NCLEX-RN: Maternal–Newborn Nursing

Maternal–Newborn Nursing: Complications of Labor and Delivery

Focus topic: Maternal–Newborn Nursing

Maternal–Newborn Nursing: Fetal Distress

Focus topic: Maternal–Newborn Nursing

Assessment
A. Assess fetal heart rate: above 160 or below 110 beats/min indicates distress; signs of oxygen lack; or infection.
B. Check for meconium-stained fluid. During hypoxia, bowel peristalsis increases, anal sphincter may relax, and meconium is likely to be passed.
C. Assess for fetal hyperactivity.
D. If labor is monitored, check:

  • Variable deceleration pattern.
  • Late deceleration pattern.
  • Fetal pH below 7.2.

Implementation
A. Discontinue Pitocin if being infused.

B. Turn client to left side; if no improvement, turn to right side. This procedure relieves pressure on umbilical cord during contractions and pressure of uterus on the inferior vena cava.
C. Administer oxygen via mask at 10–12 L/min.
D. Correction of hypotension: Increase perfusion of IV fluids.
E. Notify physician.
F. Prepare for emergency cesarean delivery if no improvement.

COMPLICATIONS AND SIGNS OF FETAL DISTRESS

Focus topic: Maternal–Newborn Nursing

Maternal–Newborn Nursing

Maternal–Newborn Nursing: Vena Cava Syndrome (Supine Hypotensive Syndrome)

Focus topic: Maternal–Newborn Nursing

Definition: Shocklike symptoms that occur when venous return to the heart is impaired by weight of gravid uterus causing partial occlusion of the vena cava.

Assessment
A. Assess for risk factors—multiple pregnancies, obesity, polyhydramnios.
B. Assess shocklike symptoms caused by reduced cardiac output.

  • Hypotension.
  • Tachycardia.
  • Sweating, dizziness, pallor.
  • Nausea and vomiting.
  • Air hunger.

C. Assess for fetal distress; caused by reduced flow of blood to placenta from reduced cardiac output.

Implementation
A. Assist mother to turn to left side (use a wedge pillow) to shift weight of fetus off inferior vena cava.
B. Provide oxygen with tight mask if recovery is not immediate after positioning.
C. Monitor fetal heart rate to determine fetal status.

Premature Rupture of the Membranes

Focus topic: Maternal–Newborn Nursing

Definition: The spontaneous rupture of membranes (before 37 weeks’ gestation) prior to the onset of labor.

Assessment

A. Assess latent period: time from rupture of membranes to onset of labor; interval period is time from rupture of membranes to delivery of fetus.
B. Major maternal risks associated with premature rupture of the membranes (PROM) are ascending uterine infection and precipitation of preterm labor.

  • Assess time between membrane rupturing and when labor began—risk of infection may be directly related to time involved.
  • Observe for signs of infection: elevated temperature, chills, malaise, white blood cells (WBC), and increased uterine tenderness.

C. Assess for signs of labor or prolapsed cord.
D. Observe amniotic fluid for foul odor or signs of fetal distress (meconium staining).

Implementation
A. Monitor for signs of contractions.
B. Monitor for fetal heart tones at least every 4 hours until labor begins.
C. Alleviate client’s fears of “dry birth.”
D. Record time, amount, color, and odor of ruptured membranes initially, then every 4 hours and prn.
E. Record vital signs, especially temperature, every 4 hours and prn.
F. Monitor for most common neonatal risk—respiratory distress syndrome.

Preterm Labor and Delivery

Focus topic: Maternal–Newborn Nursing

Definition: Labor that occurs prior to the end of the 37th week of gestation.

Characteristics
A. Predisposing factors.

  • Conditions such as chronic pyelonephritis, cervical incompetence, multiple pregnancies, past history of premature births, sepsis in the fetus, and placental disorders.
  • Sometimes no specific cause can be identified.

B. Attempts to arrest preterm labor are contraindicated when:

  • Pregnancy is 37 weeks or over.
  • Ruptured membranes exist; delivery may be delayed if there are no indications of infection to allow fetus to mature.
  • Maternal disease exists: abruptio placenta, etc.
  • Fetal problems such as Rh isoimmunization become threatening.

C. A drug such as Celestone (betamethasone) may be given to the mother to hasten fetal maturity by stimulating development of lecithin when membranes are ruptured and premature labor cannot be arrested—decreases incidence of respiratory distress syndrome.

Assessment
A. Observe for abrupt change in fetal heart tones or signs of distress.
B. Assess vital signs—blood pressure, pulse, temperature, and respirations.
C. Evaluate for signs of infection, respiratory distress, cardiac status.
D. Check intake and urinary output.
E. Examine urine for glucose and protein.
F. Check for presence of edema.
G. Assess maternal emotional state.

Implementation
A. Teach pregnant client early warning signs of preterm labor and to notify healthcare providers early.
B. Encourage adequate hydration, especially if weather is hot, to prevent irritable uterine contractions, which may lead to preterm labor.
C. Maintain bed rest; place client on left side.
D. Continuous monitoring of contractions, vital signs, and fetal heart tones.
E. Administer medications (tocolytics) according to protocol.
F. Keep client informed and provide support: may be fearful, feel guilty, or be anxious; decreasing anxiety is primary goal.
G. Careful observation for signs of complications such as tachycardia.
H. Provide for hygiene and general comfort care.

Prolonged Pregnancy

Focus topic: Maternal–Newborn Nursing

Definition: Pregnancy over 42 weeks’ gestation—degeneration of placenta, thus decreased blood to fetus.

Characteristics
A. Amniotic fluid decreases and vernix caseosa disappears; infant’s skin appears dry and cracked.
B. Infant may lose weight.

Maternal–Newborn Nursing

C. Chronic hypoxia may occur due to placental dysfunction.
D. Determination of gestational age usually made to ascertain actual duration of pregnancy—estriol studies, sonography.
E. Contraction stress test (CST) may be done to determine fetus’s ability to tolerate labor.
F. Labor stimulated with Pitocin (oxytocin) and Prostin (prostaglandin) for cervical ripening.
G. Cesarean delivery if induction contraindicated.

Assessment
A. Determine actual gestational age.
B. Assess results of CST to determine fetus’s viability.
C. Assess vital signs of client for baseline data before labor is induced.
D. Assess psychological state of client and need for support.
E. Assess external resources of client.

Implementation
A. Monitor fetal heart rate continuously—report any late or variable deceleration immediately.
B. Support mother during labor process.
C. Prepare for possibility of emergency cesarean section.
D. Monitor induction of labor if natural labor process does not occur.
E. Support family during labor and delivery.

Prolapsed Umbilical Cord

Focus topic: Maternal–Newborn Nursing

Definition: Displacement of the umbilical cord below the presenting part. The cord may protrude through the cervix and into the vaginal canal.

Characteristics
A. Rupture of the membranes before engagement.
B. Abnormal presentation.                                                                                                                                                                                                                          C. Premature infant: Presenting part does not fill the birth canal, allowing the cord to slip through.
D. Polyhydramnios.

Assessment
A. Observe for presence of cord palpated or seen on vaginal examination.
B. Assess abnormal fetal heart pattern: Cord may become compressed and cause fetal hypoxia.

Implementation
A. Place client in knee–chest or modified Sims’ position with hips elevated on pillows.
B. Insert fingers of sterile, gloved hand into vagina to lift presenting part off umbilical cord until fetus delivered.
C. Administer oxygen (5 L) to mother by mask.
D. Call for assistance.
E. Notify physician.
F. Continuously monitor fetal heart rate (baseline above 110 beats/min and variable decelerations relieved if cord compression lessened).
G. Do not attempt to push in cord.
H. Stay with client and offer support.
I. Prepare for immediate delivery, by cesarean section if necessary.

Amniotic Fluid Embolism

Focus topic: Maternal–Newborn Nursing

Definition: The escape of amniotic fluid into the maternal circulation. It is usually fatal to the mother.

Characteristics
A. Amniotic fluid contains debris such as lanugo, vernix, and meconium, which may become deposited in pulmonary arterioles and result in cardiopulmonary collapse.
B. Usually enters maternal circulation through open venous sinus at placental site.
C. Predisposing factors.

  • Premature rupture of membranes.
  • Tumultuous labor.

D. High maternal mortality rate—85%.

Assessment
A. Observe for acute dyspnea with hypotension.
B. Assess for sudden chest pain.
C. Check for cyanosis.
D. Assess for CNS hypoxia: changes in LOC, seizures, etc.
E. Observe for pulmonary edema.
F. Check vital signs for indications of shock.
G. Assess for uncontrolled hemorrhage (massive DIC).

Maternal–Newborn Nursing

Implementation
A. Institute efficiency measures to maintain life.
B. If client survives, provide intensive care treatment.
C. Keep family informed and provide emotional support.

Inverted Uterus

Focus topic: Maternal–Newborn Nursing
Definition: A condition in which the uterus turns inside out, usually during delivery of the placenta.

Assessment
A. Observe for shock, hemorrhage, or severe pain.
B. Check for mild symptoms with incomplete uterine inversion.

Implementation
A. Assist with treatment for shock.
B. Monitor for hemorrhage.
C. Monitor vital signs.
D. Assist client while replacement of uterus (if done vaginally) is done.

Rupture of the Uterus

Focus topic: Maternal–Newborn Nursing

Definition: The splitting of the uterine wall accompanied by extrusion of all or part of uterine contents into the abdominal cavity. Baby usually dies, and mortality rate in mothers is high due to blood loss.

Assessment
A. Observe for acute abdominal pain and tenderness.
B. Establish that presenting part is no longer felt through cervix.
C. Assess for a feeling in client that something has happened inside her.
D. Evaluate for cessation of labor pains (no contractions).
E. Evaluate for any external bleeding (usually bleeding is internal).
F. Assess for signs of shock: pale appearance, pulse weak and rapid, air hunger, and exhaustion.
G. Evaluate fetal status.

Maternal–Newborn Nursing

Iplementation
A. Be alert for symptoms since immediate diagnosis is necessary if fetus and mother are to survive.
B. Call for assistance, stay with client, and notify physician.
C. Prepare for emergency surgery.

Dysfunctional Labor (Dystocia)

Focus topic: Maternal–Newborn Nursing

Definition: Dystocia occurs with prolonged and difficult labor and delivery. Labor is considered prolonged when it extends for 24 hours or more after the onset of regular contractions.

Characteristics
A. Dysfunctional uterine contractions.

  • Uterine contractions inefficient; hence, cervical dilatation, effacement, and descent fail to occur.
  • Contributing factors.
    a. False labor.
    b. Oversedation or excessive anesthesia.
    c. “Unripe” cervix.
    d. Uterine contractions that are hypertonic
    or hypotonic.
    e. Uterine abnormalities such as fibroids.
    f. Cephalopelvic disproportion (CPD).
    g. Malpositions.
    h. Uterine or other abnormalities.

B. Abnormal presentations and positions.

  • Occiput posterior position.
    a. Usually prolongs labor because baby must rotate a longer distance (135 degrees or more) to reach symphysis pubis.
    b. May lead to persistent occiput posterior (head does not rotate) or deep transverse arrest (head arrested in transverse position).
    c. Treatment.
    (1) Head usually rotates itself with contraction.
    (2) Rotation may be done by physician manually or with forceps.
  • Breech position prolongs labor because soft tissue of fetus’s bottom does not aid cervical dilatation as does the fetal skull.
  • Face presentation: rare; results in increased prenatal mortality.
    a. Chin must rotate so it lies under symphysis pubis for delivery.
    b. If baby is delivered vaginally, the face is usually edematous and bruised, with marked molding.
    c. Cesarean delivery is indicated if face does not rotate.
  • Transverse lie.
    a. Long axis of fetus at right angles to long axis of mother.
    b. Spontaneous conversion may occur.Cesarean delivery is the usual treatment.

C. Cephalopelvic disproportion (CPD).

  • Disproportion between the size of the fetus and size of the pelvis.
  • Head is large.
  • Size of shoulders may also complicate delivery.
  • Causes.
    a. Multiparity: Birth weight may progress with each pregnancy.
    b. Maternal diabetes.
    c. Large baby.
    d. Fetal abnormalities.
    (1) Hydrocephalus.
    (2) Tumors.
    (3) Abnormal development.
  • Size may be determined by sonography and x-ray.
  • Treatment.
    a. Vaginal delivery if disproportion is not too great. May be fetal injuries: brachial plexus, dislocated shoulder.
    b. Cesarean delivery indicated if disproportion too great.
Maternal–Newborn Nursing

Assessment
A. Observe rate of progress as well as overall length of labor.

  • Latent phase may be considered prolonged.
    a. Parous: Labor extends 14 hours or longer.
    b. Nulliparous: Labor extends 20 hours or longer.
  • Active phase may be considered prolonged.
    a. Parous: Dilatation is lower than 1.5 cm/hr and descent is less than 5 cm/hr.
    b. Nulliparous: Dilatation is slower than 1.2 cm/hr and descent is less than 1 cm/hr.
  • Arrested labor—labor fails to progress beyond a certain point.

B. Signs of distress in the mother.

  • Infection.
    a. Elevated temperature.
    b. Elevated pulse.
  • Exhaustion.
    a. Loss of emotional stability.
    b. Lack of cooperation.
    c. Ketonuria.
  • Dehydration.
    a. Dry tongue and skin.
    b. Concentrated urine.
    c. Acetonuria (ketonuria).

C. Signs of distress in the fetus.

  • Hypoxia.
    a. Irregular heart rate.
    b. Heart rate above 160 or below 110 or decrease of 20 points below baseline.
    c. Passage of meconium in the vertex position.
  • Generalized infection.
    a. Irregular heart rate.
    b. Heart rate above 160 or below 110.

Implementation
A. The course of dysfunctional labor varies with cause.
If labor is induced:

  • Promote rest: Darken room, reduce noise level.
  • Position client for comfort.
  • Give client a back rub.
  • Provide clean linen and gown, and allow client to bathe or shower if permissible.
  • Promote oral hygiene.
  • Give client reassurance and support.
  • Explain procedures to client.
  • Let client express feelings and emotions freely.

B. Monitor client’s progress.

  • Watch for signs of exhaustion, dehydration, and acidosis.
  • Monitor vital signs.
  • Maternal–Newborn NursingMonitor fetal heart rate.
  • Monitor progress of labor.
  • Watch for signs of excessive bleeding and fetal distress.
  • Encourage client to void q 2 hr and check bladder for distention.

C. Administer medications as ordered.
D. Prepare for cesarean section if necessary.

Precipitate Delivery

Focus topic: Maternal–Newborn Nursing

Definition: Rapid or sudden labor of less than 3 hours’ duration, from onset of cervical changes to delivery of infant.

Assessment
A. Obtain quick admission history by asking focused questions.

  • “Do you want to push?”
  • “Have your membranes ruptured?”
  • “Are you bleeding?”
  • “Have you had a baby born quickly before?”

B. Assess client’s ability to understand your directions.
C. Evaluate resources (proximity of physician and/or other assistance).
D. Assess client’s psychological state and need for support at this time. Establish rapport quickly.
E. Assess signs and symptoms of impending delivery.

  • Desire to push.
  • Frequency of strong contractions.
  • Heavy bloody show.
  • Membranes ruptured.
  • Bulging rectum.
  • Presenting part visible.
  • Severe anxiety.

F. Observe for above signs continually as labor may progress with unexpected rapidity.

Implementation
Assisting with Delivery
A. Never leave the client unattended during this time.

  • Never hold baby back; allow it to progress naturally.
  • Ask another employee to notify the physician.
  • Bring the emergency delivery pack to room.
  • Have client pant rather than push to avoid rapid delivery of the head.

B. Reassure client that you will remain with her and provide care until the physician arrives.
C. Put on sterile gloves if they are available and if there is time.
D. Break membranes immediately if they have not done so spontaneously.
E. With a clean or sterile towel (if available), support baby’s head with one hand, applying gentle pressure to the head to prevent sudden expulsion and undue stretching of the perineum or brain damage to the infant.
F. If cord is draped around baby’s neck, with free hand gently slip it over the head.
G. If you have a bulb syringe, gently suction baby’s mouth and wipe blood and mucus from mouth and nose with towel, if available. Shoulders are usually born spontaneously after external rotation. If shoulders do not deliver spontaneously, ask client to bear down to deliver them.
H. Support the baby’s body as it is delivered.
I. Hold infant level with placenta until cord clamping is done.

  • If infant is held high, blood may flow back into placenta and cause anemia.
  • If infant is held below level of placenta, extra blood could cause polycythemia.

J. All manipulation should be gentle to avoid injury to mother and baby.

Care After Delivery
A. After delivery, hold baby securely over hand and arm with the head in a dependent position to allow fluid and mucus to drain.
B. If baby does not cry spontaneously, gently rub baby’s back or the soles of baby’s feet.
C. Dry baby to prevent heat loss.
D. Place the baby on the mother’s abdomen to provide warmth. The weight on the uterus will help it to contract.
E. Palpate mother’s abdomen to make sure uterus is contracting.
F. Watch for signs of placental separation.
G. Support placenta in your hand after it is expelled.
H. Clamp the cord after it stops pulsating if clamp or ties are available. Cord need not be cut; there will be no bleeding from the placental surface.
I. Wrap the baby in a blanket.
J. Put the baby to the mother’s breast. This reassures the mother that the baby is all right and helps contract the uterus.
K. Check the uterus after delivery of the placenta. Make sure the uterus is contracting.
L. Keep an accurate record of the time of birth and other pertinent data.
M. If baby is delivered unassisted, in bed, before the nurse arrives (precipitate delivery), the nurse should immediately:

  • Check the baby to make sure breathing is established.
  • Monitor closely for signs of hemorrhage (increased risk of lacerations, abruptio placenta).

N. Comfort mother and family.
O. Monitor newborn closely for signs of aspiration, asphyxia, or intracranial trauma.

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