Maternity Final Exam Study Guide

Naegle's Rule

Start of last menstrual period minus 3 months plus 7 days

Presumptive Signs of Pregnancy

What does the women feel?
ex. amenorrhea, nausea, vomiting, excessive fatigue, urinary frequency, breast changes, quickening (feel first fetal movements)

Probable Signs of Pregnancy

What can the provider see?
ex. pelvic organ changes, abdominal enlargement, Braxton-Hicks contractions, abdominal striae, uterine souffle (hear blowing sound over uterus), positive pregnancy test, changes in skin color, palpation of fetal outline (ballott

Positive Signs of Pregnancy

What do the tests confirm?
ex. auscultation of fetal heartbeat, fetal movement (4-5 months), and visualization of the fetus


G: Gravida: # of pregnancies (including the current one)
T: Term deliveries (38 weeks and up)
P: Pre-Term deliveries (20 to 37 weeks)
A: Abortions/Losses
L: Living children


Birth after 20 weeks regardless of whether or not the infant is born alive or dead


One birth at more than 20 weeks


No births at more than 20 weeks


2 or more births at more than 20 weeks


Any pregnancy, regardless of duration, including present pregnancy


No pregnancies


First pregnancy


2 or more pregnancies


Time between conception and onset of labor
Considered the Prenatal period


Time from onset of true labor to the birth of infant and placenta


Time from birth until the woman's body returns to essentially pre-pregnant condition


The number of weeks since the first day of the last menstrual period


Birth before completion of 20 weeks or birth of a fetus/infant that weighs less than 500 grams

Preterm or Premature Labor

Labor that occurs after 20 weeks but before completion of 38 weeks gestation

Post Term Labor

Labor that occurs after 42 weeks gestation


Infant born dead after 20 weeks gestation

Initial Pregnancy Assessment Tests

Urinalysis (hCG, pH, specific gravity, glucose, protein, leukocytes)
Lab: blood type, Rh factor, CBC, Syphilis test (RPR), Rubella, Hep B, HIV, antibody

First Trimester Assessment Tests (11-14 weeks)

1. Ultrasound (U/S): nuchal translucency (thick neck fold indicative of down syndrome)
2. Serum
3. Abnormal Values SUGGEST aneuploidy (abnormal # of chromosomes): Chorionic Villus Sampling at 10-13 weeks
-Lithotomy position (vaginal exam position)

Early Second Trimester Assessment Tests (15-20 weeks)

1. U/S: fetal structural visualization
2. Serum: Quad (increased indicates neural tube; decreased indicates down syndrome)
3. MSFP: high (indicative of neural tube defects) or low (indicative of down syndrome)

Pregnancy Assessment Tests: Amniocentesis

- Early in pregnancy: genetic screening (tri-chromosomal or neural tube defects)
- Late in pregnancy: hemolytic disease and fetal lung maturity
- Before: abdominal skin prep, assess for pain, U/S monitoring during, CEFM before and after, Rhogam
- After: C

Pregnancy Assessment Tests: Gestational Diabetes

Done at 24-28 weeks

Pregnancy Assessment Tests: GBS (Group B Strep)

- Tested at 36 weeks
- GBS positive moms need antibiotics at onset of true labor to reduce the likelihood of passing the infection to the baby
- If passed to baby, can cause meningitis

Electronic Fetal Monitoring: Strip interpretations and interventions

Variable: Cord Compression
Early: Head Compression
-No need to intervene
-Sign of progression
Accelerations: Oxygenation
-Signs of fetal reserves to cop with stress of contractions
-Contractions causes

Stages of Labor: Stage One

Stage 1: Onset of regular uterine contractions to full cervical effacement and dilation
� Latent: 0-3cm
� Active: 4-7cm
� Transition: 8-10cm
o Assessment:
� Pain: continuously
� Palpate contractions: q15 to 30 minutes
� Auscultate FHR
� Vaginal Exam

Stages of Labor: Stage Two

Stage 2: Ten cm to birth of the baby
� Latent: calm period of rest; passive descent of fetus into birth canal
� Descent: active pushing and urge to bear down (Ferguson Reflex)
� Transition: Presenting part on the perineum; bearing down efforts most effect

Stages of Labor: Stage Three

Stage 3:
-Placental separation and expulsion
-Firmly contracting fundus
-Change in shape of uterus
-Sudden gush of dark blood
-Apparent lengthening of umbilical cord
-Vaginal fullness
o Assessment:
� APGAR on infant
� S/S of placental separation within 30

Stages of Labor: Stage Four

Stage 4: Post-partum
-Postanesthesia recovery
-Interactions with newborn
-Family-Newborn relationships
o Assessment:
� Fundal position
� VS
� Perineum/Lochia
� Bladder/voiding
� Return of sensation
o Interventions:
� Massage fundus: boggy uterus = more bl

Impending Labor: Signs and Symptoms

- Lightening (baby drops lower into the pelvic cavity; allows for easier breathing and less heartburn; puts more pressure on bladder so women has to go to the bathroom more frequently)
- Irregular contractions
- Energy spurt
- Urinary frequency
- Bloody s

Pregnancy Complications: Placenta Abruption

- Separation of the placenta from the wall of the uterus
- 10-15% of all perinatal deaths
- Dark red bleeding with rigid abdomen
- Increasing abdominal size
- Fetal HR changes (late decels)
- Intervention: C-Section

Pregnancy Complications: Placenta Previa

- Implantation of placenta over or near the cervix
- Dilation exposes the villi which causes bright red bleeding
- Painless (can be painful with uterine activity)
- Normal FHR monitoring
- Risk: Asian, prior C/S, high G/P, smoking, and male fetus
- Interv

Pregnancy Complications: Type 1 Diabetes Mellitus/ Gestational Diabetes

Existing Diabetes
-1st trimester: lower insulin doses due to N/V and lower food intake
-2nd trimester: rises 2-4 fold; glucose use and storage increases; maturation of placenta and increased hpi
-Renal threshold for glucose lowers causing glucosuria

Pregnancy Complications: Health History Risk Factors

-Metabolic Disorders (Diabetes Mellitus and Thyroid Disorders)
� Macrosomia, shoulder dystocia, pre-eclampsia, eclampsia, pre-term labor, infections, hydramnios, IUGR, fetal distress, stillbirth, neonatal death, congenital anomalies
-Cardiovascular Disord

Pregnancy Complications: Preeclampsia

� Pre-Seizures
� Predominant symptoms: protein in the urine, high blood pressure, edema, headache, hyperreflexia (test deep tendon reflex of patella, if they kick out, they have hyperreflexia)
� Therapy:
-Magnesium Sulfate Infusion: IVPB 4-6 loading dose

Pregnancy Complications: Preterm Labor

o Labor (contractions with cervical changes) occurring between 20 and 36 weeks gestation
� Results in: immature body systems, respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis
o Education and prompt intervention nec

Cervical Exam Interpretation

� Cervical Dilation: 0-10 cm
� Cervical Effacement: percentage of shortening (starts at 50%)
� Pelvic station: In relation to ischial spines

Labor/Delivery Emergencies: Signs of Potential Complication

� Hypertonic CTX (>90 seconds)
� CTX < 2 min apart
� Increased intrauterine pressure
�Arrest in labor progress
�Change in VS
�S/S of hypovolemia
�Too high, too low, or ominous decels
�Irregular FHR; fetal arrhythmias
Vaginal Fluids:

Labor/Delivery Emergencies: Shoulder Dystocia

� Head is born, but anterior shoulder cannot pass under pubic arch
� Head emerges but then retracts against the perineum (turtle sign) and external rotation does not occur
� Causes: excessive fetal size (greater than 4000 grams) and maternal pelvic abnorm

Labor/Delivery Emergencies: Prolapsed Umbilical Cord

Cord lies below the presenting part of the fetus
Contributing Factors:
� Long umbilical cord (greater than 100 cm)
� Malpresentation (breech)
� Transverse lie
� Unengaged presenting part
Risks: Fetal hypoxia resulting from cord compression

Labor/Delivery Emergencies: Rupture of the Uterus

o Rare but serious
o Causes:
� Separation of the scar from previous classical incision
� Uterine trauma
� Congenital uterine abnormality
o Causes during labor:
� Intense spontaneous uterine contractions
� Labor stimulation (oxytocin, prostaglandin)
� Over

Labor/Delivery Emergencies: Rupture of Pre-Existing Cerebral Aneurysm

Caused by strain of pushing

Labor/Delivery Emergencies: Formation of Pulmonary Embolism

Pregnancy puts women in a state of hypercoaguability

Labor/Delivery Emergencies: Amniotic Fluid Embolism (Anaphylactoid Syndrome of Pregnancy)

o Respiratory and Circulatory collapse
o Amniotic fluid containing debris
o Debris enters maternal circulation
o Debris blocks pulmonary circulation
o High mortality rate: 80-90%
� Acute dyspnea
� Severe hypotension
� If mother survives: hemorrhage

Labor/Delivery Emergencies: Hemorrhage (3rd and 4th stage complications)

� Alterations in VS
� Pallor
� Light-Headedness
� Restlessness
� Decreased Urinary output
� Alterations in LOC

Amniotic Fluid: Function, Normal vs. Abnormal Findings, Rupture of Membranes

keep fetus warm, keep baby lubricated so it can move easily and body parts don't grow together, develops lungs, liquid "shock absorber", helps develop urinary and digestive track
Pale, straw-colored, flecks of lanugo or vernix; watery wi

Cultural Competency/Family Centered Care

� Ask if there are any cultural practices the family would like
� Check the facility's policy
� If against policy, ask the doctor for an order

Function of the Placenta

Provides oxygen and nutrients to the fetus

Abnormal Labor Patterns

o Powers: dysfunctional uterine contractions
� Hypertonic Uterine Dysfunction: frequent contractions with no changes
� Hypotonic Uterine Dysfunction: weakening or cessation of contractions
o Passage: alterations in pelvic structure
� Pelvic Dystocia: cont

Breastfeeding: Position

o Positioning: mom's will have different preferences depending on the birth and comfort levels
- C-section moms: football hold, to relieve pressure from abdomen
- Moms with episiotomies: side-lying, to prevent perineal pressure from sitting up

Breastfeeding: Proper Latch

o Nipple and areola in baby's mouth
o Rounded full cheeks
o Lips appear rounded around breast tissue (not creased in the corners)
o Baby's head/body in alignment and brought to the breast
o Mom and baby are 'belly to belly' a tugging sensation felt (not a

Breastfeeding: Complications and Treatment

o Engorgement: usually on 3rd to 5th day PP and lasts 24 hours
-feedings q2hrs
-Ice packs and raw cabbage leaf compress
-Pump or hand-express to relieve pressure
o Sore nipples: not normal
-often result from poor positioning, incorrect latch, or monilial

Breastfeeding: Maternal Care

o Diet: additional 200-500 cal/day if breastfeeding
o Weight loss: if breastfeeding, discourage attempt to lose weight due to nutritional needs for lactation
o Exercise: Light/moderate OK (encouraged for physical and emotional well-being)
o Rest: fatigue,

Breastfeeding: Advantages

o For the Infant:
- Specific antibodies and cell-mediated immunologic factors
- Lower incidence of certain allergies
- Less likely to die of SIDS
- May have protective effect against childhood lymphoma and Type 1 and 2 DM
o For the Mother:
- Decreased ris

Post-Partum: Assessment

o Breasts
o Uterus
o Bladder
o Bowels
o Lochia
o Episiotomies (if they had one)
o Homan's Sign
- (+) if pain when foot is dorsiflexed
o Emotional State

Post-Partum Problems: Hemorrhage

o Acute - first 24 hours after childbirth
-Uterine atony:
Risk: over-distended uterus (macrosomia, multiple gestation), obesity, pitocin use, prolonged labor, retained placenta
Meds: Pitocin, Cytotec, Methergine (not IV or if hypertensive), Hemabate (not

Post-Partum Problems: Hypovolemic Shock

o Rapid intervention
-Restore blood volume
-Treat cause of hemorrhage
o Classic signs:
-Maternal dyspnea, tachycardia, thready pulse
-Dropping blood pressure, increasing tachycardia
o Nursing interventions
-Summon help
-Rapid infusion of crystalloids/RBC'

Post-Partum Problems: Uterine Subinvolution

o Occurs 1-2 weeks after birth
o Retained placental fragments
-Retained placental fragments continue to produce progesterone, inhibit prolactin & milk production
o Pelvic infection
-Prolonged lochial discharge
-Irregular or excessive bleeding

Post-Partum Problems: Perineal Discomfort

o Assess perineum for hematoma, bleeding, s/s of would infection
o Ice-filled glove wrapped in wash cloth for first 24 hours to reduce perineal edema and provide comfort (On 20 mins/Off 10 mins)-avoid latex gloves if patient allergic
o Sitz baths to start

Post-Partum Problems: Infections

o Endometritis - initial 24-36 hrs GBS, late-onset Chlamydia
o Infections of perineal wound, c-section wound
o UTI (Cystitis, Pyelonephritis)
o Mastitis - rarely occurs in first two weeks postpartum
-Treatment: abx, freq. breastfeeding, moist heat compres

Post-Partum Problems: Post-Partal Thromboembolic Disease

Clot formation common in obesity & surgery - use alternating compression units
o Superficial venous thrombosis - saphenous veins, 3-4 days after birth (tx - bed rest, moist heat, elevation of limb, analgesics)
o DVT - hx of thrombosis, diagnosis results i

Post-Partum Problems: DVT Treatment

o IV heparin therapy, bed rest, leg elevated, analgesia,
o 3 - 5 days
o Oral anticoagulant therapy (warfarin) started then and cont. x ~ 3 months
o Elastic stockings when allowed to ambulate
o Education: diagnosis and treatment

Post-Partum Problems: Post-Partum Blues/Depression/Psychosis

o Blues:
-Transient period of depression (50-70%)
-Occurs first week or two after birth
-Mood swings, anger, weepiness, anorexia, sleeping problems, feeling letdown, fatigue
-Etiology unknown
-Functioning not impaired
-Normal and usually resolves naturall

Post-Partum: Criteria for Early Discharge

o Able to care for self
o Able to care for baby
o Uncomplicated Pregnancy, Labor, and Birth

Post-Partum: Maternal Adaptations

o Uterus firms
o Afterpains: overdistention of uterus
o Placental Site: lining functional in 16 days; site of attachment 6 weeks to heal
o Lochia
o Cervix: soft after birth, 2-3 days post-partum shortened, firm and regains form
o Vagina: returns to size b

Newborn: Safety Practices

o Check identification bands are in place
o Report suspicious people
o Never leave newborn alone in their room
o Do not lift baby if feeling weak, faint, or unsteady
o Always keep an eye and hand on baby when it is out of the crib
o Protect baby from infe

Newborn: Adaptation of Newborn


Newborn: Major Body System Findings


Newborn: Jaundice

What is it? Hyperbilirubinemia: yellow discoloring of skin and sclera
How common is it? 25-50% of all term newborns and 90% in premature infants
What are the causes?
o Overproduction of bilirubin
-Hemolytic disease
-Rh incompatibility (Rh negative mother

Newborn: Parental-Newborn Interactions/Bonding

Observe parent-infant interactions for comfort level:
o Changing diapers
o Wrapping and handling the infant
o Feeding the newborn
o Position infant on back to sleep
o Correct use of bulb syringe
o Avoid leaving the baby alone
o Proper bathing techniques