MCN Exam 2 Study Guide – Complete Colin MacKenzie

Labor and Birth Process & Nursing Management During Labor & Birth
1. Premonitory Signs of Labor
a. Cervical Changes:
i. Softening (ripening)
ii. Shortening
iii. Effacement (dialation)
b. Lightening:
c. Increased Energy Level
d. “Bloody Show”
e. Braxton Hicks Contractions
f. Spontaneous rupture of membranes
2. True Labor vs. False Labor:

3. Factors Affecting the Labor Process (the 5 P’s):

a. Passageway:
i. Birth canal
ii. Platypelloid shape cannot deliver naturally
iii. To deliver naturally woman must be fully effaced (10 cm.)
1. Caused by contractions AND fetal head pushing down on the
cervix

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b. Passenger (the fetus)

c. Powers:
i. Uterine contractions
d. Position:
i. Lie – how the baby’s spine is positioned in the uterus compared to the
mother’s spine
1. Head down = vertex (cephalic)
a. This is the position we want
2. Butt down = breech
3. Sideways = transverse
a. Baby can not be delivered in this position unless it can be
turned (c-section if unable to do so)
ii. Presentation – part of the fetus that’s entering the birth canal first
1. Vertex:
a. Most common position
b. Molding may occur
i. Consistent pushing that puts pressure on the
sutures of the skull that can give the baby a “cone
head” appearance
2. Breech:
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a. Frank: legs flexed at the hips; feet by the shoulders

b. Full or complete: thighs and legs are flexed
c. Footing: one or both feet come through (not a good thing)
i. Will require a c-section
3. 3 letter description based on the position of the fetus’ head:
a. 1st letter – left or right side of the woman’s pelvis
b. 2nd letter – presenting part
i. Occiput = back of the head
1. Most successful
ii. Mentum = chin
iii. Sacrum
rd
c. 3 letter – front or back of the woman’s pelvis
i. Anterior (face pointed away from the spine towards
the belly button), posterior (face towards the
spine), transverse

d. LOA is the most common and favorable position, followed

by ROA
iii. Attitude – relationship of fetal body parts to one another
1. Flexion: chin and extremities pulled into torso
2. Extension: chin and extremities extended away from torso
iv. Station – how far down in the birth canal has the presenting part (head or
butt) reached
1. Engagement: when fetus reaches 0 station

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v. Floating: term used when engagement has not occurred, because the
presenting part is freely movable above the pelvic inlet
e. Psychological Response or Psyche
4. Cardinal Movements of Labor
5. Initial Maternal Assessment:
a. Review of pre-natal records
i. First and most important question: When is your baby due?
ii. At 37 weeks most physicians send over the pre-natal records to the
hospital to prep for delivery
1. We will act more quickly if the woman is 30 weeks vs. 37 weeks
b. Current labor and amniotic fluid status
i. False labor or true labor?
ii. Have the membranes ruptured?
c. Personal medical/surgical, and social history
d. Plans and desires for labor and birth
e. Cultural preferences
6. Lab Studies:
a. Hgb/Hct and blood typing
i. Primarily for rH and ABO incompatibility
b. Hepatitis B surface antigen (HbsAg)
i. If positive, newborn should be given immunoglobins against hep B within
1st 12 hours of birth

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1. Mother can breastfeed once this has been completed

c. VDRL (syphilis)
d. GBS (Group B Strep)
i. 25% of women have this as a naturally occurring flora in their vagina
ii. Can cause serious problems for the baby if they contract it during delivery
(i.e. pneumonia, meningitis)
iii. Most common infection in newborns
e. Drug screening
f. HIV (with consent)
g. Urinalysis
7. Group B Strep (GBS) Prophylaxis:
a. The following would require prophylactic treatment:
i. Previous infant with GBS disease
ii. GBS bacteriuria in the current pregnancy or a UTI during pregnancy
iii. Positive vaginal-rectal GBS screening at 35-37 weeks
iv. Unknown GBS status at onset of labor (culture not done or results
unavailable)
1. Labor at less than 37 weeks’ gestation
2. Rupture of membranes for 18 hours or longer
3. Intrapartum temperature of 100.4°F or greater
b. Treatment:
i. Penicillin G or ampicillin are most commonly prescribed
1. Loading dose of 5 million units intravenously
2. 2.5 million units every 4 hours until delivery
8. Current Labor & Amniotic Fluid Status
a. Need to know IF and WHEN membranes ruptured
b. Analysis of amniotic fluid status
i. Should be watery, clear, slight yellow tinge
ii. Odor should not be foul
iii. Volume between 700-1,000 mL
iv. Nitrazine paper used confirm amniotic fluid is present
1. Paper should turn a deep blue if so (alkalinity)
2. Paper remains yellow if no amniotic fluid is present
v. Speculum can be inserted and a sample taken
1. Positive sign of ruptured membranes is “ferning”
c. Analysis of fetal heart rate (FHR or FHT)
i. Monitoring of FHR during before and during labor
d. Uterine contraction pattern
i. External device is called a tocotransducer
ii. Internal device is an IUPC (intrauterine pressure catheter)
e. Vaginal exam/fetal descent
i. Performed to see how far down the fetus is and how dilated the woman
is

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ii. Caution must be taken to avoid causing an infection of the uterine lining
(chorioamnionitis)
f. Leopold’s maneuvers
i. Externally feeling the uterus by an examiner to determine the following:
1. Number of fetuses
2. Presenting part
3. Lie
4. Attitude
5. Descent
6. Probable location where fetal heart tones can best be auscultated
a. Vertex: FHT should be assessed below the pt.’s umbilicus in
either the right or left lower quadrant
b. Breech: FHT should be assessed above the pt.’s umbilicus
in either the right or left upper quadrant
ii. Provider can tell where the back is because the back of the fetus is
smooth, whereas the front is not (because of the arms and legs)
iii. Helps to determine the expected presentation for labor and delivery, and
which method will be used

9. Assessing Fetal Heart Rate:

a. Intermittent Monitoring:
i. Allow freedom of movement for the woman
ii. May miss fetal heart rate problem
1. Could be fetal oxygenation problem or a cord injury
b. Continuous Monitoring
i. Restricts movement since equipment as at the bedside
1. Info is sent to nurses' station as well
ii. Identifies concerning changes in fetal heart rate much more quickly
c. External or Internal Monitoring
i. Fetal scalp electrode used in high risk situations
ii. Woman has ruptured membranes and be at 2 cm. and head must be low
enough for scalp electrode to be attached
1. Electrode is actually screwed into the baby’s head
a. Increased risk for infection
b. Can not use on a woman with HIV or herpes

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d. Artifact
i. Need to look at 10-12 minutes of a strip to feel comfortable about fetal
well being
10. What is her Cervical Dilation and Effacement?
a. If woman is full term, with non-ruptured or ruptured membranes, do a vaginal
exam
b. If woman is preterm:
i. Limit the number of vaginal exams if membranes are ruptured
ii. If woman is in active labor, her dilation status must be checked as a
baseline
11. Documentation Cervical Dilation, Effacement & Station:
a. How do we document this:
i. Always cervical dilation first
ii. Always cervical effacement second
iii. Always fetal station third
iv. Example:
1. Halfway dilated, halfway effaced, 3 cm above the ischial spine
a. Notated as: 5/50/-3
2. Fully dilated, ¾ effaced, at the ishcial spine
a. Notated as: 10/75/0
3. 8 cm dilated, completely effaced, 2 cm below the ischial spine
a. Notated as: 8/100/+2
4. 2 cm dilated, ¼ effaced, 1 cm above the ischial spine
a. Notated as: 2/25/-1
12. Powers (Uterine Contractions):
a. Oxytocin (hormone) is released by the body and causes the contractions
b. Assessing Uterine Contractions
i. Frequency
ii. Duration
1. We count from the beginning of one contraction to the beginning
of the next, in minutes
iii. Intensity
1. Rule of thumb:
a. Mild contraction – will indent, feels like pushing in on your
nose
b. Moderate contraction – slight indentation, feels like
pressing on the tip of your chin (there’s still some give
between the skin and the fundus)
c. Strong contraction – no indentation, like pressing on the
forehead
iv. Interval
1. Rest time when oxygen is delivered to the placenta and the fetus
v. Maternal pushing occurs when…
1. Mother is fully dilated

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2. Head is coming down into the positive areas of the pelvis

3. Mother will feel like she needs to have a bowel movement
c. Contractions are involuntary, rhythmic, and intermittent
i. Meaning they are not one on top of the other
ii. Relaxation between them is where blood flow is restored to the uterus
and placenta and the baby
d. Contractions cause dilation and thinning of the cervix
13. Position (Maternal):
a. Encourage movement if at all possible
b. Squatting helps to enlarge the pelvis
c. Kneeling helps rotate the fetus
d. Any position other than supine or upright may…
i. Give the mother control
1. If mother is on her side, not supine, and off the vena cava, it
allows more blood to go back to her heart to get delivered to the
placenta and fetus
ii. Reduce length of labor and incidence of assisted deliveries
iii. Reduce tears and use of episiotomies
iv. Assist gravity for fetal descent
14. Psychological Response:
a. Preparation for childbirth
b. Trust in staff and partner to help and support
c. Clear information of the process and procedures
d. Control over decisions being made
e. Control over breathing
15. 4 Stages of Labor:
a. 1st Stage:
i. Labor process until the woman is completely dilated and effaced
ii. Acceptable dilation is 1 cm. per hour
iii. Assessment:
1. Perform Leopold maneuvers
2. Vaginal exam as ordered to determine whether pt. is in true labor
and if membranes have ruptured
3. Monitor:
a. Dilation
b. Effacement
c. Station
d. Fetal position
iv. 3 components:
1. Latent
a. Cervical change 1-3 cm; effacement 0-40%
b. Mild contractions every 5-10 minutes for 30-45 seconds
c. Woman will more than likely be talkative and eager
2. Active

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a. Cervical change 4-7 cm; effacement 40-80%

b. Moderate contractions every 2-5 minutes for 45-60
seconds
c. Mother may express feelings of helplessness
d. Anxiety and restlessness increase as contractions become
strong
3. Transition
a. Cervical change 8-10 cm; effacement of 80-100%
b. Strong contractions every 2-3 minutes for 60-90 seconds
c. Mother will feel tired, restless, and irritable, expressing she
cannot continue
d. N/V may occur
e. Have an urge to push
f. Increased rectal pressure which feels like needing to have a
bowel movement
g. Increased bloody show
h. Most difficult part of labor
v. Nursing Care:
1. Pay close attention to FHR and contraction patters
2. If membranes rupture while you are present, documentation is
key
a. If membranes have ruptured…
i. Assess FHR to ensure fetus is not under stress
ii. Verify presence of amniotic fluid (nitrazine paper
test (paper turns blue indicates amniotic fluid)
and/or microscopic test – “ferning” indicates
presence of amniotic fluid)
iii. Expected finding:
1. Fluid is clear, odorless, and color of water
iv. Abnormal finding:
1. Yellow/green color (indicates presence of
meconium), foul odor
3. Encourage pt. to void regularly; at least every 2 hours (although
they may not feel the need secondary to the birthing process
and/or anesthesia)
4. Listen for pt. to express the desire to have a bowel movement (can
indicate complete dilation)
nd
b. 2 Stage:
i. Pushing to expel the fetus and delivery
1. Pushing can take a long time, especially if its a first birth
2. Preferred Method:
a. Spontaneous pushing (laboring down)
i. Woman is in charge of pushing
ii. Doesn’t push until she feels a strong urge to do so

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iii. Better outcomes for mother and baby

iv. Less risk for oxygenation issues and tearing of the
perineum
v. May take longer for the baby to be delivered
3. Old Method:
a. Directed pushing (old method, not used anymore)
i. By the caregiver, Valsalva maneuver for 10 seconds,
breathe, 10 seconds again
ii. Deep breath in, hold your breath and push for 10
seconds, then breath again
iii. Problems with this method:
iv. Tiring for the mother
v. Decreases oxygen delivery to fetus and increases
risk to perineum (could tear it…ouch!)
ii. Nursing Care:
1. Allow rest prior to onset of pushing
2. Allow woman to push as needed and not as directed
3. Encouragement, watch the baby descend
a. Put a mirror down by the perineum so she can see
4. Push 6-7 times with each contraction, not one long push
5. Stay alert for complications
6. Ready for immediate care of the newborn
7. Provide cold compresses
8. Cleanse perineum as needed
iii. Needing Extra Room??
1. Lacerations (caused by pushing) to perineum are described by
depth
a. 1st degree: through skin
b. 2nd degree: through muscle
c. 3rd degree: through the anal sphincter muscle
d. 4th degree: through the anterior rectal wall
iv.
rd
c. 3 Stage:
i. BP, pulse, and respirations q 15 minutes
ii. Delivery of the fetus and then the placenta
iii. Nursing Care:
1. Administer oxytocics if prescribed to stimulate the uterus to
contract and thus prevent hemorrhage
2. Administer analgesics
iv. Placenta delivery should not be rushed
v. This should be a time of uninterrupted bonding of mother and baby
vi. Assessments during and after delivery of placenta
1. Gush of dark red blood as placenta separates
2. Umbilical cord lengthening

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a. When placenta detaches the umbilical cord gets “longer”

(meaning more of it is coming out)
3. Fundus should feel firm
4. Examination of the placenta and membranes a 2nd time (after the
provider has done it) to ensure it is intact and nothing was left
behind (i.e. a piece of the placenta)

d. 4th Stage:
i. Assessment:
1. Maternal vital signs (BP and pulse) q 15 minutes for the 1st 2 hours
after delivery; then q 4 hours for the 1st 8 hours after birth; then at
least q 8 hours
2. Fundus and lochia q 15 minutes for the 1st hour
3. Urinary output
4. Baby-friendly activities of the family
ii. Nursing Actions:
1. Massage uterine fundus and/or administer oxytocics to maintain
uterine tone and prevent hemorrhage
2. Encourage voiding to prevent bladder distention
3. Assess episiotomy or laceration repair for erythema
iii. Restoration Stage (right after delivery for 1-4 hours)
1. Initial bonding of the mother and the newborn
2. Excited and awake
3. Critical to watch for post-partum hemorrhage, bladder distention
(can cause more bleeding)
4. 1 pad an hour is too much bleeding
16. Pain Management During Labor:
a. Sources of Pain During Labor:
i. 1st Stage:
1. Internal visceral pain that can be felt as back and leg pain
a. Causes: dilation, effacement, stretching of the cervix;
distention of lower segment of the uterus; contractions
2. Appropriate pain management:
a. Opioids, epidural analgesia, CSE (combined spinal-
epidural), nitrous oxide
nd
ii. 2 Stage:
1. Somatic and occurs with fetal descent and expulsion; described as
burning splitting, and tearing
a. Causes: pressure and distention of the vagina and
perineum; pressure and pulling on the pelvic structures;
lacerations of the soft tissues (cervix, vagina, and
perineum)
2. Appropriate pain management:

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a. Epidural analgesia, CSE (combined spinal epidural), nitrous

oxide, local infiltration anesthesia, pudendal block, spinal
block
iii. 3rd Stage:
1. Pain with expulsion of the placenta is similar to pain experienced
during the 1st stage
a. Causes: uterine contractions; pressure and pulling of pelvic
structures
th
iv. 4 Stage:
1. Pain caused by distention and stretching of the vagina and
perineum incurred during the 2nd stage with a splitting, burning,
and tearing sensation
b. Non-pharmacologic (works for some, but not a lot of people):
i. Walking and position changes
ii. Hydrotherapy
iii. Therapeutic touch
iv. Imagery
v. Acupuncture
vi. Breathing techniques
c. Systemic Analgesics – IV Opioids (butorphanol, meperidine):
i. Lessen pain without loss of feeling or muscle movement
ii. Reduce awareness of pain and are calming, given IV
iii. Can be given up to 4 hours of start of delivery
1. If given 1-4 hours of delivery, the medication will not have enough
time to get out of the fetus’ blood stream
2. If given within 1 hour of delivery, or later than 4 hours from
delivery (i.e. delivery occurs at 1000, medication could be given
before 0600 or after 0900), the medication will either be through
the mother and baby’s system, or it will not have enough time to
reach the baby
iv. Does NOT slow labor down
d. Local anesthesia (Lidocaine):
i. Prevent pain in a small area of the body (for episiotomy)
1. Specifically, the perineum
e. Regional analgesia and regional anesthesia (epidural):
i. Lessen or block pain below the waist (Bupivacaine plus fentanyl)
1. Woman may not feel the contractions
ii. Prolongs 2nd stage of labor
iii. Woman should be given 1 L of LR prior to placement
1. Increases volume of fluid in the body
a. Hypotension can occur from the medications used in the
epidural, and the fluids help decrease chance of that
hypotension from occurring

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iv. Local anesthetic and opioid placed directly into the lumbar epidural space
NOT the spine!
v. Catheter remains inserted for continuing analgesia
vi. 60-90% of women have them
vii. Mother should be placed in left lateral position after epidural is inserted
viii. Complications:
1. Hypotension
a. Can lead to fetal distress
2. Respiratory depression (mother)
3. Allergic reaction
4. Intravascular injection
5. Fever/infection
a. After placement
b. Would manifest, typically, after a few days
ix. Contraindications:
1. Previous spinal surgery
2. Spinal abnormalities
3. Coagulation defects
4. Anticoagulation therapy
5. Infection
6. Obesity (sometimes)
f. Pudendal Nerve Block:
i. Done prior to an episiotomy
ii. Numbs both sides
17. Episiotomy:
a. A cut to make more room for the baby to pass through
i. Either right mediolateral or left mediolateral
18. Administration of oxytocin Post Delivery:
a. Typically given once the shoulders of the baby are out to continue contractions
i. Contractions cause uterine wall blood vessels to contract and decrease
the risk of PPH (post partum bleeding)
b. If the woman was given oxytocin to induce labor, the drip will be continued up to
4 hours post delivery
c. oxytocin dosing
i. 10 units oxytocin IM or
ii. 20-40 units in 1 liter of normal saline or LR
19. Assess the Perineum and Fundus After Delivery of the Placenta:
a. With a firm fundus:
i. Bright red trickling blood is NOT normal
1. Should be more like a period (bleeding, and it stops, bleeding, and
it stops)
2. This is indicative of a laceration
3. Get the provider right away
a. Will require suturing

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b. With a “boggy” fundus (i.e. soft, like squeezing an IV bag):

i. Bright red flowing blood is NOT normal
1. More than likely caused by uterine atony
a. Failure of the uterus to contract after childbirth which
would constrict the severed blood vessels
2. This needs to be fixed
a. Oxytocin should be given to help muscles contract
ii. Dark blood and clots are NOT normal
1. Suspect retained placenta

Nursing Management of Labor and Birth at Risk

1. Nurse’s Role in Promoting Labor Progress:
a. Evaluate regularly:
i. Contractions – adequate, causing cervical dilation, rest interval between
them, frequent or infrequent, etc.
ii. FHR – baseline, accelerations or decelerations
iii. Fetal descent
iv. Cervical dilation (1cm per hour in active labor)
b. Provide:
i. Relaxation and stress reduction
c. Promote empowerment
i. Allow expressions of fear and concern
ii. Provide encouragement
2. Problems with the Powers:
a. Preterm labor – contractions start too early
b. Prolonged pregnancy – contractions won’t start at all
3. Preterm Labor (PTL):
a. Contractions prior to the start of the 37th week of gestation
i. Regular contractions with dilation and effacement
b. Common symptoms:
i. Uterine contractions
ii. Cramping or lower back pain
iii. Pelvic pressure or “fullness”
iv. Increase in vaginal discharge over normal
v. GI cramping
vi. Urinary frequency
vii. N/V and/or diarrhea
viii. Unusual leaking of fluid from the vagina (i.e. ruptured membranes)
ix. Change in cervical dilation
x. Regular uterine contractions with a frequency of every 10 minutes or
greater, lasting 1 hour or longer
c. Risk factors:

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i. Maternal age (less than 18 and greater than 35)

1. Older women because of possibility of co-morbidities
ii. Low socioeconomic status
iii. Alcohol, drugs, smoking
iv. History of preterm labor and/or birth
v. Diabetes and/or chronic hypertension
vi. Pregnancy with multiple fetuses
vii. PPROM and/or late/no prenatal care
d. Is it Really Preterm Labor?
i. Ask if she is having more than 6 contractions per hour?
ii. Have the woman count the number and length of the contraction and
describe the pain of the contraction

e. Things we need to know in order to treat PTL:

i. Membrane status
ii. Dilated?
iii. Infection related to the uterus (chorioamnionitis)
1. Inner layer of the uterus is infected, typically from prolonged
rupturing of the membranes
iv. Gestational age
v. Lab tests:
1. Fetal fibronectin, cervical culture, CBC, urinalysis
f. Management of PTL:
i. Tocolytic therapy:
1. Done to stop labor
2. Typically done before the 34th week of pregnancy
a. After this time it is generally accepted hat the fetus’s lungs
are developed enough to allow for delivery
ii. Tocolytic therapy medications:
1. Magnesium Sulfate (MgSO4) - intravenously
a. Also used for preeclampsia to reduce the risk of seizures
b. Stops labor

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i. Relaxes uterine muscles to stop and prevent

contractions
c. Has a neuroprotective response on the fetal neuro system
d. For preeclampsia:
i. Decreases cerebral excitability and thus the risk of
seizures in women with preeclampsia
e. After initial loading dose, give 1-4 gm/hour
i. Monitor FHR continuously
f. Monitor mother for the following complications:
i. HTN and or depressed DTRs
ii. LOC change
iii. Hot flashes and/or diaphoresis
iv. Burning at IV site
v. Drowsiness
vi. N/V
vii. Blurred vision
viii. Respiratory rate <12 breaths per minute
ix. Headache and/or urine output less than 30 mL/hr
1. Signs of preeclampsia
x. Discontinue if pt. exhibits manifestations of PE
(chest pain, SOB, respiratory distress, audible
wheezing and crackles, productive cough
containing blood-tinged sputum)
xi. Urinary output < 30 mL/hr or 100 mL/4 hr
xii. Severe hypotension
xiii. Chest pain
g. Contraindications:
i. Active vaginal bleeding, dilation > 6 cm,
chorioamnionitis, > 14 weeks of gestation, acute
fetal distress
ii. Do NOT give to a pt. who has myasthenia gravis
2. breathine – subcutaneously
a. Bronchodilator
b. Used for a few days (48-72 hours)
***Magnesium Sulfate and breathine are only used to buy time and only for a few days***
3. nifedapine - orally
a. BP medication
i. Monitor for:
1. Headache, flushing, dizziness, nausea
2. Orthostatic hypotension
b. Used every 4-6 hours to reduce contractions
c. Should NOT be administered concurrently with mag.
sulfate
4. Progesterone - suppository vaginally

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a. Used to increase levels of progesterone

b. Helps to decrease contractions
c. Given weekly
5. Corticosteroids (betamethasone)
a. Given to promote fetal lung maturity
b. 2 doses IM 24 hours apart
c. May repeat in 7 days if the mother has not delivered
d. Improvement in lung maturity can be seen after 24 hours
e. Reduces risk of respiratory distress syndrome and
intraventricular hemorrhage in the preterm infant
f. Monitor mother for infection (common issue with
corticosteroid use)
6. Home monitoring (i.e. fetal kick counts)
7. Diagnostic testing
a. Done on a woman who’s membranes have not ruptured
b. Fetal fribronectin (protein produced by the chorion)
i. Marker for impending membrane rupture within 7-
14 days
4. Prolonged Pregnancy:
a. Past the end of the 42nd week
b. Risks of being “post term:”
i. Placental insufficiency
1. Can not provide nutrients and oxygen to the fetus as the placenta
ages
ii. Fetal macrosomia
1. Baby larger than 4,000 grams
a. Last month of pregnancy fetus gains half a pound per week
iii. Shoulder dystocia
1. Issue with getting the shoulders out at delivery
iv. Brachial plexus injuries
v. Cephalopelvic disproportion (CPD)
1. Head of the fetus is larger than the pelvic opening
c. Prolonged Pregnancy Management:
i. Primary focus is fetal well being
ii. NST (non-stress test) done twice a week
iii. Daily fetal movement counts
1. Looking for at least 10 in 2 hours
iv. Biophysical profile
1. Score of 6-8 requires a re-test within 24 hours
2. Score of 4 or less means the baby needs to be delivered
3. Score of 5 is up to the provider what direction they’d like to go
v. Possible cervical ripening and induction of labor
1. If NST and BPP or amniotic fluid look okay, it is possible to let the
mother go a bit longer (to 42 weeks) before inducing

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5. Indications for Induction of Labor:

a. Being post term
b. Uncontrolled or worsening gestational HTN
c. Gestations diabetes
d. PROM or PPROM
e. Uterine infection
f. Maternal or fetal medical conditions (i.e. preeclampsia)
g. Placental insufficiency
h. Non-reassuring NST
6. Contraindications for Induction of Labor:
a. Placenta previa (woman will need a c-section)
b. Abruption
c. Baby who is laying transverse
d. Umbilical cord prolapse (emergent situation, c-section is needed)
e. Active genital herpes (c-section is needed)
f. Classical c-section scar (vertical, not horizontal)
i. Woman can possibly deliver vaginally, but we cannot induce labor
1. Increased risk of a ruptured uterus
7. Induction of Labor:
a. Deliberate initiation of uterine contractions to stimulate labor
i. Indications:
1. Post term pregnancy (greater than 42 weeks)
2. Dystocia due to inadequate uterine contraction
3. Prolonged rupture of membranes
4. Intrauterine growth restriction
5. Maternal medical complications (re-isoimmunization, DM,
pulmonary disease, gestational HTN)
6. Chorioamnionitis
7. Fetal demise
ii. Complications:
1. Nonreassuring FHR
a. Abnormal baseline less than 110 or greater than 160/min
b. Loss of variability
c. Late or prolonged decelerations
d. Nursing Care:
i. Notify provider
ii. Place pt. in a side-lying position to increase
uteroplacental perfusion
iii. Increase rate of IV fluid to 200 mL/hr unless
contraindicated
iv. O2 at 8-10 L/min via face mask
v. Tocolytic terbutaline 0.25 mg SC to diminish uterine
activity

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vi. If unable to restore reassuring FHR, prepare for an

emergency cesarean birth
b. Cervical ripening based on Bishop Score
i. A “ripe” cervix is:
1. Short, gets soft, starts to efface, possibly has some dilating
ii. An “unripe” cervix is:
1. Long, hard/firm, not open at all
iii. Benefits:
1. Eliminates need for oxytocin administration to induce labor
2. Lower the dosage of oxytocin needed
3. Promote a more successful induction
iv. Indications:
1. Failure of the cervix to dilate and efface
2. Failure of labor to progress
v. Nursing Interventions:
1. Assess for the following:
a. Urinary retention
b. Rupture of membranes
c. Uterine tenderness or pain
d. Contractions
e. Vaginal bleeding
f. Fetal distress
2. Assist pt. to void before the procedure
3. Pt. should remain in a side-lying position
4. Monitor FHR and uterine activity
5. Notify provider if uterine tachysystole or fetal distress is noted
6. Monitor for potential adverse effects (N/V, diarrhea, fever, uterine
tachysystole)
7. Proceed with caution in pts who have glaucoma, asthma, and
cardiovascular or renal disorders
c. Possible amniotomy (artificial rupturing of the membranes)
d. Oxytocin
i. Not always the first option
ii. Mother must be monitored every 15 minutes when given this
iii. Observing for overstimulation of contractions
1. Need rest interval between them for the fetus
2. Fetal heart tones will be impacted if this occurs
8. Bishop Score:
a. Determines whether cervical ripening would be needed, or if we can go directly
to oxytocin administration
b. Score of less than or equal to 6: will need a cervical ripening agent
c. Score of greater than 8: will more than likely not need a cervical ripening agent
and we can go directly to oxytocin

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d. Score of 7 is up to the provider

e. Lower the score means the longer the delivery will take
9. misoprostol:
a. “Ripens” cervix to help begin contractions
b. Inserted into cervix every 6 hours (once it is inserted it can NOT be taken out)
c. Monitor FHR and contraction pattern closely (woman will be on a toco and FHR
monitor)
d. May cause hypertonicity of uterus (very firm contraction) or FHR changes
e. Induction (giving oxytocin) cannot be done for 4 hours after last dose
i. Example: if misoprostol is given at 0600, then oxytocin has to be given at
1000
1. Doing so would be like doubling up on the medication which can
lead to issues with too frequent contractions
10. oxytocin:
a. Uterotonic agent used for induction or augmentation of labor
i. Intravenously, on medication pump per protocol
ii. Baseline and ongoing vital signs and FHR assessments
iii. Contraction pattern may become hypertonic causing decreased fetal
heart rate variability (indication that the fetus is not doing too well)
1. Desired contraction pattern is every 2-3 minutes, lasting about 1
minute each
iv. Rapid dilation of cervix may occur leading to precipitous delivery
(delivering too quickly), cervical laceration or rupture of uterus
11. oxytocin for Induction of Labor:
a. 10 units oxytocin (Pitocin) piggyback in 1000 mL Lactated Ringers
b. Infusion pump piggybacked into main IV line
c. Start at 1-2 mU/hour
d. Assess contraction and fetal heart rate patterns every 15 minutes in first stage
and every 5 minutes in second stage
e. Monitor I/O and voiding, vital signs and pain
i. oxytocin is an antidiuretic
ii. Water retention is common
iii. Could become hyponatremic
1. s/s: nausea, muscle cramps, headache, seizures
f. Provide emotional support
12. oxytocin for Augmentation of Labor:
a. augmentation – woman was in labor, but the contractions have slowed down and
she needs some “help”
i. Same oxytocin as for induction of labor
ii. Same dosing and administration
iii. Same nursing management and complications
iv. Simply called “augmentation” and not “induction”
13. Dystocia:
a. Abnormal or difficult labor related to the 5 P’s
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i. Progress of labor deviates from normal

ii. Characterized by slow, abnormal progression of labor
iii. Primary reason for a first cesarean section
iv. Becomes apparent during “active phase of labor” (4 cm)
1. Termed “Failure to Progress” of dilation or descent of the head
b. Risk Factors:
i. Short stature, obesity
ii. Age greater than 40
iii. Uterine abnormalities
iv. Pelvic contracture or pelvic soft tissue obstructions
v. Cephalopelvic disproportion (fetal head larger than maternal pelvis)
vi. Fetal macrosomia
vii. Fetal malpresentation and/or malposition
viii. Multifetal pregnancy
ix. Hypertonic or hypotonic uterus
x. Maternal fatigue, fear, or dehydration
xi. Inappropriate timing of anesthesia or analgesics
c. Expected Findings:
i. Lack of progress in dilation, effacement, or fetal descent during labor
1. Hypertonic uterus: easily indent-able, even at peak of contractions
2. Hypotonic uterus: cannot be indented, even between contractions
ii. Pt. is ineffective in pushing with no voluntary urge to bear down

d. Contraction Types:
i. Hypertonic Contractions (aka Tachysystole)
1. No relaxation between contractions
2. 5 or more contractions in 10 minutes

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3. Contractions last more than 2 minutes

ii. Hypotonic:
1. Slowing down
2. Mild to no pain
3. Infrequent contractions (no more than 3 in 10 minutes)
4. Risk for postpartum hemorrhage increases due to lack of
contractions of the uterus
e. Nursing Care:
i. Encourage pt. to engage in regular voiding
ii. Encourage position changes to aid in fetal descent or to open up the
pelvic outlet
iii. Encourage ambulation
iv. Apply counterpressure to sacral area to alleviate discomfort
v. Continue monitoring FHR
vi. Prepare for a forceps-assisted, vacuum-assisted, or c-section birth
vii. Assist with amniotomy, application of fetal scalp electrode, and/or
intrauterine pressure catheter
14. Hypertonic Contractions & Tachysystole:
a. Risks for hypertonicity:
i. Precipitous birth
1. Labor and delivery in < 3 hours
ii. Trauma to the woman and/or fetus
iii. Fetal hypoxia
iv. Uterine Rupture
b. Interventions:
i. D/C oxytocin
ii. Left lateral position
iii. Oxygen
iv. Increase plain IV fluids (lactated ringers with no sugar)
v. Closely monitor FHR
vi. Contact provider
vii. Promote rest and relaxation
15. Abnormalities in Length of Labor:
a. Arrested dilation
i. Head is not descending down into the pelvis
ii. Lack of dilation for 2 or more hours
b. Arrested descent of the head
i. Fetal head doesn’t descend in station for 1 or more hours
c. Protracted disorders
i. Slower than normal rate of labor and delivery
ii. Lasts more than 18-24 hours
d. Precipitous
i. Labor and delivery that starts and ends in 3 or less hours
1. Risk Factors:

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a. Hypertonic uterine dysfunction

b. Oxytocin stimulation
c. Multiparous pt.
2. Expected Findings:
a. During labor:
i. Low backache
ii. Abdominal pressure and cramping
iii. Increased or bloody vaginal discharge
iv. Palpable uterine contractions
v. Diarrhea
b. Postbirth:
i. Assess maternal perineal area for indications of
trauma or lacerations
ii. Assess baby’s color and for indications of hypoxia
iii. Assess for indications of trauma to presenting part
of fetus, especially on cephalic presentation
3. Nursing Care:
a. Do not leave the pt. unattended
b. Encourage pt. to maintain a side-lying position to optimize
uteroplacental perfusion and fetal oxygenation
c. Prepare for rupturing of membranes upon crowning
d. Control rapid delivery by appyling light pressure to the
perineal area and fetal head (gently pressing upward
toward the vagina)
e. Deliver fetus BETWEEN contractions
i. Ensure the cord is not around it’s neck
4. Complications:
a. Maternal:
i. Cervical, vaginal, or perineal lacerations
ii. Uterine rupture
iii. Amniotic fluid embolism
iv. PPH
b. Fetus:
i. Fetal hypoxia due to hypertonic contractions or
umbilical cord around fetal neck
ii. Fetal intracranial hemorrhage due to head trauma
from rapid birth
16. Problems with the Passenger:
a. Position
b. Presentation
i. Best position for labor is occiput anterior
ii. Posterior can lead to longer labor and possibly dystocia
c. Number (twins, triplets, etc.)
i. Multiple babies at one time can cause overextension of the uterus

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1. Could lead to postpartum hemorrhage

d. Size of the fetus
17. Shoulder Dystocia:
a. Only way to diagnose this is when the anterior shoulder fails to deliver shortly
after the head

18. Brachial Plexus Injury:

a. Due to pressure on the neck from shoulder dystocia
b. Signs and Symptoms:
i. Abnormal Moro reflex on injured arm
ii. Baby won’t use the affected arm
iii. Decreased grip
c. Can go away, but can also lead to lifelong issues as well

19. Prevention/Treatment for Shoulder Dystocia:

a. Woman’s legs are pulled up to her abdomen

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b. Suprapubic Pressure:
i. Pressing down on the suprapubic bone with as much pressure as possible
ii. Pressure is NOT placed on the fundus (cause that’s where the feet are)
iii. If baby is not able to be pushed out, the provider may break the collar
bone
20. Problems with the Passageway:
a. Placenta Previa – delivered via c-section due to risk of bleeding
b. Abruptio Placentae (Placental Abruption) – delivered via c-section due to risk of
bleeding
21. Problems with the Psyche:
a. Psychiatric illnesses or increased anxiety
b. Increased stress related hormones are released
i. Reduce uterine contractility
ii. Reduce utero-placental perfusion
c. Tranquilizers can be given during the birthing process to help relieve that anxiety
22. Obstetric Emergencies:
a. Prolapsed umbilical cord
i. EMERGENT SITUATION
ii. Cord protrudes along or ahead of the presenting part of the fetus
iii. Total or partial occlusion of the cord due to the pressure on the cord from
the head of the baby
iv. Causes rapid deterioration of fetal perfusion
v. Head SHOULD be at 0 station to help make sure the cord doesn’t come
down first
vi. Risks for Prolapsed Cord:
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1. Malpresentation (breech)
2. Growth restriction
3. Prematurity
4. Ruptured membranes at high station
5. Hydramnios
6. Grandmultiparity (5 or more births)
a. Woman’s uterus will not be able to go back to its “original”
shape/strength after this many births, thus the increased
risk for a prolapsed cord
7. Multifetal gestation
vii. Prevention:
1. Verify station prior to artificial rupture of membranes
2. Check FHT during and after artificial rupture
viii. Treatment:
1. Prepare for emergency c-section
2. Position changes to help relieve pressure on the cord
3. Monitor FHTs and apply oxygen if needed/ordered
4. If you find the cord pulsing, insert your gloved hand into the
vagina and lift up, keeping your fingers there and call for help to
try to decrease the pressure on cord until the baby has been born

b. Uterine Rupture:
i. Tearing of uterus at site of previous c-section scar (vertical scar)
ii. Signs and Symptoms:
1. First and most reliable – sudden fetal distress during labor
2. Acute, continuous abdominal pain with or without epidural

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3. Irregular abdominal contour (no longer looks like an upside down

pear)
4. Loss of station of the presenting part of the fetus
5. Hypovolemic shock of the fetus or mother
c. Abruptio Placenta (Placental Abruption):
i. Premature separation from a normally implanted placenta after 20 weeks
ii. Caused by forcing blood into the under layer of the placenta causing
detachment
1. As bleeding gets worse, the pain gets worse
iii. Focus on the cardiovascular status of the mother and delivery of the fetus
by c-section if it is alive
1. Will deliver vaginally if the fetus is not alive
iv. Risk Factors:
1. Any hypertensive problems
2. Seizures
3. Uterine rupture
4. Trauma
5. Previous history of abruption/placental pathology
6. Coagulation problems
7. Smoking
8. Cocaine use
v. Nursing Care:
1. Palpate uterus for tenderness or tone
2. Assess FHR pattern
3. Immediate birth is the management
a. Administer IV fluids, blood products, and medications as
prescribed
b. Oxygen 8 to 10 L/min via face mask
c. Monitored maternal VS observing for declining
hemodynamic status
d. Continuous fetal monitoring
e. Assess urinary output and monitor fluid balance
d. Amniotic Fluid Embolism:
i. Break in barrier between maternal circulation and amniotic fluid
1. Typically, from a placental abruption or uterine trauma
2. Rare and often fatal
a. Significant maternal and newborn morbidity and mortality
ii. Little bit of amniotic fluid gets into the woman’s bloodstream
1. Similar to a DVT
iii. Signs and Symptoms:
1. Sudden onset of hypotension, hypoxia, coagulopathy
2. Suspect any woman with sudden dyspnea
3. Indications of respiratory distress (restlessness, cyanosis, dyspnea,
pulmonary edema, respiratory arrest)

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4. Indications of coagulation failure (bleeding form incisions and

venipuncture sites, petechiae and ecchymosis, uterine atony)
5. Indications of circulatory collapse (tachypnea, hypotension, shock,
cardiac arrest)
iv. There is NO way to prevent this
v. Risk Factors:
1. Placenta previa or abruption
2. Preeclampsia
3. Eclampsia
4. Hypertensive disorders
5. Oxytocin administration
6. DM
7. Cesarean birth
8. Labor induction
9. Forceps-assisted birth
10. Uterine rupture
11. Cervical laceration
12. Meconium-stained amniotic fluid
vi. Nursing Care:
1. Administer O2 via mask at 8-10 L/min
2. Assist with intubation and mechanical ventilation
3. Perform CPR if necessary
4. Administer IV fluids
5. Position pt. on one side with pelvis tilted at a 30-degree angle to
displace the uterus
6. Administer blood products to correct coagulation failure
7. Insert indwelling urinary catheter (measure hourly urine output)
8. Monitor maternal and fetal status
9. Prepare for an emergency c-section if the baby has not been
delivered
23. Birth Related Procedures:
a. Amnioinfusion:
i. Warm, sterile Normal Saline or Lactated Ringer’s infused into uterus
through the intrauterine pressure catheter after membranes have
ruptured, but the woman is not ready to deliver
1. This simulates amniotic fluid and gets the baby away from the
cord
2. Only done when the woman is in labor
3. 250mL to 500 mL by infusion pump over 20-30 minutes
ii. Watch for hypertonic uterus due to fluid not coming back out after
delivery has been completed
iii. Monitor I&O very closely
1. Observe pad under mother for leaking infused liquid

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a. Weigh a dry chuck and then the one under the mother and
subtract them from each other to get a measurement of
the fluid lost versus infused
iv. Monitor contraction pattern closely
v. Indications:
1. Oligohydramnios caused by any of the following:
a. Uteroplacental insufficiency
b. PROM
2. Thick meconium stained fluid
a. Attempting to keep it out of the baby’s lungs
3. Severe or prolonged variable decelerations
vi. Contraindications:
1. Amnionitis (infection of the uterine cavity)
2. Hydramnios
3. Uterine hypertonia
a. Hypertonic contractions
4. Known uterine anomaly
5. Placental abruption or placenta previa
vii. Interventions:
1. Continually assess intensity and frequency of uterine contractions
2. Continually monitor FHR
3. Monitor fluid output from the vagina to prevent uterine
overdistentation
b. Assisted Delivery Devices:
i. Forceps
ii. Vacuum Extraction:
1. Provider performed procedure
2. Woman pushes while provider pulls suction attached to scalp
3. You only have 3 attempts
a. Once maximum has been reached, must alternate device
(forceps) or do a c-section
4. Nurse’s responsibility is to track the number of unsuccessful tries
24. Birthing the “Other” Way (c-section):
a. Vaginal Birth After Cesarean (VBAC):
i. Risks for attempting natural delivery after a previous c-section
1. Uterine rupture
2. Hemorrhage
ii. Contraindicated:
1. Previous classical uterine incision (vertical scar)
2. Myomectomy (removal of fibroids)
b. Incision Types:
i. Low vertical incision (old school method)
ii. High vertical incision
1. Done to get the baby out ASAP

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iii. Low transverse incision

1. Longer procedure, but a smaller scar
2. Allows for VBAC on subsequent pregnancies

Recognizing and Reporting Child Abuse

1. KID’S’ HOUSE MISSION STATEMENT:
a. To prevent child abuse and to aid child abuse victims and their families with
coordinated services in a child friendly environment, from report and
investigation through treatment and resolution.
2. “Child Abuse” means…
a. Intentional infliction of physical or mental injury upon a child
b. Intentional act that could reasonably be expected to result in physical or mental
injury to a child, OR
c. Active encouragement of any person to commit an act that results or could
result in physical or mental injury to a child
d. Engages in violent behavior that demonstrates a wanton disregard for the
presence a child and could reasonably result in serious injury to the child
3. What are the Numbers?
a. 4.1 million reports annually (7.5 million)
b. ~ 1 in 4 children experience some form of child abuse in their lifetime
c. ~ 5 deaths/day from child abuse/neglect
d. 1 in 10 will be sexually abused before 18yo
e. <2yo – 80% fatal head injuries are non-accidental
f. Total lifetime economic burden – (fatal & nonfatal)
i. ~$124 billion
4. Who Are The Abusers?
a. 59% of perpetrators – FEMALE
b. 41% of perpetrators – MALE
c. 81% of perpetrators – PARENT ACTING ALONE
5. Risks Factors:
a. Socioeconomic status
b. Gender/age
c. Depression or other mental health illness
d. Drug/alcohol usage in the home
e. Domestic Violence
f. Parental history of abuse
g. Animal cruelty
6. What is the most common form of child abuse?
a. Answer: NEGLECT
i. 30% child abuse deaths d/t neglect
ii. 63.7% child abuse deaths – neglect contributed to death

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iii. 70% deaths d/t neglect alone or with other forms of abuse were in
children <3yo
7. Neglect:
a. Act of omission – failure to provide adequate clothing, nutrition, shelter, medical
care, dental care, supervision, education
b. Abandonment
c. May be chronic or acute
d. Accounts for more child abuse deaths than any other type of abuse
8. Types of Neglect:
a. Medical neglect (includes dental neglect)
b. Drowning
c. Motor vehicle crashes
d. Children left unattended in vehicles
e. Co-sleeping; unsafe sleeping
f. Firearms
g. Drug endangered children
9. Sexual Abuse:
a. Involvement of adults, older children or adolescents in sexual activities with
children who cannot give the appropriate consent and who do not understand
the significance of what is happening to them
10. Consider sexual abuse if…
a. They tell you they’ve been sexually abused
b. Injury to the genital area
c. Sexually transmitted disease
d. Pregnancy
e. Child reports/engaged in inappropriate sexual behavior
11. True or false, children disclose about sexual abuse immediately after it occurs?
a. Answer: False
i. Average time to disclose is 6 months
ii. Not uncommon to only disclose once an adult or not at all
b. Why?
i. May be aware of serious consequences of disclosure
ii. Love for offender & fear they will be upset
iii. Fear of being removed or having offender (often a family member)
removed
iv. Fear financial consequences to family
v. Threatened by offender
vi. Pressure by offender/family to retract
vii. Fear reaction of adults
viii. Confusion because sexual act felt good
12. True or false, children who disclose their abuse and later recant their story were lying about
the abuse?
a. Answer: FALSE

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i. Not uncommon for child to recant following initial detailed account of

abuse
ii. May be pressured to recant by offender or family
iii. May feel guilty about effect of disclosure on family
iv. May be coerced/bribe
13. Know This!
a. Children rarely lie about abuse
b. Children’s disclosure of abuse may vary in their content because of reluctance &
fear to tell what happened
14. True or false, children who experience psychological maltreatment usually don’t experience
the severe mental health problems faced by victims of physical or sexual abuse?
a. Answer: FALSE
i. Emotionally abused children experience anxiety, depression, low self-
esteem, PTSD & suicidality at the same rate &, in some cases, at a greater
rate than children who were physically or sexually abused.
15. Emotional Abuse:
a. A repeated pattern of damaging interactions between parent(s) and child that
becomes typical of their relationship
b. Child repeatedly feels unloved, unwanted, worthless
c. Most commonly occurring type of abuse, but least likely to be reported
d. Consider emotional abuse if…
i. Lack of attachment
ii. Lack of responsiveness to their environment
iii. Failure to thrive
iv. Child discloses repeated pattern of emotional abuse
16. Recognizing Child Abuse:
a. Detailed History
b. Physical exam
c. Diagnostic studies
d. Interview of child, siblings, parents, caretakers
17. Discrepancies Between the History & Injury?
a. History given by parent does not explain the injury
i. As in shaken baby: common explanation parents give is they fell off the
couch
b. Child reports injury done by parent
c. Child afraid to go home
d. Multiple injuries, various stages of healing
e. Delay in seeking medical attention
i. This accounts for a fair number of deaths
1. Ex.) sepsis after 3rd degree burns
f. No history offered
g. History changes over time
h. Child developmentally not capable or would not reasonably be expected to have
acted as described

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i. Child gives unbelievable explanation

j. Serious injury blamed on another child
18. Identifying Suspicious Injuries:
a. Accidents or Abuse?
i. Typical sites – elbows, knees, shins, facial scratches
ii. Inflicted sites – buttocks, low back, genitals, ears, neck
19. True or false, 80% of abusive fractures occur in children less than 18 months old?
a. Answer: TRUE
i. <3yo -24% of fractures in children are inflicted
ii. 80% of abusive fractures occur in children <18 mos.
iii. Most common inflicted fractures:
1. Skull
2. Humerus
3. Femur
4. Tibia
5. Ribs
20. Classic Metaphyseal Lesion (CML):

21. Bite Marks:

a. Semi-circular or oval
b. Can be viewed with ultra-violet light
c. < 2.5cm vs. 2.5-3.5cm
i. Measure from top incisor to lower incisor
22. True or false, the most common manifestation of physical abuse is bruising?
a. Answer: TRUE
23. Suspicious Bruising:
a. INFANTS – non-mobile
i. Upper arms, thighs
ii. Face, ears, neck
iii. Genitalia
iv. Abdomen
v. Buttocks

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b. PATTERNS TO LOOK FOR…

i. Wire loops – elliptical shapes
ii. Belt, belt buckle, shoe, etc. – look for pattern
iii. Hand – parallel lines
iv. Ligatures – circumferential marks
24. Burns:
a. Up to ¼ of all physical abuse is caused by some type of burn
b. Most children are burned by some type of heated liquid
c. Scald Burns:
i. Thick liquids maintain heat much longer, more extensive burn
ii. Typical accident is a splash or spill
iii. Typical inflicted scald burn has well demarcated margins
d. Flame Burns:
i. Commonly inflicted on hands or feet
ii. Punishment for playing with fire
e. Contact Burns:
i. Made with heated objects
ii. Look for pattern
iii. Location is revealing!
f. Electrical Burns:
i. Severity dependent on strength of current, skin resistance & contact time
ii. Often in context of neglect
g. Chemical Burns:
i. Important to know the causative agent
ii. Amount of damage dependent on agent, strength, quantity, duration, &
extent of penetration
iii. Access MSDS
h. Radiation Burns:
i. Direct or indirect
ii. Often in context of neglect
25. Abusive Head Trauma (AHT):
a. AHT involves an inflicted injury to the head and its contents, including those
caused by both shaking and blunt impact
b. The term "shaken baby syndrome" (SBS) is commonly used to describe one form
of AHT
c. Head of an infant = 25% of body wt.; weak neck musculature; high water content
in brain
i. Veins in brain are stretched, exceed elasticity
ii. Tear, causing bleeding
iii. Brain strikes skull
iv. Immediate swelling
d. Primarily affects children age 2 and under (avg age is 5 – 6 months)
e. 70% perpetrators-male
f. 25% of AHT babies die, while up to 70% have lifelong disabilities

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g. CRYING is #1 trigger
26. WE ARE ALL MANDATORY REPORTERS!
a. Any person who knows, or has reasonable cause to suspect, that a child is
abused, abandoned, or neglected by a parent, legal custodian, caregiver, or
other person responsible for the child’s welfare shall report such knowledge to
the department
27. Methods of Reporting:
a. 1-800-96-ABUSE
b. 1-800-914-0004 (FAX; complete form, request confirmation)
28. How to Report:
a. Provide your name, work address & phone number
b. Provide child’s name, age, race, sex, DOB
c. State your concern for child’s safety & what type of abuse is taking place
d. If possible, give names of siblings
e. Provide parent/caretaker information
f. Request name & ID number of hotline counselor
29. Mimics of Child Abuse:
a. Things that look like child abuse but are NOT child abuse
i. Mongolian Spots
1. Blue birthmarks that present after birth (they fade by 4-5 years of
age)
ii. Coining
1. Vietnamese
iii. Cupping
1. Latin, Eastern European countries
iv. Moxibustion
1. Asian
v. Impetigo
vi. Herpes Zoster
vii. Phytophotodermatitis

Contraction & Fetal Heart Rate Monitoring

1. Evaluation of Initial Labor Strip:
a. Contractions
i. Frequency, duration, intensity
b. Fetal Heart Rate
i. What is the baseline FHR?
1. Normal (110 to 160 bpm), bradycardia, tachycardia
ii. Are there periodic changes?
iii. Accelerations or decelerations?
c. Is this a reassuring strip?
2. Involuntary Contractions of Uterine Muscles Cause Effacement and Dilation of the Cervix:

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a. Period of relaxation is important for oxygenation of the fetus

i. No blood flow to the uterus at the peak (acme) of the contraction, which
means decreased oxygen
b. Frequency:
i. From the beginning of one contraction to the beginning of the next
ii. Measured in minutes
c. Duration:
i. Measurement of a single contraction from beginning to end
ii. Measured in seconds
d. Rest Interval:
i. Period between contractions
ii. Measured in seconds
3. Contraction Types:
a. Hypertonic/tachysystole
i. 5 or more contractions in a 10-minute period, thus a contraction longer than
2 minutes in duration
ii. If the woman is on oxytocin, it should be stopped if this pattern appears
b. Hypotonic
i. Happens because of overstretching of the uterus (i.e. grandmultiparity)
ii. Also be caused by multiparity, or a large baby
4. Assessing Fetal Heart Rate:
a. Baseline
i. Measured in a 10-minute period
1. To call a change in FHR baseline, look at a 10-minute period of the
FHR strip
ii. Normal is 110-160 beats per minute (bpm)
iii. Bradycardia < 110 bpm for 10 minutes or more

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1. Causes: pain meds, hypoglycemic mother, epidural

iv. Tachycardia > 160 bpm for 10 minutes or more
1. Causes: infection (mother has a fever or an infected placenta)
a. Intervention: take the woman’s temperature
v. Both can be very serious if FHR variability and late FHR decelerations are
present
b. Variability
i. Beat to beat changes in fetal heart rate
ii. Moderate variability is normal
5. FHR Variability

a. If we go from moderate to minimal, something with the fetus has changed

i. Just keep an eye on it for a bit, as it could be nothing serious (i.e. the fetus is
“asleep”)
6. Periodic Changes in the FHR:
a. Accelerations:
i. Increase in FHR by 15bpm or more, lasting for 15 seconds
ii. Denotes a healthy fetus
b. Decelerations:
i. Three types of decelerations:
1. Early:
a. Start at the beginning of the contraction
b. Ends before the end of the contraction
c. Caused by head compression
2. Late:
a. Starts well after the contraction starts
b. Recovers well after the contraction ends
c. These are ominous

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d. Caused by placental insufficiency

3. Variable:
a. Can happen anywhere in the contraction pattern
b. Caused by cord compression
c. FHR variability is NOT the same as variable decelerations
ii. Early and late have a “U” shape
iii. Variable is more like a “V” (rapid drop, and rapid rise)
c. Interventions:
i. VEAL—CHOP – TOAST
ii. Early decelerations:
1. May want to check the cervix to see if the woman is ready to deliver

V.E.A.L. C.H.O.P. T.O.A.ST.

Fetal Heart Observation Related To Intervention
Variable decelerations Cord compression Turn pt. on side to relieve
pressure on cord
Early decelerations Head compression Ok (no intervention needed;
will resolve at end of
contraction)
Accelerations Okay (normal) Acceptable (no intervention
needed)
Late decelerations Placental insufficiency STop (Stop Pitocin; Turn pt. on
side; O2 via facemask; ↑ Plain
IV fluid

Childhood Communicable Diseases and Immunizations

1. Preventing the Spread of Disease:
a. Hand washing
b. Isolation precautions (Box 37.3, pp. 1338-1339)
i. Tier 1 – Standard Precautions
1. Applied to all children
a. Regardless of pt.’s diagnosis
b. Applies to all body fluids
2. Handwashing and PPE if exposure to body fluids is expected or
likely
ii. Tier 2 – Transmission-based precautions
1. Pt.’s who have a known of suspected infection
2. Include airborne (measles, varicella TB), droplet (diphtheria,
pertussis, flu, mumps, rubella, scarlet fever), and contact
(diphtheria, scabies, multidrug-resistant bacteria) precautions
3. These pt.’s are not able to go to the playroom

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a. Child life specialist can visit the pt. and bring toys
2. Variations in Pediatric A & P:
a. Immature responses of the immune system
b. Decreased inflammatory response (newborns especially)
c. Limited exposure
d. Decreasing passive immunity
i. Passive immunity is immunity that was conferred to the fetus from the
mother in utero
e. Incomplete immunization protection
3. Nursing Assessment of the Child with a Communicable Disease:
a. Full health history
b. Physical examination:
i. Assess any lesions or wounds
ii. Accurately describe rashes
iii. Observe the child’s behavior
iv. Assess hydration status
1. Ex.) how many wet diapers has the child had?
v. Measure vital signs
c. Lab and diagnostic testing
4. Nursing Management of the Child with a Communicable Disease:
a. Fever is a sign of illness, not a disease, it is the body’s weapon to fight infection
b. Manage fever:
i. Antipyretics:
1. Increase comfort
2. Decrease metabolic demands due to the fever
3. Unable to give children aspirin until they are 19 due to associated
risk of Reye Syndrome after a viral infection
4. Dosing Info:
a. Acetaminophen: 10-15 mg/kg/dose
i. No more than q 4 hours
ii. No more than 5 doses in a 24-hour period
b. Ibuprofen: 4-10 mg/kg/dose
i. ONLY children older than 6 months of age
ii. No more than 4 doses in a 24-hour period
ii. Non-pharmacologic interventions:
1. Lightweight, or no blanket
2. Tepid bath
3. Fans
c. Parental education:
i. Rectal temps should NOT be done on children due to risk to the anus
ii. Temperature concerns:
1. Infants with a temp at or above 38 C (100.4) have to be seen due
to increased risk of meningitis

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2. Older infants who have a fever for greater than 5 days, or greater
than 105 need to be seen
3. Neonates with a temp below 97.7 should be seen immediately
(can indicate sepsis)
4. Children’s temps may vary by as much 1.8 degrees over a 24-hour
period (peaking in the evening)
5. Call the provider if child is listless or lethargic, regardless of
temperature
d. Manage skin rashes
e. Promote hydration
i. Oral fluids
ii. Proper IV fluid management
iii. Strict I & O
iv. Fluid status
v. Watch for s/s of dehydration
5. Common Drugs for Communicable Diseases:

6. Bacterial Infection Pathogens:

Infection Gram negative pathogens Gram positive pathogens

Burns Pseudomonas aeruginosa Staphylococcus aureus

Skin infections S. aureus

Throat Streptococcus pyogenes

Otitis media Haemophilus influenzae Streptococcus pneumoniae

Pneumonia H. Influenzae S. pneumoniae

Septicemia Escherichia coli S. aureus, S. pyogenes

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Urinary tract E. coli Enterococcus sp.

7. Antibiotic Spectrum of Activity:

a. We start with a broad spectrum abx until the offending organism is identified
8. Pertussis (whooping cough):
a. Acute respiratory disorder caused by Bordetella pertussis bacteria
b. Children < 4 years old
i. Mostly occurs in children 12 months or younger
1. More severe in those less than 6 months of age
c. Increasing in adolescents and young adults (vaccine does not last forever)
d. Risk Factors:
i. Lack of immunizations
e. Diagnosed via nasal swab
f. Nursing Assessment:
i. Physical exam of the child:
1. Auscultate breath sounds
2. Assess respiratory status
ii. 7-10 days of URI symptoms
iii. Paroxysmal coughing spells up to 4 weeks
1. Strong cough multiple times per day
2. Get red in the face
3. Can become cyanotic
iv. Convalescence occurs over several months
g. Nursing Management:
i. Provide respiratory support
ii. Maintain patent airway
1. Bulb syringe is often used
iii. Encourage fluids
iv. Reassure family
v. Antibiotic education
vi. Very young children often admitted to ICU
vii. Droplet precautions
h. Treatment of choice is Zithromax
i. Complications:
i. Seizures, pneumonia, death
j. Education:
i. Pregnant women between 27-36 weeks should have pertussis vaccine
every time they’re pregnant
ii. Children should have more than 1 vaccine (part of Tdap)
iii. Infected family members may unknowingly pass whooping cough on to a
newborn
9. Varicella (chicken pox):
a. Caused by varicella zoster virus

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i. Highly contagious from 1-2 days prior to appearance of rash until all
lesions have crusted over
ii. Incubation period approx. 3 weeks
iii. Starts out as a cold normally, and then the rash develops
iv. Hallmark of chicken pox is varying stages of the rash at the same time
b. 3 routes of transmission:
i. Direct contact with lesions
ii. Respiratory secretions (airborne)
iii. Transplacentally
1. This is why the woman should be vaccinated before becoming
pregnant
c. Signs and Symptoms:
i. Prodromal symptoms (fever, malaise, anorexia, headache, mild abdominal
pain) may be present 24-48 hours before onset of the rash
ii. Lesions often appear 1st on the scalp, face, trunk, then extremities
d. Nursing Assessment:
i. Assess distinct rash pattern and symptoms
1. Rash progression:
a. Macular lesion
b. Popular
c. Pustular
d. Finally, scabbing over
ii. Note immunization status
iii. Assess for complications
e. Nursing Management:
i. Isolation (contact & airborne)
ii. Supportive care/skin care
iii. Antiviral therapy and/or IVIG for high-risk
f. Treatment:
i. Airborne and contact precautions are needed
ii. Antihistamines are very important
g. Complications:
i. Possible necrosis if a pox is scratched and becomes infected
ii. Arthritis
iii. Hepatitis
iv. Thrombocytopenia
v. Pneumonia
vi. Glomerulonephritis
vii. Encephalitis
viii. Sepsis
ix. Meningitis
x. Death
10. Rubeola (measles):
a. Caused by the measles virus

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b. Transmitted by small droplets

i. Primarily in the nasopharyngeal secretions
1. Can also be in the blood and urine
ii. Infectious 1-2 days before symptoms until 6 days AFTER the rash starts
c. Signs and Symptoms:
i. 2-4 days of fever and cough
ii. Red eyes
iii. Conjunctivitis
iv. Kolpik spots
v. Red, maculo-papular rash that starts at the head and moves down the
body
d. Nursing Assessment:
i. Assess distinct rash
ii. Note Koplik spots
iii. Assess immunization status
iv. Monitor for complications
e. Nursing Management:
i. Isolation (airborne and contact)
ii. Supportive care/skin care
iii. Bed rest for the 1st few days
iv. Possible Vitamin A supplementation (to help reduce blindness)
v. Cool mist humidifier and gentle eye care
f. Complications:
i. Pneumonia
ii. Encephalitis
iii. Blindness
iv. Death
11. Parotitis (mumps):
a. Caused by paramyxovirus
b. Saliva and droplet transmission
c. Nursing Assessment:
i. Assess symptoms:
1. Fever
2. Earache
3. Malaise
4. Swelling (can be unilateral or bilateral)
ii. Note gland swelling and pain
1. Causes pain while chewing
iii. Assess for complications
d. Nursing Management:
i. Isolation
ii. Supportive care
iii. Soft diet (swelling can make it difficult to swallow)
iv. Pain management

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v. Fluid management and hydration

e. Complications:
i. Deafness
ii. Sterility in males
12. Principles of Immunity:
a. Immunity:
i. Ability of the body to recognize “self” from “not self,” and destroy and
remove antigens
1. Antigen – foreign organisms
2. Pathogen – antigens that cause disease
b. Antibodies
i. Also known as immunoglobulins
ii. Produced to remove antigens
iii. Specific to an invading organism
13. Types of Immunity:
a. 2 types – passive and active
i. Passive Immunity:
1. Immunoglobulins are transferred from one person to another
2. Lasts only weeks or months
3. IVIG, maternal breast milk
4. No immunologic memory (body doesn’t remember when faced
with the pathogen again)
ii. Active Immunity:
1. Own immune system generates immune response
2. Lasts for years or lifetime
3. Natural pathogens or vaccines
4. Immunologic memory
14. Immunizations:
a. Revolutionized children’s health care in the 20th century
b. Shift from disease treatment to prevention
15. Classification of Vaccines:
a. 2 types:
i. Live attenuated vaccines
1. Modified organisms which replicate in the body but don’t cause
disease
ii. Inactivated vaccines
1. 3 types:
a. Whole:
i. Contain killed whole organisms
b. Fractional:
i. Contain pieces of organism
1. Protein-based (toxoid)
2. Polysaccharide, or “pure”
a. Not for children less than 2

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3. Polysaccharide-Conjugate
c. Recombinant:
i. Genetically engineered
2. Weaker antigen
3. Require multiple doses (boosters)
16. Immunization Descriptions (starting in infancy [2 months]):
a. Diphtheria, Pertussis, and Tetanus Vaccine
i. Route = IM
ii. DTaP for children under 7
1. Higher concentration of diphtheria and pertussis than tetanus
iii. Tdap for older children & adolescents
1. Higher concentration of tetanus vs diphtheria and pertussis
iv. Rising pertussis cases since 1970
b. Haemophilus influenzae Type B Vaccine (Hib):
i. Route = IM
ii. Causes life-threatening illnesses in children under age 5
1. Meningitis, epiglottitis, septic arthritis
c. Polio Vaccine:
i. Route = SC or IM
ii. Inactivated polio vaccine (IPV) currently recommended in US
iii. Killed virus, poses no risk of infection
d. Hepatitis B (Hep B)
i. Route = IM
ii. Recombinant vaccine
iii. Series of 3 vaccines usually started at birth before discharge from hospital
e. Pneumococcal vaccine:
i. Route = IM
ii. Streptococcus pneumoniae cause of serious infection < age 2
1. Most common cause of pneumonia, meningitis, and sepsis
iii. Conjugate vaccine (PCV13 - 13 strains) started in infancy
iv. Polysaccharide vaccine (23 strains) ONLY given to high risk children > age
2
1. Ex.) children without a spleen, sickle cell, renal disease, cardiac
issues, diabetes
f. Rotavirus vaccine:
i. Route = PO
ii. Most common cause of severe gastroenteritis
iii. Given in 2 doses to those less than 32 weeks of age
iv. Live vaccine, given by oral route to infants
17. Immunization Descriptions (> 12 months):
a. Measles, Mumps, and Rubella Vaccine (MMR):
i. Route = SC
ii. Live attenuated virus combination
iii. 2 doses given to children > 12 months of age

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b. Varicella Vaccine (chicken pox):

i. Route = SC
ii. Live attenuated virus (VAR)
iii. 2 doses given to children > 12 months of age
c. Hepatitis A Vaccine (Hep A):
i. Route = IM
ii. Inactivated whole virus vaccine
iii. One of the most frequently reported diseases in the US
iv. 2 doses given to children > 12 months of age
v. Children are carriers of this which is why the vaccine is necessary (it can
spread to adults)
18. Immunization Descriptions (pre-adolescent; 11-12 years of age):
a. Meningococcal Vaccine (MCV4):
i. Route = IM
ii. Neisseria meningitidis causes meningitis and sepsis
iii. 10-12% of infected persons die within 24 hours of contraction
1. 20% of survivors suffer long-term consequences such as loss of a
limb
b. Human Papillomavirus Vaccine (HPV):
i. Route = IM
ii. Infection most common in adolescents and young adults who are sexually
active
iii. HPV causes genital warts that can lead to cervical cancer
19. Immunization Descriptions (annual > 6 months):
a. Influenza vaccine:
i. Route = IM/IN/ID
ii. Universally recommended > 6 months of age
iii. Quadrivalent
iv. < 9 years of age – initially need 2 vaccines, 1 month apart
1. If you only get 1, the next time you get it, you still have to get 2
v. IN route to healthy children starting at 2 years until 18 years of age
1. 0.25ml: 6-35 months 0.5ml: >36 months
20. Immunization Management:
a. Advisory Committee on Immunization Practices (ACIP) updates vaccine schedules
yearly
b. Report any clinically significant adverse reaction to the Vaccine Adverse Event
Reporting System (VAERS)
c. Proper storage
d. Proper administration
e. Proper screening
f. Proper documentation
21. Screening:
a. Is the child sick today?
i. Can give a vaccine if the child shows the following:

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1. Runny nose
2. “Little cold”
3. Low grade fever (up to 101)
4. Little cough
b. Does the child have allergies to medications, food, vaccines, or latex?
c. Has the child had a serious reaction to a vaccine in the past?
d. Does the child have lung, heart, kidney or metabolic disease?
e. If 2-4 years old, has your child had problems with wheezing or asthma?
f. Has your child ever had intussusception (telescoping of the intestine upon itself,
usually after a viral illness; commonly occurs around 6 months of age)?
g. Has the child or family member had a seizure or nervous system problem?
h. Does the child have cancer, leukemia, HIV, or other immune problem?
i. In the past 3 months, has the child taken cortisone, prednisone, other steroids,
or anticancer drugs?
j. In the past year, has the child received a transfusion of blood?
i. Cannot have a live vaccine within 12 months of this
k. Is the child/teen pregnant or could become pregnant during the next month?
l. Has the child received vaccinations in the past 4 weeks?
22. Precautions vs. Contraindications vs. Permanent Contraindications:
a. Precautions:
i. Increase the risk of adverse reaction (benefits weighed against risk)
ii. Reduce the ability of the vaccine to produce immunity
iii. Seizures, prolonged crying, high fever (pertussis), moderate-severe
illness, recent receipt of IG
b. Contraindications:
i. Conditions that advise withholding vaccine
ii. Temporary Contraindications:
iii. Severe immunodeficiency, antiviral therapy (viral vaccines), pregnancy
(live vaccines)
c. Permanent Contraindications:
i. Anaphylaxis (causative vaccine)
ii. Encephalopathy (pertussis)
iii. Intussusception (rotavirus)
23. To Immunize or Not to Immunize:
a. Child with minor illness?
i. Yes
b. Child with temperature of 100˚F?
i. Yes
c. Child on antibiotics?
i. Yes
d. Child with stable HIV?
i. Yes
e. Breast feeding infant?
i. Yes

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f. Child with pregnant household contacts?

i. Yes
g. Child with autism?
i. Yes
h. Hives after previous injection?
i. NO!
i. Allergy to eggs or egg products?
i. Yes, except for influenza vaccine
24. Administration Routes:

25. Infant Vaccine Administration:

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a. Preferred site is the vastus lateralus

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26. No injections into the deltoid (not enough muscle mass) or abdomenToddler /Preschooler
Vaccine Administration:

a. Preferred site is the vastus lateralus

b. Deltoid can be used if child has adequate muscle mass
27. School age & Adolescent Vaccine Administration:

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a. All injections go into the deltoid

28. Reactions to Immunizations:
a. Mild (common):
i. Low grade fever (101-102)
ii. Pain and swelling at site
iii. Fussiness
iv. Poor appetite

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v. Rash, 1-2 weeks after getting a LIVE vaccine

b. Severe (rare):
i. Fever greater than 103
ii. Seizures
iii. Anaphylaxis
iv. Inconsolable crying for more than 3 hours
29. Post-Vaccine Interventions:
a. Tylenol every 4 hours for pain or fever
i. Not to exceed 5 doses/day
b. No ibuprofen to infants younger than 6 months of age
c. No ASA to any child under 19 years of age
d. Warm baths or cool compresses (especially for the vastus laterallus)
e. Encourage ambulation or use of affected extremity
30. Documentation:
a. Child’s name
b. Date given
c. Vaccine name
d. Manufacturer
e. Lot number
f. Expiration date of vaccine
g. Site of injection
h. Route
i. VIS date (the date on the sheet)
j. Facility
k. Name of administering HCP
31. Barriers to Immunization:
a. Parental concerns regarding safety (autism is the biggest)
b. Misconceptions
c. More than 1 health care provider
d. Multiple children in family
e. Cost
f. Concern about multiple vaccines
32. The Beginning of the “Anti-Vaccine Movement:”
a. Andrew Wakefield
i. 1998-Paper linked MMR to autism & Crohns disease
ii. No other researchers could reproduce his results
iii. 2004-Undisclosed conflicts of interest were found out ($$$$)
iv. 2010-The Lancet retracted Wakefield’s paper as fraudulent
v. Mid-2010-Lost his ability to practice in England
vi. 2011-Moved to Austin, Texas where he has a following, but is not licensed
by the American Board of Medicine to practice
33. Some Results of the Distrust:
a. US Measles Outbreaks since Wakefield’s paper
i. 2008: 12 cases in San Diego (first cases in 17 years)

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ii. 2008-2015 state outbreak-131 cases (49% had refused vaccination)

iii. 2011: 118 cases
iv. 2013: 20 cases, members of a church in Texas (encouraged not to
vaccinate by the pastor)
b. US Measles Outbreaks since Wakefield’s paper
i. 2014: 20 in NYC alone
ii. 12/2014-6/2015: 21 state outbreak with 173 cases linked to one child at
Disneyland
iii. 2017: 78 cases in Minneapolis
1. 65 were Somali-Americans who had heard a talk by Dr. Wakefield
and chose not to vaccinate
iv. 2015… 12 months …… 694
v. 2019… 4 months ….. 704
34. Overcoming Barriers:
a. Combination vaccines
i. Decreases the number of vaccinations necessary
b. Vaccines for Children (VFC) program implemented in 1994
c. Establish medical home
d. Verify immunization status at every visit
e. Verify status of siblings accompanying child
f. Maintain centralized record

Postpartum
1. Uterine Involution (shrinking):
a. Uterus, cervix and vagina return to pre-pregnant size
i. Takes up to 6 weeks
b. Uterus and fundus decrease in size 1cm (1 fingerbreadth) a day
i. If this doesn’t happen, that means there’s a problem!
c. Fundus not palpable after ~10 days after delivery
d. After-pains are common
i. Exacerbated by breastfeeding and oxytocin release
ii. Can be relieved by walking/exercise (will go away on their own
eventually)
e. Complications in labor, delivery or in the post-partum period can delay involution

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2. Lochia (bleeding after pregnancy):

a. Manifestations of abnormal lochia:

i. Excessive spurting of bright red blood from the vagina, possibly indicating
a cervical or vaginal tear
ii. Numerous large clots and excessive blood loss
1. Indicated by saturation of a pad in 15 min or less
iii. Excessive flow (pad saturation within 1 hour)
iv. Foul odor (suggests infection)
v. Persistent heavy lochia rubra in the early postpartum period beyond day
3 (could be due to possible retained placental fragments)
vi. Continued flow of lochia serosa or alba beyond the normal length of time
can indicate endometritis (especially if accompanied by fever, pain, or
abdominal tenderness)
3. Cardiovascular:
a. Blood volume and cardiac output decreases are related to:
i. Blood loss at delivery
ii. Diaphoresis
iii. Diuresis
iv. Weight loss (due to lochia, delivery, and diuresis) of about 19 lbs. during
the 1st 5 days after delivery
v. Takes approx. 4 weeks to return to normal
b. Hematocrit stays stable or increases due to plasma reduction

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i. Acute decrease in hematocrit is unexpected

c. Pulse decrease is normal (40-60 bpm)
d. Hypercoagulable (increased clotting) state remains for 2-3 weeks
i. Increased risk for DVTs and PE
e. Possible orthostatic hypotension within the 1st 48 hours postpartum
f. Assessment:
i. Compare VS, blood component changes, and cardiovascular changes with
baseline pregnancy VS
ii. Assess pedal pulses, skin turgor, and legs and feet for edema
iii. Inspect legs for redness, swelling, warmth (indications of venous
thrombosis)
g. Nursing Care:
i. Encourage fluid intake
ii. Encourage early ambulation
iii. Apply antiembolism stockings
4. Gastrointestinal System:
a. No longer pressure on the abdominal organs related to the fetus
b. Constipation
i. Decreased peristalsis causes decreased bowel tone
ii. Fear of pain with bowel movement
c. Increased appetite and thirst
i. Energy expenditure and NPO status during labor
d. Assessment:
i. Assess report of hunger (woman should have a good appetite)
ii. Assess bowel sounds
1. Spontaneous bowel movement might not occur for 2-3 days after
delivery
a. Secondary to decreased intestinal muscle tone during
labor, prelabor diarrhea, dehydration, or medication
adverse effects
iii. Assess for discomfort with defecation due to perineal tenderness,
episiotomy, lacerations, or hemorrhoids
iv. Assess rectal area for varicosities (hemorrhoids)
e. Nursing Care:
i. Encourage interventions to promote bowel function
1. Early ambulation, increased fluids, intake of high-fiber foods
2. Stool softeners
a. Enemas and suppositories are contraindicated for those
who have 3rd or 4th degree perineal lacerations
3. Encourage pt. to ambulate or rock in a chair to promote passage
of flatus
4. Avoid gas-forming foods
5. Anti-flatulence medications can be required
5. Urinary System:

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a. May have difficulty voiding:

i. Anesthetic block (epidural) inhibits neural functioning of bladder
ii. oxytocin (Pitocin) has an antidiuretic effect
iii. Lacerations or swelling of the perineum
iv. Hematomas
b. Displacement of the uterus with a full bladder
i. Inhibits contraction of uterus causing uterine atony (noncontracting)
c. Output:
i. Diuresis of up to 3,000 mL a day, starts in the first 12 hours
1. Excessive urine diuresis (more than 3,000 mL/day) is normal
within the 1st 2-3 days after delivery
ii. < 150 mL per void may indicate retention
iii. Has not voided in 4-6 hours post-delivery may require catheterization
d. Assessment:
i. Assess for evidence of a distended bladder:
1. Fundal height above the umbilicus or baseline level
2. Fundus displaced from midline over to the side
3. Bladder bulges above the symphysis pubis
4. Excessive lochia
5. Tenderness over the bladder area
e. Nursing Care:
i. Assist pt. to void w/in 6-8 hours of delivery
1. If pt. is unable to do so, catheterization may be required
ii. Void frequently to prevent possible displacement of the uterus and atony
iii. Measure the first few voiding’s to assess for proper emptying
iv. Encourage pt. to increase fluid intake
6. Assisting with Elimination:
a. Privacy, get up as soon as possible
b. Pain management
c. Increasing fluids
d. Stool softener or laxatives, dietary changes
e. For difficulty voiding:
i. Warm water on the perineum
ii. Hearing the running tap water
7. Musculoskeletal System:
a. Fatigue and exercise intolerance
i. Hip and joint pain due to decreased progesterone and relaxin
b. Joints eventually return to pre-pregnant state
i. Permanent increase in shoe size
c. Abdominal wall stretching
i. Loss of muscle tone requiring specific exercises
d. Nursing Assessment:
i. Assess abdominal wall for diastasis recti (separation of the rectus muscle)
1. Usually resolves within 6 weeks

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e. Nursing Care:
i. Prevent falls
8. Integumentary System:
a. Darkened pigment to face, abdomen and nipples fade with decreased estrogen
and progesterone
b. Striae gravidarum fade but don’t disappear
c. Temporary hair loss can occur within 3 months of delivery due to decreased
estrogen levels
d. Diaphoresis can be profuse in early postpartum period as increased body fluids
of pregnancy return to normal
9. Respiratory System:
a. Respiratory rate 16-24 breaths per minute
b. Diaphragm returns to normal position
i. Pregnancy experienced SOB and rib pain resolve
c. Lung function changes of pregnancy return to normal quickly
10. Endocrine System:
a. Estrogen and progesterone levels drop quickly after delivery of placenta
i. Decreased estrogen causes breast engorgement
1. Breastfeeding keeps estrogen levels low
2. Is dependent on frequency of breast feeding
ii. Progesterone
1. Levels begin to increase again with menstrual cycle
iii. Prolactin
1. Remains elevated in women who are breastfeeding
11. Lactation:
a. Beginning milk is called colostrum
i. Very good for the baby
ii. High in protein and carbohydrates but not milk fat
iii. Lasts for a couple of days until “true” milk comes in at the 4-5 day mark
b. Sucking on the breast stimulates hormone release
i. Prolactin stimulates milk production
ii. Oxytocin causes the let down release of milk
12. Postpartum Assessment:
a. Begins within an hour of delivery
i. Frequent vital signs and fundal checks--hospital protocol
1. Typically every 4 hours
b. On the post-partum unit:
i. Patient history
ii. Pregnancy, labor and delivery events and interventions
1. Ketorolac, if given IV for pain post-delivery, must be given at least
4 hours prior to breastfeeding since it will pass to the baby in the
breast milk
c. Vital signs:
i. Temperature as high as 100.4 can be normal in first 24 hours

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ii. Remember that bradycardia can be normal the first week

iii. B/P can vary with position but should be similar to ranges in labor
iv. Pre-medicate for pain
1. If persistent perineal pain despite medication, look for a
hematoma-more in PP Comp
d. Fundal assessment:
i. Non-dominant hand should be placed on the pubis synthesis
ii. Dominant on the fundus
iii. Checking to see if it’s firm
1. If it’s not, rub it in a circular motion to stimulate contractions to
firm it up again

13. BUBBLE EEP:

a. Physical assessment track to follow post-delivery

14. Providing Comfort:

a. Peri-bottle should be used with all post-delivery women
i. Filled with warm soapy water to keep the perineum area clean
15. Predisposition to DVT:
a. Venous stasis (especially in the feet)
i. Compression of the large veins by gravid uterus slows blood flow back to
the heart
b. Hypercoagulability
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i. Simply due to pregnant state

c. Localized vascular damage
i. During the birthing process
ii. Damage causes activation of the body’s clotting mechanism
d. Prevention:
i. Get the woman as active as possible and as much as possible
ii. Wear compression stockings
iii. Drink a lot of water
16. Subtle Signs of DVT:
a. Lower extremity tightness or aching relieved by rest
i. Typically in the left leg
b. Edema in the affected leg
c. Warmth, tenderness and/or redness in the affected calf
i. Homan’s sign is not recommended by some institutions
d. Low grade fever
e. We won’t know if we don’t examine the patient!
17. Psychological Responses:
a. Taking-in:
i. Immediately after birth until about 24-48 hours
ii. Mother depends on others to help meet her needs and relives the birth
process
b. Taking-hold:
i. 3 days post-partum and lasts for several weeks
ii. Mother is more self-sufficient but still needs reassurance
iii. Preoccupied with the present
c. Letting-go:
i. Occurs 3 weeks after delivery
ii. Reestablishes relationships with others
iii. Adapts to parenthood
iv. More confident in ability to care for newborn
18. Bonding and Attachment:
a. Bonding is the emotional attraction that starts in the first 30-60 minutes to a few
hours after the birth
i. Continuation of the relationship that began during the pregnancy
ii. During this time, infant is quiet and alert and looks at the mother
b. Attachment is the strong affection between the infant and mother or significant
other
c. Tips for Bonding:
i. Touch and skin to skin contact
ii. Read and sing to baby
iii. Talk and smile making eye contact
iv. Rock and hold baby as much as you can
v. Feed the baby often and in your arms
vi. Put baby on your chest to hear your heartbeat

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d. Factors Affecting Attachment:

i. Background of the parents
ii. The infant
iii. Care practices
1. Baby should be with the mother right when the cord is cut, and all
post-delivery checks and tasks are done in the same room as the
mother
iv. Occurs most readily when parent’s expectations have been met
1. Temperament, gender, health, and appearance
19. Psychosocial Assessment:
a. Emotions and Bonding:
i. Monitor mother’s interest in the newborn
1. Is she feeding and caring for the newborn?
2. Is she interested or disinterested?
3. Does she want the baby in the nursery all the time?
4. Use a standard postpartum screening tool on all post-natal
women
5. Postpartum depression is the most common complication of
pregnancy
20. Edinburgh Depression Scale:
a. Mother should fill it out herself, in private
b. Must answer all the questions
c. Often done when she has already gone home
d. Questions are asked about her feelings for the last 7 days, not just the day she
does it
e. If she has a borderline high score, it should be repeated at the end of the second
week
21. Postpartum Blues (most benign):
a. Transient emotional disturbances
b. Anxiety, irritability, insomnia, sadness
c. Begin at 3-4 days and last up to 2 weeks
d. Typically resolves once mother gets better sleep
i. Help around the house is a great way to assist
e. No formal treatment other than reassurance
22. Newborn Feeding:
a. Support a woman’s infant feeding method
i. What kinds of things influence her choice?
ii. Contraindications to breastfeeding
1. HIV positive mother
2. Galactosemic infant
3. Certain medications
23. Promoting Breastfeeding:
a. Initiate within 30-60 minutes of birth
b. Exclusively breast feed on demand

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i. At least every 2-3 hours

ii. If the baby is up and crying, assume they want to feed
iii. May need to wake the baby if they aren’t waking up every 2-3 hours to
feed
c. Lactation consultant
d. Encourage “rooming in”
e. Increase maternal caloric intake by 500 kcal/day and fluid intake to 2 quarts/day
f. Refrain from using lotions or soap on breasts except lanolin cream
24. Breast Care:
a. Wear well fitting, supportive bra 24 hours/day
i. Soft on the top
ii. One that will allow the mother to lower it from the top
b. Ice packs to sore breasts
c. Air dry breasts after feeding
d. Lanolin cream once dry
e. If bottle feeding:
i. No stimulation or heat (stimulates milk expression) to express milk
1. If in the shower, keep the back to the water
ii. Ice to breasts
iii. Cabbage leaves may help dry milk
25. Discharge Education:
a. Ovulation returns but menses do not always
b. Sexual activity can resume after 4-6 weeks
c. Discuss vaccines for mom and baby
d. Newborns should be at home and NOT go out right away (high risk of infection)
e. Mom has to take care of herself and take breaks to help recovery
f. Talk about postpartum depression

Postpartum: Contraceptives
1. 4 Methods of Contraception:
a. Behavior Methods
b. Barrier Methods
c. Hormonal Methods
d. Permanent Methods
2. Ideal Contraceptive for Women:
a. Ease of use
b. “Naturalness”
c. Safe and effective
d. Non-hormonal
e. Immediately reversible
f. Minimal side effects
3. Behavioral:

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a. Abstinence:
i. Only sure way to prevent pregnancy
ii. Decreases risk of STIs and HIV
b. Fertility Awareness:
i. Use physical signs that change with menstrual cycle to predict fertility
(approx. 14 days prior to next cycle)
ii. Changes in cervical mucus and placement of cervix
iii. Basal body temperature elevations with ovulation
1. Body temp taken orally
iv. Woman’s individual standard days method
v. Coitus interruptus (withdrawal)
vi. Lactation amenorrhea method
1. Not a good contraceptive method
2. Theory is that prolactin inhibits the start of another cycle which
would cause the woman to get pregnant again
4. Barrier:
a. Condom (Male and Female)
b. Diaphragm and cervical cap are prescription only
i. Diaphragm latex, cervical cap latex or silicone
ii. Requires refitting and must be placed correctly
iii. Spermicide is needed
iv. After pregnancy or weight loss/gain of 20 lbs. requires a refitting
c. Contraceptive sponge is non-prescription
i. Requires action on the part of the woman
1. Non-hormonal
2. In conjunction with a spermicide
3. Specific insertion and leave in time periods
4. Sponge more spontaneous; contains spermicide within it
5. Hormonal (OCP’s):
a. OCP = oral contraceptive pills
b. Fewer health risks with changes in hormone combinations
c. Advantages and disadvantages (Comparison Chart 4.1 p 148)
d. Health history
i. Do not require pap smear to obtain prescription
e. Risk Factors
i. DVTs
ii. Hypertension and smoking
iii. Use with caution with women who smoke
f. Antibiotic use requires alternate method of birth control
g. Early signs of complications A-C-H-E-S (Box 4.6 p. 149)
i. A – abdominal pain (gallbladder)
ii. C – chest pain/SOB
iii. H – headaches, hypertension or stroke
iv. E – eye problems (related to HTN)

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v. S – severe calf pain r/t DVT

h. OCP’s mimic pregnancy, which means woman will be hypercoagulable
i. Advantages of OCPs:
i. Regulate & shorten menstrual cycle
ii. Decrease severe cramping/bleeding
iii. Improve acne & reduce incidence of menstrual headaches
iv. Decrease incidence of rheumatoid arthritis
v. Protect against loss of bone density and reduces risk of osteoporosis
vi. Regulate and shorten menstrual cycle
vii. Decrease severe cramping and bleeding
viii. Reduce anemia
ix. Reduce ovarian and colorectal cancer
x. Decrease benign breast disease
xi. Reduce risk of endometrial cancer, colorectal cancer, and ovarian cancer
xii. Improve acne and reduces incidence of menstrual headaches
xiii. Minimize perimenopausal symptoms
xiv. Decrease incidence of rheumatoid arthritis
xv. Improve PMS symptoms
xvi. Protect against loss of bone density and reduces risk of osteoporosis
j. Disadvantages of OCPs (chart 4.1 page 148):
i. Offer no protection against STI’s
ii. Modest risk for venous thrombosis and pulmonary emboli
iii. Increased risk for migraine headaches
iv. Increased risk for myocardial infarction, stroke, and hypertension for
women who smoke
v. High cost for some women
vi. Offer no protection against STI’s
vii. Pose slightly increased risk of breast cancer
viii. Modest risk for venous thrombosis and pulmonary emboli
ix. Increased risk for migraine headaches
x. Increased risk for myocardial infarction, stroke, and hypertension for
women who smoke
xi. May increase risk of depression
xii. User must remember to take pill
xiii. High cost for some women
6. Other Hormonal Options:
a. Injectable
i. Works 12 weeks, but has more menstrual cycle irregularities
ii. Progesterone only (this means possible bone loss)
b. Transdermal
i. 3 weeks on/1 week off
ii. More risk for venous thrombosis and embolism
c. Vaginal rings
i. 3 weeks in/1 week out

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ii. Absorbs hormones through the vaginal mucosa

d. Implantable
i. Can last up to 3 years!
7. Intrauterine Device (IUD):
a. T-shaped hormonal object inserted in the uterus:
i. Hormonal (progestin) or non-hormonal (copper)
ii. Causes inflammation
1. Makes uterus nonconductive to implantation
iii. Inhibits sperm and ova from meeting
iv. Long term use
1. 5-7 years for hormonal
2. 10 years for non-hormonal
b. Warning signs of potential IUD Complications:
i. P-A-I-N-S:
1. P= Period late, pregnancy, abnormal spotting, or bleeding
2. A= Abdominal pain, pain with intercourse
3. I= Infection exposure, abnormal vaginal discharge
4. N= Not feeling well, fever, chills
5. S= String (on bottom of the IUD) length shorter or longer or
missing
8. Emergency Contraception:
a. Depending on the brand
i. Most effective the earlier it is used
ii. Best results under 72 hours post sexual activity
b. Hormonal and can be used 3, 5, or 7 days after unprotected intercourse
depending on brand
c. Copper releasing IUD can be inserted up to 7 days post unprotected intercourse
i. Can be left in for long term contraception
d. Sold OTC only if 18 or older, by Rx for those younger
e. Most of these pills use levonorgestrel, a form of progesterone
f. These do NOT cause an abortion, they prevent ovulation or fertilization
9. Permanent Methods:
a. Tubal ligation (Women)
i. Laparoscopic
ii. Trans-cervical
iii. Non-surgical:
1. coils inserted thru the cervix into the fallopian tubes which causes
tissues growth to close off the tubes (can take upwards of 3
months
b. Vasectomy (Men)
10. Important Factors to Consider:
a. Age
b. Health status
c. Frequency of sexual intercourse

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d. Number of partners
e. Desire to have children in the future
f. Side effects
g. Effectiveness rate
h. Comfort
i. Personal preference

Postpartum Complications
1. High Risk Postpartum Conditions:
a. Postpartum hemorrhage
b. Thromboembolic conditions
c. Postpartum infection
d. Postpartum affective disorders

2. Postpartum Hemorrhage (PPH):

a. Leading cause of death worldwide in the postpartum period
b. Most preventable cause
c. Physiologic symptoms are not apparent until a woman has lost a significant
amount of blood (upwards of 2,000 mL)

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i. This is due to the increased blood volume during pregnancy

d. Most of the time this happens within 4 hours of birth due to placental delivery
e. Loss of blood:
i. > 500 mL after vaginal birth is not normal
ii. > 1,000 mL after cesarean birth is not normal
iii. > 1,500-2,000 mL blood loss and need for more than 5 units of blood
f. Timing:
i. Early – within 24 hours after birth
ii. Late – 24 hours to 12 weeks after birth
g. Causes:
i. Early:
1. Uterine atony (most common)
2. Lacerations from trauma
3. Hematoma
ii. Late:
1. Subinvolution of the uterus
2. Clotting disorders
h. Risk Factors for PPH:
i. Labor:
1. Prolonged: due to a lax uterus
2. Precipitous: can cause trauma to the vaginal area or the cervix
3. Oxytocin can also cause a risk factor
ii. Fetus:
1. Multiple gestation
2. Large fetus
3. Grandmultipara woman (more than 5 deliveries over their
lifetime)
iii. Uterus:
1. Infection
2. Manual extraction of the placenta (if it has not detached within 30
minutes of delivery)
3. Polyhydramnious
iv. Maternal:
1. Preeclampsia
v. Delivery:
1. Operative births (c-section or vacuum birth)
2. Forceps usage
i. Specific Causes of PPH (p. 844, Table 22.2):
i. #1 Tone
1. Uterine muscle tone
2. Primary cause
ii. #2 Tissue
1. Retained placental tissue
iii. #3 Trauma
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iv. #4 Thrombin
v. Hypovolemic shock is a LATE symptom of hemorrhage after delivery

j. #1 Tone:
1. Overdistention of uterus
2. Distended bladder
3. Infection
4. Use of anesthesia
5. Use of magnesium sulfate
6. Prolonged, rapid, or forceful labor
ii. Uterine Atony (Failure of the Uterus to Contract)
1. Most common causes:
a. Distended uterus in pregnancy
b. Distended bladder postpartum
2. Treatment:
a. Fundal massage
b. Monitor I&O’s

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i. Remember to look under the pt.

c. Fluid bolus and increased IVFs
d. Administer uterine stimulant medication (pg. 847, Drug
Guide 22.1)
i. Uterine Stimulant Medications:
1. oxytocin: 20-40 units/L IV infusion in LR or
10 units IM
a. Most common med given
b. Never give undiluted IV
c. IM would be for a “lesser bleeding
problem”
d. Stimulate the uterus to contract to
control bleeding
Nursing Considerations (oxytocin): assess fundus for evidence of contraction; monitor VS q 15
min; monitor uterine tone to prevent hyperstimulation
2. misoprostol: 800 mcg PR;
a. Contraindicated with active CVD or
hepatic disease
b. Use with caution in women with
asthma, active CV, renal, pulmonary,
or hepatic disease
c. Stimulated the uterus to contract to
reduce bleeding
Nursing Considerations (misoprostol): NEVER GIVE UNDILUTED AS A BOLUS INJECTION IV
3. dinoprostone: 20 mg vaginal
suppository/PRN
a. monitor BP frequentl since
hpotension is a frequent side effect
along with vomiting and diarrhea,
nausea, and temp elevation
4. prostaglandin PGF2a: 0.25mg IM
a. Both are contraindicated with active
CV, renal, pulmonary or hepatic
disease
b. Stimulates uterine contractions due
to uterine atony when not controlled
by other methods and to reduce
bleeding when not controlled by
oxytocin
Nursing Considerations (prostaglandin PGF2a): assess VS, uterine contractions, pt.’s comfort
level, and bleeding status; monitor for possible adverse effects such as fever, chills headache
N/V, diarrhea, flushing, and bronchospasm; CONTRAINDICATIONS: asthma or active CVD,
pulmonary, renal, or hepatic disease
5. methylergonovine: 0.2mg IM

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a. (PO after acute bleeding stops)

b. Contraindicated with current HTN
c. Stimulates uterus to contract to
prevent and treat PPH due to atony
or subinvolution
Nursing Considerations (methylergonovine): assess baseline bleeding, uterine tone, and VS q 15
minutes; monitor for possible adverse effects such as HTN, seizures, uterine cramping, N/V, and
palpitations; report any complaints of chest pain immediately; CONTRAINDICATIONS: HTN
k. #2 Tissue:
i. Retained placental fragments, or blood clots, which may lead to:
1. Uterine inversion
a. Uterus goes thru the cervix and prolapse out
b. Risk Factors:
i. Retained placenta
ii. Tocolysis (slowing or halting of labor during the
birthing process)
iii. Fetal macrosomia
iv. Nulliparity
v. Uterine atony
vi. Vigorous fundal pressure
vii. Abnormally adherent placental tissue
viii. Fundal implantation of the placenta
ix. Excessive traction applied to the umbilical cord
x. Short umbilical cord
xi. Prolonged labor
c. Expected Findings:
i. Pain in lower abdomen
ii. Dizziness
iii. Low BP
iv. Increased pulse
v. Pallor
vi. Vaginal bleeding
d. Nursing Care:
i. Maintain IV fluids
ii. Administer oxygen
iii. Stop oxytocin
iv. Avoid unnecessary traction on the umbilical cord
2. Fundal prolapse to or through the cervix
3. Subinvolution:
a. Incomplete involution of uterus or failure to return to
normal state after birth
i. INVOLUTION should take 4-6 weeks normally
b. Causes:
i. Retained placental fragments (RPOC)

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ii. Distended bladder

iii. Infection or uterine myoma
1. Fibroid that interferes with uterine
contractions)
c. Signs & Symptoms:
i. “Boggy” uterus
ii. Lochia progression abnormal
iii. Postpartum fundal height higher than expected
iv. Prolonged vaginal bleeding
d. Treatment:
i. Uterine stimulants
ii. Antibiotic prophylaxis
ii. Remember, fully inspect the placenta twice after it is expelled
l. #3 Trauma:
i. Damage to the genital tract
ii. Lacerations (vaginal, perineal, or cervical)
1. Continuous trickling of bright red blood with contracted (firm)
uterus
2. Call provider right away
3. Causes:
a. Pushing too soon, precipitous delivery
b. Abnormal fetal presentation or forceps delivery
iii. Other Traumas:
1. Hematoma – collection of blood due to tissue trauma
2. Uterine rupture – due to previous cesarean section or surgery
a. Risk Factors:
i. Congenital uterine abnormality
ii. Uterine trauma
iii. Overdistention of the uterus from a fetus who is
large for gestational age, multifetal gestation, or
polyhydramnios
iv. Hyperstimulation of the uterus
v. Forceps-assisted birth
vi. Multigravida pt.’s
b. Expected Findings:
i. Pt. reports sensation of ripping, tearing, or sharp
pain
ii. Uterine tenderness
iii. Physical Assessment:
1. Nonreassuring FHR with indications of
distress (bradycardia, variable and late
decelerations, and absent or minimal
variability)

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2. Change in uterine shape and fetal parts

palpable
3. Cessation of contractions
4. Loss of fetal station
5. Manifestations of hypovolemic shock
(tachypnea, hypotension, pallor, and cool
clammy skin)
c. Nursing Care:
i. Administer IV fluids
ii. Administer oxygen
iii. Administer blood product transfusion if prescribed
iv. Prepare for an immediate cesarean birth
iv. Hematoma:
1. Signs and Symptoms:
a. Vaginal or perineal swelling
i. Bluish purple or skin colored palpable collection of
blood
b. Pain may be severe
c. Change in VS disproportionate to blood loss
2. Treatment:
a. Ice packs
b. Pain medication
c. Decreased pressure when sitting
d. Monitor closely for rupture
m. #4 Thrombin:
i. Disorders that interfere with clot formation - coagulopathies
ii. Determine risk during pregnancy
1. Family and personal history
iii. Common abnormal results:
1. Decreased platelet and fibrinogen levels
2. Increased PT, PTT
3. Prolonged bleeding time
iv. Clotting Disorders:
1. Idiopathic Thrombocytopenia Purpura (ITP)
a. Platelet destruction by autoantibodies
b. Temporary disorder caused by an infection
c. Treatment:
i. Glucocorticoids and immune globulin (IVIG)
2. von Willebrand Disease (vWD)
a. Inherited disorder (autosomal dominant)
b. Deficiency of von Willebrand factor
i. Prolonged bleeding time
ii. Impaired platelet function
c. vWD factor increases during pregnancy

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d. Signs and Symptoms:

i. Nosebleeds, menorrhagia, hematomas
3. DIC (Disseminated Intravascular Coagulation):
a. EMERGENT SITUATION!
b. Clotting system abnormally activated
i. Bleeding and clotting occur at the same time
c. Signs & Symptoms:
i. Bleeding from multiple sites (i.e. gums, nose, IV
sites)
ii. Abnormal lab values and vital signs
d. Treatment:
i. Correct underlying cause
ii. Maintain tissue perfusion
1. Aggressive fluid administration
2. Blood products if needed
n. Another “T” (#5 Traction):
i. Excessive force on umbilical cord during 3rd stage of labor
1. Pulling on cord to hasten 3rd stage causing lack of uterine
separation from placenta during placental delivery
ii. Can result in uterine inversion
iii. Uterine Inversion:

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3. PP Hemorrhage:
a. Recognition and Prevention:
i. Assess risk factors on admission to L&D unit
ii. If present, type and screen or cross for blood
iii. Review protocol for hemorrhage
b. Readiness:
i. Clearly defined protocol
ii. Mass transfusion protocol
iii. Hemorrhage cart kept nearby
iv. Know who to call, how the blood arrives, and availability of blood
products
c. Response:
i. Get help & assign roles
ii. 2nd IV 16-18 gauge
iii. Stat labs (CBC, coagulation studies, fibrinogen)
iv. Announce vital signs & cumulative blood loss
v. If transfusing, do not wait for lab results
d. Reporting:
i. Huddle about high risk patients and post event debrief
ii. Conduct multidisciplinary review for all events

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iii. Monitor outcomes of all hemorrhages to increase response and positive

outcomes
e. Nursing Management of PPH:
i. Focus on underlying cause
ii. Assess fundal tone
1. If it’s boggy, massage and give uterotonic drugs, IV fluids
2. Frequent monitoring of VS
iii. Assess/estimate blood loss
1. Pad counts
iv. Assist client to void
v. Prepare for removal of retained parts (placental)
vi. Assess for hemorrhagic shock
vii. Institute emergency measures for DIC
f. Prevention:
i. Controlled management of the 3rd stage of labor
ii. Gentle cord traction
iii. Uterotonic medication
iv. Uterine massage after the placenta is out
v. Inspecting placenta for completeness
vi. Alert for abnormal bleeding (i.e. bright red trickling)
vii. Monitoring lab values
1. Ex.) decreased hemoglobin or coagulation abnormalities
4. Thromboembolic (TE) Conditions:
a. Pre-pregnancy Factors:
i. Use of OCP, smoking, prolonged standing
ii. History of TE disease or endometritis
iii. Current varicosities
b. Pregnancy Related Factors:
i. Bedrest
ii. Maternal diabetes
iii. Obesity
iv. AMA
v. Multiparity
vi. Cesarean birth
c. Postpartum Types:
i. Superficial venous thrombosis
ii. DVT
iii. PE
d. Postpartum Risk Factors:
i. Venous stasis
ii. Hypercoagulation
iii. Injury to blood vessel
e. Educate pt. that this can happen after they go home, so let them know the signs
and symptoms

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f.Nursing Assessment of DVT/PE:

i. DVT:
1. Pain in lower extremities
2. Redness/warmth along vein
3. Calf edema
4. Positive Homans’ sign-no longer done
ii. Pulmonary Embolism-PE:
1. Sudden onset SOB/chest pain
2. Diaphoresis/anxiety
3. Change in vital signs: increased RR, increased HR, decreased BP,
decreased pulse-ox
4. Change in mental status
g. Prevention of DVT/PE:
i. Encourage ROM (active or passive)
ii. Use compression stockings/devices
iii. Elevate legs
iv. Avoid smoking, OC, trauma, prolonged standing
v. During Treatment:
1. Analgesia, rest, elevate affected leg
2. Antiembolism stockings
3. Warm compresses
4. Anticoagulation therapy
a. Heparin followed by warfarin
5. Postpartum Infection:
a. Definition:
i. Fever of 38°C (100.4°F) or higher
ii. Occurs after the first 24 hours post birth
iii. Occurs on at least 2 days in the first 10 days
b. Risk Factors:
i. Surgical birth
ii. Prolonged ROM
iii. Prolonged labor with multiple vaginal checks
iv. Extremes of patient age
v. Low socioeconomic status
vi. Anemia
6. Metritis:
a. Sterile environment until rupture of sac
b. Increased risk after Cesarean birth
c. Within 6 weeks of birth
d. Signs and Symptoms:
i. Pain, backache
ii. Foul-smelling or abnormal progression of lochia
iii. Leukocytosis
e. Maintain upright position

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7. Wound Infection:
a. Surgical incision, episiotomy, lacerations
b. > 24-48 hours post delivery
c. Redness, warmth, swelling
8. Urinary Tract Infection:
a. Caused be urinary catheterization, manipulation, trauma
b. Usually occurs 2-7 days post delivery
c. Signs and Symptoms:
i. Dysuria, frequency, urgency, low-grade fever, hematuria
9. Mastitis:
a. Caused by milk stasis, engorgement
b. Risk factors: poorly fitting bra, missed feedings, rapid weening (stopping
suddenly)
c. Most often unilateral
d. First 2 weeks postpartum
e. Most common organism: S. aureus
f. Signs and Symptoms:
i. Flu-like symptoms (chills, fever, malaise)
ii. Red/warm/very painful
g. Woman must still have milk removed from the effected breast
10. Nursing Management of PP Infections:
a. Administer appropriate antibiotics and analgesia
b. Provide emotional support
c. Promote fluid and electrolyte balance
d. Assess perineum, wounds and vital signs frequently
i. REEDA – redness, edema, ecchymoses, discharge, approximation of skin
edges
e. Prevention by aseptic technique and hand hygiene
11. Postpartum Affective Disorders:
a. Extraordinary changes in the life of the patient
i. Varied reactions
ii. Decreased estrogen and progesterone
b. 3 Classifications:
i. Baby Blues
ii. Postpartum Depression
iii. Postpartum Psychosis
12. “Baby Blues”
a. Common (50-90%)
b. Mild depression symptoms
c. Peaks on day 4-5 and resolves by day 10
d. Self-limiting
e. No formal treatment
f. Follow-up necessary
13. Postpartum Depression (PPD):

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a. Form of clinical depression, affects up to 20%

b. Feelings worsen over time, requires treatment
c. Symptoms last longer and are more severe than BB
d. Requires treatment:
i. Antidepressant/antianxiety meds
ii. Psychotherapy
iii. Marital counseling…assess father’s status
e. Edinburgh Postnatal Depression Scale
14. Postpartum Psychosis

a. Treatment:
i. Hospitalization
ii. Psychotropic meds
iii. Psychotherapy/group therapy
15. PP Affective Disorders:
a. Signs and Symptoms:
i. Poor personal hygiene
ii. Weight loss
iii. Not responding to infant’s cues
b. Risk Factors:
i. Poor coping skills
ii. Low self-esteem
iii. Numerous life stressors
iv. Previous psychological problems or family history
v. Substance abuse
vi. Limited social support network

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c. DO NOT NEED TO KNOW THE PERCENTAGES!

16. What Can A Nurse Do to Help?
a. Become educated & educate family about life changes
b. Encourage verbalization of feelings
c. Assist in structuring patient’s day/care
d. Reinforce need for good nutrition/rest/exercise
e. Provide referrals for support after discharge
f. Use Edinburgh Postnatal Depression Scale

Genetic Inheritance
1. Chromosome Abnormalities:
a. Can either be inherited or due to random events during early embryonic
development
i. Monosomy – one copy of a particular chromosome
ii. Trisomy – three copies of a particular chromosome
1. Trisomy 21 – Down Syndrome
2. Genetic Inheritance Patterns:
a. Autosomal:
i. Gene responsible is located on one of the 22 pairs of autosomes (non-sex
determining chromosomes)

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ii. Recessive:
1. 2 recessive alleles are needed to express the phenotype
2. 1 from each parent
iii. Dominant:
1. Only 1 allele is needed to express the phenotype
b. X-Linked:
i. Gene responsible is located on the X chromosome
ii. Recessive:
1. Only 1 allele is needed, and ONLY men are affected
2. It is found on the X chromosome donated by the mother
3. Autosomal Recessive:

4. Autosomal Dominant:

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5. X-linked Recessive:

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Postpartum Assessment
1. BUBBLE EEP:
a. Acronym to denote the components of the postpartum maternal nursing
assessment:
i. B = Breasts (and nipples)
ii. U = Uterus
iii. B = Bladder
iv. B = Bowels
v. L = Lochia
vi. E = Episiotomy (or uterine incision, lacerations)
vii. E = Extremities (lower)
viii. E = Emotions (bonding)
ix. P= Pain
2. BUBBLE EEP:
a. Breasts:
i. Soreness or cracking of nipples
ii. Flat or inverted nipples
iii. History of breast surgery that may interfere with milk production
iv. Milk production causing increased firmness of breasts
b. If the mother is not breastfeeding, what does the nurse tell her about preventing
on-going milk production?
c. Nothing that will stimulate the breasts or nipples
d. Can NOT express milk either by hand or a pump
e. Keeping back to the water in the shower
f. Use icepacks on the breasts
3. BUBBLE EEP:
a. Uterus:
i. Firmness of fundus (firm, soft, or boggy)
1. Firm – apple or pear
2. Soft – banana
3. Boggy – mushy feel
ii. Fundal height related to umbilicus (+1, +2, at U, -1, -2)
iii. Fundal location (midline, deviated R or L)
1. Deviation to the right or left could indicate the woman has a full
bladder
4. BUBBLE EEP:
a. Bladder:
i. Amount of urine
1. How much do we expect the mother to void in first few days after
delivery?
2. Every 3-4 hours
3. Up to 3,000 mL in a 24-hour period

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ii. Color and odor of urine

b. Bowels:
i. Assess bowel sounds, especially if C-section delivery
ii. Ask about passing flatus or BM
5. BUBBLE EEP:
a. Lochia:
i. Color
ii. Amount
iii. Presence of clots
iv. Teach the mother about:
1. The normal progression of lochia
2. When and why to use the peri-bottle
6. BUBBLE EEP:
a. Episiotomy (or lacerations; uterine incision):
i. Assess for skin approximation
ii. Assess for signs of infection (color, odor, drainage, warmth)
iii. Assess perineum for signs of developing hematoma
7. BUBBLE EEP:
a. Extremities (lower extremity assessment):
i. Assess for warmth or redness of calves
ii. Assess for pain in calves during ambulation or active motion of feet if on
bed rest
8. BUBBLE EEP:
a. Emotions (bonding, attachment):
i. What signs indicate that the mother is bonding with baby?
ii. Are her emotions appropriate or are there signs of baby blues or PP
depression?
9. BUBBLE EEP:
a. Pain:
i. The 5th vital sign
ii. Location and amount of pain
iii. Things that increase or decrease pain

Newborn Care & Thermoregulation

1. Newborn Vital Signs:
a. Every 30 minutes until stable for 2 hours
i. Temperature: 97.9˚-99.7˚ F (36.6˚-37.6˚ C)
ii. Pulse: 110-160 bpm
iii. Respirations: 30-60 rpm
b. HR & RR can be irregular - counted for 1 full minute
c. Always take the temp axillary

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i. Important for identification of hypothermia: critical point where

intervention must occur swiftly.
d. BP not typically taken on newborn unless clinical indication
2. Initial Bath:
a. General Info:
i. Once baby has been assessed and is stable (cardiac, respiratory, thermal)
ii. Important to wear gloves since baby is covered in maternal fluids
iii. Bath should be done under a radiant warmer and performed as quickly as
possible to limit heat loss
iv. Baby temp should be > 98.4 before bath attempted although some
facilities may have different parameters
v. Check temp 30-60 minutes after bath
vi. Cleanest to most soiled – face first
vii. Double blanket with cap afterwards
b. Beginning Procedure:
i. Gather Supplies:
1. Towels and washcloths
2. Blankets
3. Infant gown and cap
4. Chux
5. Clean bassinet linen
6. Wash basin, soap, brush
ii. Fill:
1. Basin with clean, warm water
c. Face First:
i. Eyes and face using water only (no soap!)
1. Use gauze or cotton balls
2. Clean eyes from inner to outer using separate gauze or cotton
d. Body:
i. Do not leave the newborn in the water!
ii. Keep the newborn warm by placing under a radiant warmer or
uncovering one body part at a time
iii. Use a soft washcloth or clean 4 x 4’s and mild baby bath soap
iv. Wash the umbilical cord with soap and water (this may vary by hospital)
v. Make sure to get in all the creases
vi. Wash the diaper area, dry, and apply a clean diaper
e. Head:
i. Dry body and wrap in warm dry blanket while washing head
ii. Wash the head last
1. Hold the head over a basin of clean, warm water
2. Place in a “football” hold for the shampoo
3. Lather up the head well to remove any dried body fluids in the
hair
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iii. Always wash and brush AWAY from the eyes

f. Finishing Up:
i. Dress in a clean diaper and infant gown
ii. Comb the hair and place a clean cap on the head
iii. Double wrap and give to caregiver
iv. Check the temperature in 30-60 minutes
g. Safety Concerns:
i. Baby losing body heat:
1. Keep baby under warmer during bath
ii. Prevent injury due to slippery baby:
1. Always wash baby in bassinet while supine
2. Only lift areas that need to be washed at that time
3. Infant Swaddling:
a. What is the Purpose?
i. Keeps the baby warm
ii. Provides comfort for the baby
1. They’re used to small, confined spaces (i.e. the uterus)

4. Cord Care:
a. Clamp removed usually in 24-48 hours
b. Cord usually falls off within 7-21 days.
c. Cord care according to hospital policy with each diaper change
i. Inspect with each diaper change, fold diaper down so it doesn’t rub
ii. May be cleaned with an alcohol pad at each change or plain water
iii. Do not immerse in water – no tub baths
iv. Assess for signs of infection: odor, redness, purulent drainage, bleeding
v. Parent teaching will change from yellow to brown to black
d. Parent Teaching:
i. Observe for signs of infection
ii. Allow to fall off naturally

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iii. Expose to air

iv. No tub baths until healed
5. Circumcision:
a. What is circumcision?
i. Surgical removal of all or part of the foreskin (prepuce) of the penis
b. Why is it done?
i. Hygiene, medical reasons, religious beliefs, and social/cultural
considerations
6. Circumcision Procedures:
a. Foreskin is either…
i. Surgically cut away (Gomco or Mogen)
ii. Tied and will gradually fall off (Plastibell)
1. This is the most common method
7. Circumcision Care:
a. Maintain thermoregulation during procedure
b. Pain Management:
i. EMLA
ii. Nerve block
iii. Sucrose pacifier
iv. Swaddling
c. Post Procedure Care:
i. Bleeding and voiding are the primary concerns
ii. Keep the site clean
iii. Apply Vaseline with each diaper change (for Mogen or Gomco
procedures)
iv. Do not put the baby prone
d. Parent Teaching:
i. Daily care:
1. Squeeze soapy water over area and rinse daily
a. Do not rub area with soap water
2. Apply Vaseline with each diaper change (for Mogen or Gomco
procedures)
ii. Plastibell falls off in about a week
8. Thermoregulation:
a. Newborns develop cold stress easily which can lead to hypothermia and
hypoglycemia
b. Balance between heat loss and heat production
i. Maintaining body temp without an increase in metabolic rate or oxygen
use
c. Risk Factors:
i. Thin skin
ii. Lack of shivering ability
iii. Limited fat stores/limited subcutaneous fat
iv. Limited use of voluntary muscles

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v. Large body surface area

d. Radiant Warmers:
i. Overhead heater that delivers radiant heat
ii. Reflective skin temp probe monitors the infant’s temperature
1. Heat output can be controlled manually or through the baby (like
a thermostat)
iii. Still need to monitor the baby’s axillary temp though

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