NCLEX-RN: Maternal–Newborn Nursing: Intrapartum period

Maternal–Newborn Nursing: Intrapartum period

Labor and Delivery

Definition: Labor is the process by which the products of conception are expelled from the body. Delivery refers to the actual birth.

Maternal–Newborn Nursing: Adaptive Processes

Definition: During latter months of pregnancy, the fetus adapts to the maternal uterus, enabling it to occupy the smallest space possible. The term attitude refers to the posture the fetus assumes in utero; fetal lie is the relationship of the long axis of the body to the long axis of the mother.

Presentation

Definition: The part of the fetus that enters the true pelvis first.

A. Cephalic: Head is presenting part—95–96%.

1. May be vertex, face, or brow.
2. Vertex is most common and most favorable for delivery. Head is sharply flexed in the pelvis with chin near chest.

B. Breech: Buttocks or lower extremities are the presenting part.

1. Types.

a. Complete or full: Buttocks and feet present (baby in squatting position).
b. Frank: Buttocks only presenting, or legs are extended against anterior trunk with feet touching face.
c. Incomplete: One or both feet or knees presenting, footing single or double, or knee presentation.

2. May rotate to cephalic during pregnancy but possibility lessens as gestation nears term.

3. May be rotated by physician but usually returns to breech position.

 C. Transverse lie: Long axis of infant lies at rightangles to longitudinal axis of mother (necessitates delivery by cesarean section).

Position

Definition: Relationship of the fetal presenting part to the maternal bony pelvis.

A. Position is determined by locating the fetal presenting part in relation to the maternal pelvis.

B. Client’s pelvis is divided into four imaginary quadrants: right anterior, right posterior, left anterior, and left posterior.

C. Most common positions (abbreviations usually used).

1. LOA (left occipitoanterior): occiput on left side of maternal pelvis and toward front, face down, favorable for delivery.
2. LOP (left occipitoposterior): occiput on left side of maternal pelvis and toward rear or face up.

a. Usually causes back pain during labor.
b. May slow the progress of labor.
c. Usually rotates before delivery to anterior position.
d. May be rotated in delivery room by physician.

3. ROA (right occipitoanterior): occiput on rightof maternal pelvis, toward front, face down, favorable for delivery.
4. ROP (right occipitoposterior): occiput on right side of maternal pelvis, face up. Same problems as LOP.

D. Means of assessing fetal position during labor.

1. Leopold’s maneuver: method of palpating the maternal abdomen to determine information about the fetus such as presentation, engagement position, and rough estimate of fetal size.

2. Vaginal examination.

3. Rectal examination.

Maternal–Newborn Nursing: Engagement—Lightening

A. Largest diameter of presenting part has passed the inlet of the maternal pelvis. Usually takes place 2 weeks before labor in primiparas, but often not until labor begins in multiparas.

B. May be assessed by Leopold’s maneuver or vaginal or rectal examination.

Maternal–Newborn Nursing: Station

A. Degree to which presenting part has descended into pelvis is determined by the station—the relationship between the presenting part and the ischial spines.

B. Assessed by vaginal or rectal examination.

C. Measured in numerical terms.

1. At level of spines: 0 station.
2. Cm above level of spines: –1, –2, –3.
3. Cm below level of spines: +1, +2, +3.

D. Other terms used to denote station.

1. High: presenting part not engaged.
2. Floating: presenting part freely movable in inlet of pelvis or may be movable in inlets of pelvis.
3. Dipping: entering pelvis.
4. Fixed: no longer movable in inlet but not engaged.
5. Engaged: biparietal plane passed through pelvic inlet.

Maternal–Newborn Nursing: Fetal Skull

A. Largest anatomical part of the fetus to passthrough the birth canal; usually if the head can pass, the rest of the body can be delivered.

B. Made up of seven bones: two frontal, two parietal, two temporal, and one occipital.

C. Sutures: membranous interspaces between bones.

1. Sagittal: between two parietal bones.
2. Frontal: between two front bones.
3. Coronal: between frontal and parietal.
4. Lambdoidals: between posterior margin of parietal and occipital.

D. Fontanels: points where sutures intersect.

1. Anterior—diamond shaped. Found at the junction of the sagittal and coronal sutures. Becomes ossified around 12–18 months.
2. Posterior—smaller triangular shaped. Found at the junction of the sagittal and lambdoid sutures. Becomes ossified by 2–4 months after birth.
3. Other, smaller fontanels are also present.
4. Fontanels and sutures allow for fetal skull bones to override, as they adapt to the pelvis.
5. Important points in vaginal or rectal examination to determine position of fetus— posterior or anterior.

Maternal–Newborn Nursing: The Labor Process

Focus Topic: Maternal–Newborn Nursing

Maternal–Newborn Nursing: Cause of Labor

A. Alterations in hormonal balance of estrogen (increases contractility) and progesterone (decreases contractility).

B. Degeneration of the placenta, which no longer provides necessary elements to fetus.

C. Overdistention of uterus creates stimulus— triggering release of oxytocin, which initiates contractions.

D. High levels of prostaglandins near term may stimulate uterine contractions.

E. Hormones secreted by fetus (fetal cortisol).

F. The type of contraction necessary for true labor may be produced by a combination of several of these physiological occurrences although the actual cause is unknown.

Maternal–Newborn Nursing: Forces of Labor

A. Muscular contractions primarily of muscles of uterus and secondarily of abdominal muscles.

B. Uterine muscles contract during first stages and bring about effacement and dilatation of the cervix.

C. Abdominal muscles come into play after complete cervical dilatation and help expel the baby—voluntary bearing-down effort, urge to push.

D. Contraction of levator ani muscles.

Maternal–Newborn Nursing: Duration of Labor

A. Varies depending on individual.

B. Average.

1. Primipara: up to 18 hours; some may be shorter, others longer.
2. Multipara: up to 8 hours; some may be shorter, others longer.

C. Length of labor depends on:

1. Effectiveness of consistent contractions: contractions must overcome resistance of cervix.
2. Amount of resistance baby must overcome to adapt to the pelvis.
3. Stretching ability of soft tissue.
4. Preparation and relaxation of client. Fear and anxiety can retard progress.

D. Important to judge rate of progress: should be regular progression of uterine contraction, progressive effacement and dilatation of the cervix, and progressive descent of the presenting part.

Maternal–Newborn Nursing: Uterine Contractions

A. Characteristics.

1. Involuntary: cannot be controlled by will of client.
2. Intermittent: periods of relaxation between contractions. Intervals allow client to rest and also allow adequate circulation of uterine blood vessels and oxygenation of fetus.
3. Distinguish between true labor (contractions are regular, painful, and continue with walking) and false labor—Braxton Hicks (regular, painful, but go away with walking).
4. Discomfort starts in low back, radiates to abdomen.
5. As labor progresses, intensity increases.

B. Contractions divided into three periods of intensity.

1. Increment: increasing intensity.
2. Acme: peak, or full intensity.
3. Decrement: decreasing intensity.

C. Contractions are monitored by the following:

1. Palpate: Place your fingers lightly on the fundus of the uterus (the most contractile portion) and relate what you feel in your fingers to seconds and minutes on a clock. Uterus becomes firm, then hardens, and then decreases in hardness.
2. Electronic monitoring device.

a. External: less accurate—done with pressure-sensitive button placed over the uterine fundus.
b. Internal: catheter inserted into uterine cavity to measure internal pressures and relay information to a graph.

D. Contractions are monitored for frequency, duration, and intensity.

1. Frequency: measured by timing contractions from the beginning of one contraction to the beginning of next.
2. Duration: beginning of contraction to the completion of the contraction. Cannot be measured exactly by feeling with the hand.
3. Intensity: cannot be measured by feeling; must be measured by internal fetal monitoring device. Usually refers to contraction at the beginning of labor. Peaks at about 25 mm Hg. At the end of labor, it may reach 50 to 75 mm Hg.
4. Contractions may be described as mild, moderate, or intense.

E. Purpose of contractions.

1. To propel presenting part forward.
2. To bring about effacement and dilatation of the cervix.

Maternal–Newborn Nursing: Effacement and Dilatation

A. Effacement: thinning process by which cervical canal is progressively shortened to complete obliteration. Progresses from a structure of 1 to 2 cm long to almost complete obliteration.

B. Dilatation: process by which external os enlarges from a few millimeters to approximately 10 cm.

C. All that remains of the cervix after effacement and dilatation is a paper-thin circular opening about 10 cm in diameter.

D. Primiparas efface, then dilate; multiparas efface and dilate at the same time.

Maternal–Newborn Nursing: Changes in the Uterus

A. Uterus usually becomes differentiated in two distinct portions as labor progresses.

1. Upper portion: contractile, becomes thicker.
2. Lower portion: passive, becomes thinner and more expanded.

B. Boundary between the two segments is termed the “physiologic retraction ring.”

Maternal–Newborn Nursing: Signs of Labor

Focus Topic: Maternal–Newborn Nursing

Maternal–Newborn Nursing: Assessment

A. Assess for premonitory signs: physiologic changes that take place the last several weeks of pregnancy, indicating that labor is near.

B. Observe for lightening: descent of the uterus downward and forward, which takes place as the presenting part descends into the pelvis.

1. Time in which it takes place varies from a few weeks to a few days before labor. In multigravida, it may occur during labor.

2. Sensations.

a. Relief of pressure on diaphragm. Breathing is easier.
b. Increased pelvic pressure leading to leg cramps, frequent micturition, and pressure on rectum.

C. Check presence of Braxton Hicks contractions.

1. May become quite regular but do not effectively dilate cervix.
2. Usually are more pronounced at night.
3. May play a part in ripening the cervix.

D. Evaluate for decrease in weight: There is usually a decrease in water retention due to hormonal influences.

E. Assess for cervical changes: Cervix usually becomes softer, shorter, and somewhat dilated. May be dilated 1 to 2 cm by the time labor begins.

F. Check presence of bloody show.

1. Vaginal discharge of tenacious mucus, usually pinkish or streaked with blood, is expelled from the cervix as it shortens and begins to dilate.
2. Labor usually begins within 24 to 48 hours.

G. Evaluate rupture of membranes.

1. May break any time before labor or during labor. Occasionally, membranes remain intact and are ruptured by the physician during labor (amniotomy).
2. May gush or trickle.
3. Client usually advised to come to the hospital as labor may begin within 24 hours.
4. If labor does not begin spontaneously, it is induced to avoid intrauterine infections.
5. Confirm rupture by nitrazine paper (turns blue) or ferning.
6. Note color, amount, and odor of amniotic fluid; fetal heart rate.
7. Assess for signs of prolapsed cord.

H. Assess for beginning of true labor.

1. Contractions increase in frequency, intensity, and duration.
2. Progressive cervical effacement and dilatation.
3. Progressive descent of presenting part.
4. Presence of bloody show.
5. Contractions increase in intensity with walking.

I. Differentiate true from false labor.

1. Irregular contractions.
2. Contractions may cause discomfort.
3. Usually discomfort is located in abdomen.
4. Labor usually does not intensify.
5. Discomfort may be relieved by walking.
6. Contractions do not bring about appreciable changes in cervix.
7. Sometimes difficult to differentiate false labor from true labor, and client is observed for several hours in the hospital.

Maternal–Newborn Nursing: Implementation

A. Careful monitoring of the client and fetus during the labor and delivery process.

B. Prompt recognition and treatment of complications.

C. Provision of comfort and safety measures during labor and delivery.

D. Supportive assistance to the laboring client or couple to enable them to maintain control during the labor and delivery process.

Maternal–Newborn Nursing: Fetal Assessment During Labor

Fetal Monitoring

Maternal–Newborn Nursing: Characteristics

A. Two types of electronic fetal monitoring: Doppler ultrasound—external; and fetal electrocardiography —internal. Provide for a continuous data readout of fetal heart rate and uterine contraction pattern.

B. Most common method of obtaining an external recording of the fetal heart rate is with an ultrasound transducer that picks up the motion of the fetal heart valves.

C. External monitoring of uterine contraction is done with a pressure-sensitive button placed over the uterine fundus.

D. Heart rate sounds and uterine contractions are translated into electrical impulses reproduced on a printout strip on the fetal monitor.

E. External fetal heart rate tracing does not assess fetal heart rate beat-to-beat variability. External uterine contraction monitoring does not quantify the strength of the contractions.

F. Types of external fetal monitors.

1. Abdominal electrodes: elicits fetal and maternal heart rates.
2. Phonotransducer: picks up fetal heart tones.
3. Ultrasonic transducer: picks up fetal heart tones.
4. Tocotransducer: monitors uterine activity.

G. Types of internal fetal monitors.

1. Fetal scalp electrode (FSE): attached to presenting part—gives a direct tracing of fetal cardiac activity, which is recorded without interference and indicates beat-to-beat variability.
2. Intrauterine pressure catheter (IUPC): pressure-sensitive catheter introduced into the uterus, past the fetal head, which accurately measures frequency, duration, and intensity of uterine contractions.

Maternal–Newborn Nursing: Assessment

A. Evaluate client’s and family’s knowledge of rationale for fetal monitoring.

B. Identify client’s concerns before procedure is initiated.

C. Assess client’s knowledge of procedure.

D. Evaluate position of fetus using Leopold’s maneuver. (Fetal heart tone heard best over the fetal back area.)

E. Assess fetal heart rate (FHR): normal is 110–160 beats/min.

F. Assess fetal monitor strip for early and late deceleration.

Maternal–Newborn Nursing: Implementation

A. Preparation: Explain procedure to client.

B. Initiate external fetal monitoring using tocodynamometer (place over the fundus) and ultrasound transducer (usually placed in area of fetal back).

C. Initiate internal fetal monitoring as indicated (fetal scalp electrode or internal uterine pressure catheter).

Fetal Monitoring

See Variations of Fetal Heart Rate.

A. Normal fetal heart rate (baseline): 110–160 beats/min baseline rate between contractions for a duration of at least 2 minutes (during a 10-minute segment).

B. Variability (baseline): irregular fluctuations in the baseline FHR; usually at least two cycles/min (humps) and ranges between 6 and 25 beats/min (jagged line).

1. Important indication of fetal oxygenation.
2. Decrease variability may occur with fetal sleep, fetal hypoxia, medications, or neurologic immaturity.

C. Periodic accelerations or decelerations: increase or decrease in FHR lasting at least 30 seconds, usually associated with a contraction. Three types of decelerations: early, late, variable.

1. Early deceleration: gradual decrease in FHR in which lowest point (nadir) coincides with peak of contractions.

a. Onset of deceleration to nadir at least 30 seconds.
b. Uniform shape.
c. Usually indicates head compression as result of vagal stimulation.
d. Not considered ominous.

2. Late deceleration: gradual decrease in FHR in which lowest point of deceleration occurs after the peak of the contraction.

a. Onset to nadir at least 30 seconds.
b. May indicate fetal hypoxia.
c. Caused by insufficient oxygenation of the uterus and placenta—O2 reserve for infant to tolerate contractions.

Maternal–Newborn Nursing

3. Variable deceleration: abrupt decrease of at least 15 beats/min, lasting more than 15 seconds and less than 2 minutes.

a. Shape and onset will vary.
b. Indicates cord compression (i.e., cord around neck, baby lying on cord).

D. Bradycardia: baseline drop below 110 beats/min for at least 2 minutes (during 10-minute segment) between contractions.

1. May indicate fetal hypoxia.
2. May occur with congenital heart abnormalities, prolapsed cord.3. Maternal causes: medication, maternal bradycardia.

E. Tachycardia: baseline increases greater than 160 for at least 2 minutes (during 10-minute segment) between contractions.

1. Increased maternal basal metabolic rate (BMR) (i.e., temperature, pulse) most common.
2. Increased fetal BMR.
3. Medications.
4. Initial response to stress or early hypoxia.

Maternal–Newborn Nursing: Stages and Phases of Labor

Focus Topic: Maternal–Newborn Nursing

Definition: Labor is divided into four stages: stage 1—beginning of true labor to complete cervical dilatation; stage 2—complete dilatation to birth of baby; stage 3—birth to delivery of placenta; and stage 4—first 1 to 4 hours after delivery of placenta.

Maternal–Newborn Nursing: Admission Procedures

Focus Topic: Maternal–Newborn Nursing

A. Check vital signs: temperature, pulse, respirations, and blood pressure.

B. Check fetal heart rate.

C. Determine status of membranes: intact vs. ruptured.

D. Give prep and enema (if ordered by physician).

E. See that appropriate forms are completed.

F. Determine client’s psychological state and readiness for coping with labor: some clients may complain of intense pain in very early labor.

G. Encourage client to void, and check urine for sugar, acetone, and protein.

H. Apply external fetal monitor if ordered.

I. Determine frequency, intensity (mild, moderate,

J. Determine amount and character of show.

K. Assess cervical dilatation, effacement, station, presentation, position, and vaginal discharge.

L. Keep call bell within easy reach.

Maternal–Newborn Nursing: Stage 1

Focus Topic: Maternal–Newborn Nursing

Definition: Begins with onset of true labor and ends when cervix is completely dilated at 10 cm.

Maternal–Newborn Nursing: Assessment

A. Following admission procedures, observe for degree of cervical dilatation.

B. Assess contractions: vary from mild and 5–15 minutes apart to intense and close together.

C. Evaluate cervical effacement.

D. Observe presence or increase in bloody show.

E. Assess fetal station.

F. Assess mood of client: comfortable and talkative or tired and irritable.

G. Assess membrane status: intact or ruptured.

Maternal–Newborn Nursing: Implementation

Phase One: Latent Phase

A. Evaluate labor progress.

1. Begins with onset of regular contractions and ends with dilatation of 3 to 4 cm.
2. Contractions mild, 5–15 minutes apart, lasting 10–30 seconds. Averages 6.4 hours.
3. Station varies from –2 to –1.
4. Show varies from brown to pink—scant amount.

B. Observe for ruptured membranes and take fetal heart rate immediately if membranes rupture.

C. Maintain bed rest if membranes have ruptured. (In some hospitals, the client may be allowed out of bed with ruptured membranes if the baby’s head is well engaged.)

D. Allow client to walk about if membranes have not ruptured or provide reading material for client.

E. Auscultate fetal heart rate every 30 minutes to 1 hour.

F. Check blood pressure every 30 minutes or prn.

G. Check vital signs q 4 hrs or more often if needed.

H. Start IV if ordered. Client usually NPO or clear liquids.

I. Check for bladder distention.

J. Give periodic vaginal examination to determine progress.

K. Provide support based on mother’s knowledge of the labor process.

L. Reinforce breathing techniques or teach breathing techniques if client has had no classes.

M. Keep family informed of progress.

N. Encourage the presence of client’s husband or a significant other person.

O. Reduce stimuli if client wants to rest.

Phase Two: Active Phase

A. Begins with acceleration phase.

1. Cervix dilates from 3–4 to 8 cm.
2. Fetal descent is progressive.
3. Contractions 3–5 minutes apart and lasting 30–45 seconds, moderate intensity.
4. Increase in bloody show.
5. Station varies from 0 to +1.

B. Support client as she becomes tired, less talkative, and shows lack of energy.

C. Instruct/support client on breathing/relaxation techniques.

D. Monitor fetal heart rate every 15 minutes (highrisk) to 30 minutes.

E. Apply pressure to sacrum during contraction or encourage baby’s father to do so.

F. Encourage client comfort in side-lying position; avoid lying on back to prevent supine hypotension, unless using a wedge to displace pressure from uterus on the vena cava.

G. Administer medications as ordered.

1. Tranquilizers may be given in early labor.
2. Analgesics are usually not given until labor is well established—4–6 cm dilatation.

H. Assist with anesthesia, if given, and monitor blood pressure and fetal heart rate.

I. Continue support and keep client informed.

J. Once membranes have ruptured (2–3 cm dilatation), internal fetal monitor may be applied.

 

Maternal–Newborn Nursing

 

Phase Three: Transition Phase

A. Deceleration phase is part of transition.

1. Dilatation slows as it progresses from 8–10 cm.
2. Rate of fetal descent increases.
3. Deceleration should last 3 hours for nulliparas, and 1 hour for multiparas.
4. Contractions every 1½–2 min, 60–90 seconds’ duration, strong intensity.
5. Station varies from +1 to +2—increased amount of bloody show.
6. Desire to bear down or defecate.

B. Support client as her attention and feelings become inner-directed; she may feel exhausted and no longer able to cope.

C. Care for symptoms of nausea, vomiting, trembling, burping, and crying.

D. Explain progress to client and encourage her to continue with breathing and relaxing techniques.

E. Discourage bearing-down efforts until dilatation is complete.

F. Encourage deep ventilation prior to and after each contraction to avoid hyperventilation.

G. Monitor contractions lightly with fingers as abdomen is sensitive.

H. Accept irritable behavior and aggression and continue supportive care.

I. Help client to push when ready.

J. Observe for signs of imminent delivery and prepare room for delivery or transfer client to delivery room when ready, if utilized.

Maternal–Newborn Nursing: Stage 2

Focus Topic: Maternal–Newborn Nursing

Definition: Begins with complete dilatation of cervix (10 cm) and ends with delivery of infant.

Maternal–Newborn Nursing: Mechanism of Labor and Delivery

A. Sequence of movements of presenting part through birth canal. Head usually enters transverse and must rotate LOA or ROA for birth.

C. Descent: Movement that occurs simultaneously with passage of head through pelvis.

D. Flexion: Occurs as head descends and meets with resistance. In extreme flexion, the smallest diameter of the head presents.

E. Internal rotation: Head usually enters with long diameter conforming to long diameter of inlet (usually transverse position) and must rotate before it can emerge from outlet; head rotates so that smallest diameter presents to conform to pelvis.

F. Extension: Follows internal rotation; the head, which is flexed as it passes through birth canal, must extend for birth.

G. External rotation: Soon after birth, the head rotates to either mother’s right or left side, the fetal position before birth.

H. Expulsion: With delivery of shoulders, rest of body is expelled spontaneously.

Maternal–Newborn Nursing: Assessment

A. Observe for signs of imminent delivery.

B. Check contractions every 2–3 minutes; contractions last 60–90 seconds.

C. Auscultate fetal heart rate every 5 minutes (high risk) or 15 minutes.

D. Evaluate vagina and perineum stretching and thinning to allow for passage of baby.

E. Check increase in bloody show.

F. Evaluate urge to push: involuntary bearing down.

G. Observe bulging of perineum.

H. Observe vaginal opening, which distends from a small, narrow opening to a wide, round opening.

I. Observe presenting part as it becomes more visible.

J. Check crowning: Widest diameter of baby’s head is visible and encircled by vaginal opening.

K. Observe birth of presenting part.

L. Observe rest of body as it is delivered, usually with a gush of fluid.

Maternal–Newborn Nursing: Implementation

A. If separate delivery room utilized, transfer client carefully from bed to delivery table and place in lithotomy position.

B. On birthing bed or delivery table, pad stirrups to avoid pressure to popliteal veins and pressure areas. Gently raise both legs simultaneously into stirrups to avoid ligament strain. Adjust stirrups and drape client.

C. Provide client with handles to pull on as she pushes.

D. Cleanse vulva and perineum using medical aseptic principles of surgical scrub/prep.

E. Auscultate fetal heart tone every 5 minutes or after each push; transient fetal bradycardia not unusual due to head compression.

F. Check blood pressure and pulse every 15 minutes prn.

G. Administer oxygen if fetal heart tones decrease.

H. Include baby’s father/significant other in birth experience as much as possible; explain what is happening, where to stand, etc.

I. Catheterize if bladder is distended and prevents descent.

J. Encourage mother and keep her informed of advancement of baby.

K. Encourage mother to take a deep breath before beginning to push with each contraction and to sustain push as long as possible; long pushes are preferable to frequent short pushes.

L. Encourage open glottal pushing unless there is a medical indication for rapid delivery.

Maternal–Newborn Nursing: Stage 3

Focus Topic: Maternal–Newborn Nursing

Definition: From birth to expulsion of the placenta, usually 5–20 minutes after delivery.

Maternal–Newborn Nursing: Assessment

A. Observe for signs of placental separation.

1. The uterus contracts.
2. The uterus changes from discoid to globular in shape.
3. A slight gush of blood issues from vagina.
4. Lengthening of the umbilical cord occurs.
5. Upward displacement of the uterus occurs.

B. Evaluate placenta after separation.

1. Schultze (most common): Placenta is inverted on itself, and the shiny fetal surface appears; 80% separate in center.
2. Duncan: Descends sideways, and the maternal surface appears. Separates at edges rather than center.

C. Check to ensure that placental fragments do not remain in uterus.

D. Continually assess both mother and infant for first critical hour after birth.

1. Most common cause of death in first hour is hemorrhage—assess vital signs every 15 minutes.
2. Assess condition of fundus.
3. Check lochia for color and amount.

Implementation

Focus Topic: Maternal–Newborn Nursing

A. Monitor newborn’s status and begin bonding with parents.

1. Position baby so that mother and baby may have eye-to-eye contact.
2. Dim lights of birthing room so baby can open eyes fully.

B. Monitor for signs of placental separation.

1. Uterus rises upward in abdomen; as placenta proceeds downward, umbilical cord lengthens.

2. Sudden trickle of blood appears.

3. Uterus changes from discoid to globular shape.

C. Palpate uterus to check for ballooning of uterus caused by uterine relaxation with bleeding into uterine cavity.

D. Splint or support abdominal muscles as mother bears down to assist in delivering placenta.

E. Inspect placental membranes to be sure they are intact after delivery.

F. Palpate fundus of uterus—normal position is at midline and below umbilicus.

Maternal–Newborn Nursing: Stage 4

Focus Topic: Maternal–Newborn Nursing

Definition: From expulsion of placenta to a period of 1 to 4 hours after delivery or until vital signs are stable.

Assessment

A. Continually assess both mother and infant for first critical hour or two after birth.

1. Assess firmness and position of fundus and verify that it remains well contracted to ensure that mother has minimal bleeding.

2. Assess vital signs including blood pressure every 15 minutes.

3. Assess amount and character of vaginal blood flow.

B. Check that blood pressure returns to prelabor levels and pulse is slightly lower than during labor.

1. Return of blood pressure is due to increased volume of blood returning to maternal circulation.
2. Lowered blood pressure and rising pulse may reflect increased blood loss.

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