Maternal child health nursing

Module 6

Objectives

• Abnormal labor/delivery, obstetric procedures/surgery, immediate postpartum mother/baby/family care

Risks of labor and birth

• Fetal distress resulting from:– Hypoxia• Prolapsed cord or compressed cord• Placental abruption• Placenta previa• Hypertonic uterus• Placental insufficiency

Risks of labor and birth

• Fetal hypoxia related to:– Prolapsed or

compressed cord• Umbilical cord may drop

down between presenting part and open cervix

• Cord may be pressed between fetus and maternal part

Risks of labor and birth

• Fetal hypoxia related to meconium– Hypoxic response• Hyperactive GI and relaxed anal sphincter in hypoxia

– Contributes to respiratory distress in neonate• May require neonatal resuscitation, suctioning

Head compression reflected in EFM tracing: note “mirror image”

Uteroplacental insufficiency

Preterm labor and birth

• Mechanisms of preterm labor still unknown– Maternal, fetal problems

• Delivery less than 37 weeks– lungs– Fat (including brown fat)– Circulation: impaired adaptation to newborn– Digestive system– Renal system

Preterm labor and birth

• Delivery less than 37 weeks (cont’d)– Acid/base imbalances– Neurological immaturity

• Posture, color, head size, skin/fat, lanugo, pliable cartilage (ears), undescended testes, small labia majora, weak/thin cry, immature or absent reflexes

Preterm labor and birth

• NICU care • Morbidity/mortality 3 to 4 times higher• Problems and successes depend upon

maturity at delivery and presence/absence of underlying disorders

• FON p 917 nursing care plan• Terbutaline

Premature rupture of membranes

• Break in amniotic sac before 37th week• Risk factors: genital tract infection, smoking

during pregnancy, hx PROM in previous pregnancies, bleeding during more than one trimester,

• Complications: infection, prolapsed cord, placental abruption, fetal immaturity factors

• Nursing care

Postterm delivery

• Postterm gestation: 42 weeks or more• Risk for placental insufficiency – Fetal hypoxia, malnutrition– Asphyxia, respiratory distress, hypoglycemia– May be SGA, AGA, or LGA

Dystocia

• Dysfunctional labor• Pelvic structure variations– Immaturity – malnutrition– Obesity (soft tissues)

• Fetal variations• Mother’s responses

Fetal distress

• s/s: tachycardia/bradycardia, non-reassuring FHR pattern on EFM– Rate– Variability– decelerations

• Hypoxia– Uteroplacental insufficiency– compressed umbilical cord

Fetal distress

• Intolerance of labor• Uteroplacental insufficiency or hypoxia during

pregnancy and/or labor/delivery• Electronic fetal monitoring, Doppler, fetoscope

can provide information about the FHR that guides interventions

Fetal distress

• Factors in uteroplacental insufficiency, hypoxia–Insufficient gas/nutrient exchange

between mother and fetus–Restricted oxygenation d/t impaired or

pressured umbilical cord

Fetal distress• Nursing management–Depends on underlying cause, stage of labor– Support oxygenation of mother and fetus• Position change, IV fluids, 02 by mask or

NC, DC or decrease pitocin drip–Prepare for emergency or urgent delivery• Distressed fetus likely to require

respiratory support after delivery

Electronic fetal monitoring

• First attempted in early 20th century• Linked electrical pattern of fetal heart

rate/rhythm to predictable fetal status• Electrical signals received into transmitter placed

on maternal abdomen or via fetal scalp electrode– Internal scalp electrode can only be done after ROM,

sufficient cervical dilation. • Used with tocotransducer over focal point of

contractions

EFM cont’d

• Heart rate and contraction pattern displayed on screen – relationship between contractions and FHR

• Toco can’t measure contraction intensity – Subjective– palpation

• Nurse responsible for accurate interpretation, nursing intervention and communication to midwife/physician

Doppler

• Developed for fetal monitoring in 1960s• Bounces high-pitched sound waves off fetal

heart, translating signals into auditory signal examiner can hear

• Pros: Smaller unit, more transportable; easily heard rate/rhythm

• Cons: examiner needs skill to hear and recognize deceleration patterns

Fetoscope

• FHR auscultation discussed as early as 17th century in Europe

• Allows examiner to ausculatate fetal heart rate

• Doesn’t require advanced technology or electricity

• Cons similar to Doppler interpretation

Abnormal duration of labor

• Prolonged labor– Lasting longer than usual– Length of time depends on nullipara vs multipara– Interventions depend on fetal and maternal well-

being, also membrane status– May be decreased by activity, relaxation

measures, or instrumented or surgical delivery

Abnormal duration of labor

• Precipitate labor/birth:– Less than 3 hours from onset cxns to birth – Hypertonic uterus– Multiparity– Maternal and fetal complications relate to

causative factors • Maternal: uterine rupture, lacerations, amniotic fluid

embolism, postpartum hemorrhage• Fetal: hypoxia, intracranial hemorrhage

Prolapsed cord

• FON p 811 Fig 26-6• Umbilical cord slips down into birth canal before

fetal presenting part does, causing fetal distress, hypoxia

• Pressure may be relieved by examiner’s (sterile!) gloved fingers lifting presenting fetal part off of cord or changing mom’s position

• Risk after ROM, especially PROM or rush of fluids• Emergency delivery indicated

Position change for prolapsed cord

Labor induction/augmentation

• Induction starts labor contractions• Augmentation strengthens contractions already

in progress• Indications: prolonged time after ROM, severe

PIH, postterm pregnancy, hx precipitous labor (to prevent out-of-hospital delivery), complications

• Methods: amniotomy, prostaglandin gel, oxytocin stimulation

Labor induction/augmentation

• Nursing management–Monitor effects on FHR, pattern;

palpate contractions, ensure adequate monitoring and appropriate nursing responses, I&O balance, timely record-keeping

Obstetric procedures

• Amniotomy– Artificial rupture of membranes (ROM)– Sterile– hook

• Episiotomy– Incision made in perineum to make the birthing

passage bigger– Measured in degrees

OB procedures: Forceps

• Forceps are spoon-like instruments designed to fit around fetal skull and apply traction for delivery– Multiple types for multiple fetal stations– May be used to delivery head in breech– Require skill to avoid too much pressure to fetal

skull or damaging maternal tissues– Monitor FHR

OB procedures: Forceps

OB procedures: Vacuum extraction

• Traction on fetal head using negative pressure vacuum cup

• Criteria: vertex presentation, ruptured membranes, full dilation, no cephalopelvic disproportion

• Common: caput succedaneum (newborn scalp edema) and bruising

Obstetric procedures

• Cesarean delivery– Incision– Anesthesia– Scheduled vs

unscheduled– Vaginal birth after c-

section (VBAC)

C-section

• Incision (external and uterine)– Vertical– Horizontal • Internal dissolving sutures (uterine)• Closure of outer incision and cauterization of bleeding

vessels• Staples• Dressing

– Nursing care: dressing, incision care, staple removal, education

C-section

• Anesthesia– Epidural– Spinal– General

• Scheduled vs unscheduled • VBAC and TOLAC– Vaginal birth after cesarean– Trial of labor after cesarean

C-section

• Epidural– Sterile procedure– Injection into epidural space surrounding spinal

cord– Anesthetic: lidocaine and epinephrine• Initial trial injection, then continual infusion by pump• Infusion settings set and usually adjusted only by

anesthesia provider

Epidural

Epidural

Epidural

• Risks: decreased maternal blood pressure -> decreased fetal oxygenation, headache, allergic reaction, decreased maternal movement, decreased respiratory status, decreased push ability

• Benefits: anesthesia from contractions and delivery, consciousness, fewer side effects

• Nursing care

Spinal

• Placement similar to epidural• One-time injection, lasts through surgery• Useful for C-section if anesthesia not in place

for labor• Medication placed next to spinal cord– Less medication needed – Fewer side effects

General

• General anesthesia– Rarely used – Complications include: respiratory depression

(mother or baby), uterine relaxation, risk of aspiration• Postpartum: interrupted bonding, infection, pain

• Nursing care after C-section

C-section and later births

• Scheduled vs unscheduled• VBAC – After 1-2 C-sections (ACOG)

• TOLAC (trial of labor after cesarean)Vaginal births attempted after previous C-section are

considered by most practitioners as higher-riskMay not be attempted if standing C-section team

unavailable

Nursing care prior/after C-Section• Pre-operatively:– Monitor V/S– Assess status and changes– Assess FHR, cxns, pain, bleeding, amniotic fluid– Assess pain control with epidural/spinal

placement, circulation and motor – Place Foley catheter after anesthesia placed, chart

amount, color of urine– Educate regarding procedures, expectations– Follow hospital pre-op checklist

Nursing care pre/post c-section• Post-operatively– Monitor vital signs, pain control, level of

consciousness, returning motor, sensation of lower extremities, bleeding

– Address changes quickly and report to practitioner– Chart baselines and changes – Support mother’s return to independence and

efforts to care for baby

Postpartum care

Immediate postpartum care

• Newborn– Airway, breathing, circulation– Warmth– Identification– APGAR score• 1 and 5 minutes• 8-10 total score optimal• < 7 indicates need for intervention

APGAR score sheet

Acrocyanosis

Immediate postpartum care: mom

• Needs after vaginal delivery vs C-section delivery similar:– Fluid balance: • bleeding• intake (IV, PO)• output (Foley? Toilet? Edema? Retention?)

– Pain or discomfort• Uterine cramping and tone• Perineal pain• Back pain

Immediate postpartum care: mom

• Needs (cont’d)– Medication side effects:• Nausea/vomiting• Itching• Disorientation, confusion, dizziness

– Hunger: • Cravings, cultural foods, demands

– Bowel elimination• Last BM? C-section moms at increased risk for ileus• Diarrhea or constipation? • Stool softeners, not laxatives

Immediate postpartum needs: mom

• Bonding and breastfeeding– Privacy, calm, unhurried time with newborn– Delay nonessential newborn interventions– Assist with breastfeeding or refer to someone who

can– Promote bonding within family– May need to help family figure out how to set

visitation boundaries• Rest

Postpartum assessment• FON p 842, fig 27-1; p 858 Box 27-9• Breast• Uterus• Bladder• Bowel• Lochia• Episiotomy• Emotional status

Postpartum assessment• Homan’s sign– Have mom lie on her back in bed and extend her

legs out straight. Place your hands on the balls of the feet and flex upward at the ankle. Be gentle and don’t overflex. Complaints of calf pain in response = positive Homan’s sign and further exam should be done to rule out thrombosis in the legs.

Postpartum Assessment

• Continuing assessment– Maternal• Fundus, V/S, bleeding/lochia, pain, safety, self-

care, bonding, baby care, mood/psychosocial adaptation

– Newborn• V/S, feeding, sleeping, elimination, bonding

– Family unit/support person• support of mom, baby care, breastfeeding

support, psychosocial adaptation

Postpartum Assessment/Care

• Providing maternal physical care– Comfort• Pharmacologic: ibuprofen, Vicodin• Non-pharmacologic: warmth, massage,

ambulation– Hygiene: perineal care, suture care– Ambulation and position– Food and fluid intake– Elimination: bowel and bladder

Family adaptation

• Mother’s adaptation to newborn– Joy, happiness, excitement– Indifference, disappointment, fear/anxiety,

hostility• Some “inappropriate” behaviors may be serious, some

a temporary result of interrupted or problematic birth processes• Ask questions, get information, form care plan for

teaching – evaluation very important! • Include this information in nurse-to-nurse reports

Family adaptation

• Father’s or other parent’s adaptation– Emotional response– Practical experiences – Expectations and role anticipation

• Cultural practices– Grandparent and family member roles– Breastfeeding and colostrum– Expectations of new mothers– Ask questions! Don’t assume

Family adaptations

• Siblings’ adaptation– Preparation and teaching should consider child’s

developmental stage• 2-year-old sibling may be accepting until they realize

baby comes home with them – need Mommy time• Grade-school siblings may respond to “helper” tasks

and praise• Teens may feel both curious and apprehensive – this

can be a great time for cause-and-effect and consequences teaching

Family adaptations

• Danger signs: FON p 860 Box 27-11– Passivity– Hostility– Disappointment– Lack of eye contact– Nonsupportive interactions between parents

• Require careful careplanning and intervention by nursing/medical/caregivers

Pospartum reproductive changes

• uterus– Oxytocin (posterior pituitary)

• Involution – Position after delivery to 12 hours– daily descent rate– Shortened muscle fibers – Autolysis

» Estrogen/progesterone withdrawal

– Lochia • Rubra• Serosa• Alba• Measurement (see FON p 857 Fig 27-4

Reproductive changes (cont’d)

• Fundus:– Top of uterus– Palpation point (use care after C-section)– Should be firm and contracted– Expect/teach cramping normal after

breastfeeding/massage d/t release of natural oxytocin

Reproductive changes (cont’d)

• Cervix– Edema, bruising– Ragged external os

• Vagina– Thin– Absence of rugae (through 4 weeks)– Dry (until return of estrogen)

Reproductive changes

• Perineum– Assess for bruising, edema, lacerations, tears• Frank bleeds, hematomas

– Episiotomy: assess for erythema, exudate, edema, state of sutures, approximation of edges

– Teaching• Sitz baths, 6-8 weeks healing time, pelvic rest, use of

stool softeners, liquid consumption, itching, s/s infection

Endocrine changes

• Lactation– Estrogen

• Increase in early pregnancy• Decrease after delivery

– Prolactin • Secreted by anterior pituitary gland • Stimulates milk production in alveolar cells of breast

– Oxytocin• Secreted by posterior pituitary gland• Stimulated by suckling -> contracts milk ducts to eject milk

(letdown reflex)

Endocrine changes• Menstrual cycle and fertility– Suppressed by lactation– Highly individual length of time until return:

average 45 days– Exclusively breastfeeding moms may not

experience return of fertility until six months or longer if: • Infant less than six months of age• Frequent, around-the-clock feedings are given• Menstrual periods have not resumed

Endocrine changes (cont’d)

• Ovulation may occur before 1st period: contraception may be advisable

• Postpartum contraception may include:• Spermicides (sensitivity may contraindicate)• Condoms (lubrication may help dryness)• Withdrawal • Diaphragms (can’t be fitted for at least 6 weeks

postpartum)

Breast changes

• Closely related to endocrine effects• Size increase begins early in pregnancy and

continues– Non-lactating women may see return to pre-

pregnancy size sooner than lactating women• Supportive bras and nursing bras helpful• Assess for s/s infection or breaks in skin

barrier

Gastrointestinal changes

• Appetite within normal limits soon after delivery– Changes may be due to drug or pain status

• GI motility may be decreased– Constipation– Teach: ambulation, PO fluids, fiber intake, stool

softeners• Evaluate for pain: episiotomy, hemorrhoids

Cardiovascular changes

• Vital signs – Shock, infection, PIH

• Cardiac output– Rapid decline from pregnancy

• Blood volume– Non-pregnant levels within 2-4 weeks– Diuresis, diaphoresis, intrapartum blood loss

Cardiovascular changes

• Blood values– CBC: HBG, HCT– WBCs: elevated intrapartum, return to normal

range• Coagulation– Platelet count

• varicosities

Urinary changes

• Trauma– Birth, instrumentation, episiotomy

• Increased bladder capacity• Conduction anesthesia• Risk for UTI• 5-7 days for return of urinary tone• Voiding up to 3 L/day common– Diuresis of extra blood volume

Musculoskeletal changes

• 6-8 weeks– Joint discomfort post-partum• relaxin

– Return of muscle tone • abdomen

– Return of joint stability• Considerations: adipose tissue, previous tone, exercise

– Shoe size change

Integumentary changes

• Chloasma “mask of pregnancy”• Areolar hyperpigmentation– Role in breastfeeding

• Linea nigra• Striae gravidarum – “stretch marks”• Vascular: – Spider angiomas (nevi), palmar erythema, epulis

tied to estrogen

chloasma

Integumentary changes

• Fine hair disappears• Coarse hair may remain• Fingernails return to prepregnancy state• Diaphoresis– Nights, first week postpartum

Neurological changes

• Related to reversal of maternal adaptation to pregnancy

• Trauma during labor/delivery• PIH-related• Carpal tunnel syndrome• Numbness & tingling• Headache– MUST be evaluated

Family education: SIDS

• Sudden Infant Death Syndrome– Risk factors

• Smoking (2nd and 3rd hand smoke)• Unsafe environments

– Plastic– Stuffed animals– Loose bedding

– Safe practices:• Back to sleep every time• Firm, unobstructed sleep surfaces• Avoid overheating infant

Danger signs: postpartum maternal

• Fever w/ or w/o chills• Malodorous or excessive vaginal discharge• Return to bright red vaginal bleeding after

lochia change to pink, brown, or white• Edema, erythema on legs• Pain/burning on void, inability to void• Breast changes: localized pain, heat, edema,

malodorous drainage, breastfeeding problems• Perineal/pelvic pain