ~32% of US births
- Indications: failed induction, CPD, malpresentation, fetal distress, placenta previa, prior classical C-section, maternal conditions
- Care: Pre-op: NPO, labs (CBC, type & screen), surgical consent, fetal assessment. Post-op: monitor incision, vitals, lochia, fundus, pain; early ambulation; incentive spirometry; breastfeeding support
Umbilical Cord Prolapse
- Cord descends ahead of presenting part; can be occult or overt
- Emergency! Immediate intervention needed
- Action: Call for help; place gloved hand in vagina to elevate presenting part OFF the cord; position mother in severe Trendelenburg or knee-chest position; administer O₂; prepare for emergency C-section
Shoulder Dystocia
- Anterior fetal shoulder impacted behind maternal symphysis pubis; "turtle sign" (head retracts after delivery)
- HELPERR mnemonic: Help, Evaluate for episiotomy, Legs (McRoberts maneuver — hyperflexion of thighs), Pressure (suprapubic), Enter (internal rotation), Remove posterior arm, Roll (Gaskin maneuver)
- Document: head-to-body interval; no fundal pressure!
Postpartum
Uterine Involution
- Uterus returns to non-pregnant size (~6 weeks)
- Fundus descends ~1 cm/day; by day 10–14, uterus is no longer palpable abdominally
- Afterbirth pains: cramping from uterine contractions, especially with breastfeeding (oxytocin release) and in multiparas
- Assessment: Fundus should be firm, midline; boggy fundus = atony (massage; empty bladder; methylergonovine/carboprost as ordered)
Lochia
| Type | Timing | Character |
|---|
| Rubra | Days 1–3 | Dark red, bloody, small clots (≤ plum-sized) |
| Serosa | Days 4–10 | Pinkish-brown, serosanguineous |
| Alba | Days 11–21+ | Yellowish-white, creamy |
Assess: color, amount, odor (foul = possible endometritis). Normal amount = less than a heavy menstrual period.
Breastfeeding
- Exclusive breastfeeding recommended for first 6 months
- Latch-on: mouth covers areola, lips flanged, audible swallow
- Engorgement: treat with frequent feeding; cool compresses after feeding, warm before
- Mastitis: unilateral, fever, erythema, warmth. Continue breastfeeding/pumping on affected side; antibiotics (dicloxacillin, cephalexin)
- Contraindications: HIV (US), active TB, infant with galactosemia, certain medications (chemotherapy, radioactive isotopes)
Postpartum Complications
Postpartum Hemorrhage
- Blood loss > 500 mL (vaginal) or > 1000 mL (C-section) within 24 h (early) or up to 12 weeks (late)
- 4 Ts: Tone (uterine atony — most common 70%), Trauma (laceration, hematoma), Tissue (retained placenta), Thrombin (coagulopathy)
- Management: Fundal massage, oxytocin (first-line), methylergonovine (Methergine) → avoid in HTN, carboprost (Hemabate) → avoid in asthma, misoprostol (Cytotec)
Clinical Pearl: The most common cause of early PPH is uterine atony. The boggy, "difficult to find" fundus is the classic sign. Massage first, then meds.
Endometritis
- Postpartum uterine infection; fever > 100.4°F, foul lochia, uterine tenderness
- Risk factors: prolonged ROM, C-section, chorioamnionitis, manual extraction of placenta, multiple vaginal exams
- Management: broad-spectrum IV antibiotics (clindamycin + gentamicin)
Deep Vein Thrombosis (DVT)
- Pregnancy hypercoagulable state persists ~6 weeks postpartum
- Unilateral leg pain, warmth, swelling, positive Homan's sign
- Management: anticoagulation (enoxaparin/warfarin), compression, elevate leg. Do NOT massage the leg! Monitor for PE — sudden dyspnea, chest pain, hemoptysis
Postpartum Depression (PPD) vs. Psychosis
| Feature | Postpartum Blues | Postpartum Depression | Postpartum Psychosis |
|---|
| Onset | Days 3–5 | First weeks to months | First 2–4 weeks |
| Symptoms | Mood swings, tearfulness, irritability, fatigue | Sadness, guilt, insomnia, appetite changes, loss of interest, difficulty bonding | Hallucinations, delusions, confusion, disorganized behavior, suicidal/homicidal thoughts |
| Duration | < 2 weeks | > 2 weeks | Days to weeks |
| Treatment | Support, rest, reassurance | Therapy, antidepressants (SSRIs), support groups | Psychiatric emergency; hospitalization; antipsychotics; safety first! |
Newborn
APGAR Scoring
| Sign | 0 | 1 | 2 |
|---|
| A — Appearance (color) | Pale, blue | Acrocyanosis (pink body, blue extremities) | Completely pink |
| P — Pulse (HR) | Absent | < 100 bpm | ≥ 100 bpm |
| G — Grimace (reflex/irritability) | No response | Grimace | Cough, sneeze, cry |
| A — Activity (muscle tone) | Limp, flaccid | Some flexion | Active motion, flexed |
| R — Respiration | Absent | Slow, irregular, weak cry | Good, strong cry |
Scored at 1 and 5 minutes (and every 5 min if < 7). Score 7–10: normal; 4–6: moderate depression; 0–3: severe depression.
Thermoregulation
- Heat loss mechanisms: evaporation (wet skin), conduction (cold surfaces), convection (cold air), radiation (cold objects nearby)
- Newborns are prone to hypothermia due to: large surface area-to-weight ratio, limited subcutaneous fat, immature thermoregulation, inability to shiver (uses brown fat — nonshivering thermogenesis)
- Nursing actions: dry immediately, skin-to-skin with mother, warm blankets, radiant warmer, hat, delayed bathing until temperature stable
- Normal axillary temperature: 97.7–99.5°F (36.5–37.5°C)
Hypoglycemia
- Blood glucose < 45 mg/dL (some sources: < 40 mg/dL for full-term newborn)
- Risk factors: IDM (infant of diabetic mother), preterm, LGA/SGA, cold stress, sepsis
- S/S: jitteriness, tremors, lethargy, hypotonia, poor feeding, hypothermia, cyanosis, apnea, seizures
- Management: early feeding (breast milk or formula); if symptomatic or unable to feed → IV dextrose 10% (2 mL/kg)
Clinical Pearl: Infants of diabetic mothers are at highest risk for hypoglycemia in the first 30–60 minutes after birth. Feed early and check glucose within 1 hour. Hyperinsulinemia from maternal hyperglycemia causes rapid glucose drop after cord clamping.
Hyperbilirubinemia (Neonatal Jaundice)
- Physiologic jaundice: appears day 2–3, peaks day 4–5, resolves without treatment; total bilirubin typically < 12–15 mg/dL. Due to immature liver (deficient glucuronyl transferase) + ↑ RBC breakdown
- Pathologic jaundice: appears < 24 hours, rapid rise, may indicate hemolytic disease (ABO/Rh incompatibility), G6PD, sepsis
- Management: phototherapy (lights at 425–475 nm; cover eyes, expose skin; assess skin integrity, monitor temp, hydration). Exchange transfusion for severe cases to prevent kernicterus
- Kernicterus: bilirubin deposits in brain → neurological damage, hearing loss, athetoid cerebral palsy, upward gaze palsy
Cephalohematoma vs. Caput Succedaneum
| Feature | Caput Succedaneum | Cephalohematoma |
|---|
| Location | Crosses suture lines (overlies periosteum) | Does NOT cross suture lines (between periosteum and skull) |
| Timing | Present at birth (edema from pressure) | Appears hours to days after birth (subperiosteal hemorrhage) |
| Consistency | Soft, pitting edema | Firm, tense, fluctuant |
| Resolution | Resolves in days | Resolves over weeks to months |
| Complications | Usually benign | May ↑ bilirubin (hyperbilirubinemia from resolving hematoma) |
Circumcision Care
- Procedure: dorsal penile nerve block for anesthesia; Gomco, Mogen, or Plastibell methods
- Contraindications: prematurity, hypospadias, epispadias, undescended testicles, bleeding disorder, hemophilia
- Post-procedure care:
- Apply petroleum jelly to glans for Gomco/Mogen (not needed for Plastibell)
- Check for bleeding every 30 min × 2 hours, then hourly
- Yellowish exudate at site is normal — do NOT remove (part of healing)
- No tub baths until healed (about 7–10 days)
- Notify provider if bleeding, decreased urine output, signs of infection
NNAT (Neonatal Abstinence Scoring / Neonatal Narcotic Abstinence Syndrome)
- Used for infants exposed to maternal opioids in utero (NOWS — Neonatal Opioid Withdrawal Syndrome)
- Signs of withdrawal:
- CNS: high-pitched cry, tremors, irritability, hypertonia, sleeplessness, seizures
- GI: poor feeding, vomiting, diarrhea, uncoordinated sucking, excessive rooting
- Autonomic: sweating, fever, tachypnea, nasal stuffiness, yawning, mottling
- Management: swaddling, low-stimulation environment, pacifier, frequent small feeds, pharmacologic therapy (morphine, methadone, phenobarbital) if Finnegan score ≥ 8 for 3 consecutive scores
Clinical Pearl: The Finnegan Neonatal Abstinence Scoring Tool is the most commonly used. Score every 3–4 hours. Pharmacologic treatment is indicated for scores ≥ 8 for 3 consecutive assessments or ≥ 12 for 2 consecutive assessments. Breastfeeding is not contraindicated if mother is on methadone/buprenorphine maintenance (unless other illicit drug use).