First Trimester week 0- 12 gestational age

Month 1
o Ovulation and conception
o During week 4 some home pregnancy tests will detect
o Embryo is two cells
Month 2
o Signs of preg: extreme fatigue, frequent urinartion, morning
sickness, and hormonal fluctuations
o Babys heart is beating
o Brain is formed
Month 3
o Embryo becomes fetus
o Decreased morning sickness
o Fetus size of plum
Women looking forward to changes that will be more noticeable
Prenatal monthly for first 7 months
Common discomforts
o N/V, breast tenderness, urinary frequency, UTI, fatigue, Braxton
Hicks contractions
Nutrition
o Patient should gain 1-2 kg during first trimester
Vitals
o B/P at prepregnancy range
Diagnostic Procedures
o Internal transvaginal ultrasound useful in clients who are obsess
and those in first trimester to detect: ectopic pregnancy,
abnormalities, and establish gestational age.
Causes of bleeding
o Spontaneous abortion
o Ectopic pregnancy
2-8
o majority of birth defects occur
10-12
o FHR can be heard by Doppler

Second Trimester week 12-28 gestational age

Month 4
o Babys bones are hardening and will now show up on Xray
o Baby is about 5 inches long and weighs about 5 ounces
Month 5
o Begin to feel baby kick
o Babys hearing starts to develop
o Common discomforts: backaches, indigestion, heartburn,
headaches, water retention, dizziness, constipation
Month 6
o Marks halfway mark in pregnancy!
o At end of this month baby is almost formed

Month 7
o Possible occurrences of Braxton Hicks contractions
o Brain is beginning to process sights and sounds
o Baby is about 13 inches long
Viability
o 20 weeks whether born or alive
Vitals
o BP decreases 5-10 mmHg during second trimester
Common discomforts
o heartburn, constipation, hemorrhoids, backaches, varicose veins
and LE edema
Nutrition
o Should gain approximately 0.4 kg (1lb)per week in last two
trimesters
o An increase of 340 calories is recommended during 2 nd trimester
Diagnostic Procedures
o Abdominal ultrasound is more useful after first trimester with gravid
uterus is larger
o 10-12 CVS can be performed
Causes of bleeding
o GTD
After 12 weeks
o fundal height
After 14
o Amniocentesis
16- 20
o Quickening
o FHR heard by ultrasound stethoscope
o Begin assessing fetal movement
15-22
o Maternal serum alpha-feto protein screening occurs. Used to rule
out Down Syndrome (low level) and neural tube defects (high level)
16-18
o Quad screen, a more reliable indicator of AFP, inhibin-A, a combo
analysis of HCG, and estriol
20
o BP returns to prepregnancy baseline
o Pulse increases 10-15 minutes and remains increased
o More distinguishable splitting of S1 & s2
18-32
o measurement of fundal height (approximates gestational age)
24-28
o Indirect Coombs Test for Rh- and not sensitized mothers repeated

Third Trimester week 28-40 gestational age

Month 8
o Baby is fully formed and putting on weight
o Babys lungs almost fully developed
Month 9
o Common discomforts: Braxton Hicks, pelvic pressure, difficulty
sleeping
Prenatal appointments every 2 weeks in the 8 th month & every week in the
last month
Term
o 38 weeks or more
Preterm
o 20 up to 37 weeks
Nutrition
o Should gain approximately 0.4 kg (1lb)per week in last two
trimesters
o An increase of452 calories is recommended
Common discomforts
o urinary frequency, UTI, fatigue, heartburn, constipation, backaches,
leg cramps, varicose veins and LE edema, increased intensity and
frequency of Braxton Hicks contractions
Diagnostic Procedures
o May be used in conjunction with abdominal scanning to evaluate for
preterm labor
o Nonstress Test performed
Causes of bleeding
o Placenta previa, abruptio placenta
36
o Top of uterus and fundus will reach xiphoid process
35-37
o GBS test

PostPartum
Nutrition
o Breastfeeding- an additional intake of 330 calories/day is
recommended during 1st 6 months
Additional intake of 400 calories a day during second 6
months

Folic acid- 500 mcg

Nursing Actions/Education throughout Pregnancy

Nutrition

Diagnostic Procedures
Ultrasound
Types:
o External abdominal U/S
Useful in first trimester with uterus gravid is larger
o Internal transvaginal U/S
Useful in obese clients and those in first trimester to detect
ectopic preg, ID abnormalities, & establish gestational age
o Doppler US blood flow analysis
Useful in IUGR and poor placental perfusion, and as an
adjunct in pregnancies at risk due to HTN, DM, multiple
fetuses, or PTL
Education:
o Advise client to drink 1-2 quarts of fluid prior to fill the bladder, lift
and stabilize uterus, displace bowel, and act as an echolucent to
better reflect waves
o Supine position with wedge placed under right hip to displace
uterus (prevent supine hypotension)
Education for transvaginalo Lithotomy position
o Pressure may be felt
Biophysical Profile (BPP)
Uses real time US to visualize physical and physiological characteristics of
fetus and observe for fetal biophysical responses to stimuli
Variables:
o Reactive FHR
o Fetal breathing movements
(at least 1 episode of greater than 30 duration 30 minutes)=2
o Gross body movements
(at least 3 body or limb extensions with return to flexion in
30 minutes)
o Fetal tone
(at least on3 episode of extension with return to flexion=2)
o Qualitative amniotic fluid volume (
at least one pocket that measures at least 2 cm in 2
perpendicular planes)
Findings:
o 8-10 Normal
o 4-6 Abnormal; suspect chronic fetal asphyxia
o <4 Abnormal; strongly suspect chronic fetal asphyxia

Potential dx:
o Nonreactive stress test
o Susp oligo or polyhydraminos
o Susp fetal hypoxemia or hypoxia
Presentation
o PROM
o Maternal infecion
o Decreased fetal mvt
o IUGR

Nonstress test (NST)

Most widely used for eval of fetal well being
3rd trimester
Allows nurse to assess FHR in relationship to fetal movement
Potential dx:
o Assessing for intact CNS in 3rd trimester
o Ruling out risk for fetal death in clients who have DM; used twice a
week or until after 28 weeks
Presentation
o Decreased fetal mvt
o IUGR
o Postmaturity
o Gestational DM
o Gestational HTN
o Maternal chronic HTN
o Hx of previous fetal demise
o Advanced maternal age
o Sickle cell disease
o Isoimmunization
Interpretation of findings
o Reactive- if FHR is at a normal baseline rate with moderate
variability, accelerates to 15 beats/min for at least 15 seconds and
occurs two or more times during a 20 minute period
o Nonreactive- Indicates FHR does not accelerate adequately with
fetal movement. Doesnt meet above criteria after 40 min. If so,
further eval needed (CST or BPP)
Nursing actions
o Reclining chair or semi-Fowlers, or left lateral position
o If fetus sleeping (no movements) vibroacoustic stimulation may be
activated for 3 seconds
Disadvantage- high rate of false nonreactive results due to fetal movement
response blunted by sleep cycles, fetal immaturity, maternal medications, and
chronic smoking

Contraction Stress Test (CST)

Nipple stimulation consists of woman lightly brushing her palm across nipple
for two minutes, causing pituitary gland to release endogeous oxytocin and
then stopping when contraction begins.
Analysis of FHR response to contractions (decrease placental blood flow)
determine how fetus will tolerate stress of labor
A pattern of at least 3 contractions within a 10 minute time period with a
duration of 40-60 seconds each must be obtained for assessment data
Hyperstimulation (contractions longer than 90 seconds or more frequent than
every 2 minutes should be avoided)
Oxytocin administered if fail
Interpretation
o A negative CST (normal) indicated if within 10 minute period, with 3
uterine contractions, there are no late decels of FHR
o Positive (Abnormal) indicated with persistent and consistent late
decelerations on more than half of the contractions.
Suggestive of uteroplacental insufficiency.
Variable deceleration- cord compression
Early decel- fetal head compression
o Based on findings, can determine to induce labor or Csec
Nursing Actions
o IV oxytocin
If hyperstimulation of uterus, or PTL occurs:
Monitor contractions lasting longer than 90 seconds
or occurring more frequently than every 2 min
Provide tocolytics
Maintain bed rest
Observe client for 30 min after to see contractions
have ceased and PTL doesnt begin
Amniocentesis
The aspiration of amniotic fluid for analysis by insertion of a needle
transabdominally into a clients uterus and amniotic sac under diret ultraound
guidance locating the placenta and determining position of fetus
After 14 weeks gestation
Indications:
o Previous birth with chromosome anomally
o Parent carrier
o Fam hx of neural tube defects
o Prenantal dx of genetic disorder
o Alpha fetoprotein level for fetal abnormalities
o Lung maturity assessment
o Fetal hemolytic disease

o Meconium in amniotic fluid

Interpretation
o AFP
Can be measured from amniotic fluid btw 16-18 weeks
May be used to assess for neural tube defects in fetus or
chromosome disorders
High levels- neural tube defects
Also present with normal multifetal pregnancies
Anencephaly- incomplete development of fetal skull
and brain
Spina bifida- open spine
Omphalocele- abdominal wall defect
Low levels
Chromosomal disorders (downs) or GTD (molar)
o Tests for fetal lung maturity
Can be done if gestation is less than 37 weeks, in the event
of ROM, PTL, or complication indicating Csec
Determines whether fetal can live outside or if needs to be
inj with glucocortcoids to enhance lung maturity
Lecithin/spingomyelin (L/S ratio)
2:1 ratio indicating fetal lung maturity
Presence of phosphatidylglycerol (PG)
Absence associated with fetal respiratory distress
Nursing actions
o Empty bladder prior
o Prior to procedure obtain FHR, baseline V/S
o Supine position with wedge
o Continue breathing because holding her breath with lower
diaphragm against uterus and shift intrauterine contents
o Monitor VS, FHR, and uterine contractions through and 30 min
following procedure
o Have client rest 30 min
o Administer rhogam to rho Post procedure- drink plenty of liquids and rest 24 hours pp

Percutanous Umbilical Blood Sampling (High Risk Pregnancy)

Most common method used for fetal blood sampling and transfusion
Interpretation
o Evaluates for isoimmune fetal hemolytic anemia and assesses
need for fetal blood transfusion
Complications
o Cord laceration, PTL, amnionitis, hematoma, fetomaternal
hemorrhage

Chorionic Villus Sampling (High Risk Pregnancy)

Assessment of a portion of the developing placenta which is aspirated
through a thin sterile catheter or syringe inserted through the abdominal wall
or intravaginally though cervix
First trimester alternative to amniocentesis (advantage-early diagnosis of
abnormalities)
Can be performed 10-12 weeks gestation and rapid results in 24-28 hr
Cannot determine spina bifida or anencephaly
Nursing Action
o Fill bladder prior
Complications
o Spontaneous abortion (higher risk than with amniocentesis)
o Risk for fetal limb loss
o Miscarriage
o Chorioamnionitis and rupture of mems
Advantage should be weighed heavier than disadvantage
Quad Marker and Alpha Fetoprotein (AFP) Screening
Quad marker
o blood test that ascertains information about the liklihood of fetal
birth defects.
o Does not diagnose actual defect
o More reliable findings than AFP
o hCG- hormone by placenta
o AFP- protein produced by fetus
o Estriol- protein produced by fetus and placenta
o Inhibin A- protein produced by ovaries and placenta
o 16-18 weeks gestation
o Low levels AFP Downs risk
o High levels AFP neural tube defect risk
o Higher levels than expected of hCG and inhibin A- risk for downs
o Lower levels than expected of estriol- risk for downs
Maternal serum alpha fetoprotein
o Screening tool used to detect neural tube defects
o Abnormal findings- refer for quad marker screening, genetic
counseling, US, and amniocentesis
o All preg clients 16-18
o High levels- neural tube
o Low levels- downs
Bleeding During Pregnancy

Spontaneous Abortion
Ectopic Pregnancy
Gestational Trophoblastic Disease
Placenta Previa
Abruptio placenta

Infections
HIV/AIDS
TORCH infections
Group B streptococcus B Hemolytic
Chlamydia
Gonorrhea
Candida Albicans
Medical Conditions
Incompetent Cervix (Recurrent premature dilation of cervix)
Hyperemesis Gravidarum
Anemia
Gestational DM
Gestational HTN
Early Onset of Labor
Preterm Labor
o Uterine contractions that occur between 20-37 weeks gestation
Premature Rupture of Membranes & Preterm Premature rupture of
membranes

Labor and Delivery Process

When assessing amniotic fluid post rupture, amniotic fluid should be watery,
clear, and pale to straw yellow in color
o Odor should not be foul

o Volume should be between 500-1200 mL

o Nitrazine paper used to confirm presence
Amniotic fluid is ALKALINE
Paper should be deep blue, indicating a pH of 6.5-7.5
Urine slightly acidic- paper remains yellow
Five Ps (Factors) Affect and Define Labor and Birth Process:
o Passenger: Consists of the fetus and placenta. The size of the fetal
head, presentation, lie, attitude, and position affect the ability of the
fetus to navigate the birth canal
Presentation: Part of fetus that is entering pelvic inlet first.
It can be the back of the head (occiput), chin
(mentum), shoulder (scapula), or breech (sacrum or
feet)
Lie: The relationship of the maternal longitudinal axis (spine)
to the fetal longitudinal axis (spine)
Transverse: fetal long axis is horizontal and forms a
right angel to maternal axis and will not accommodate
vaginal birth. The shoulder is the presenting part and
may require Csec if doesnt rotate spontaneously
Parallel or longitudinal: Fetal long axis is parallel to
maternal long axis, either a cephalic or breech
presentation. Breech may require Csection.
Attitude: Relationship of fetal body parts to one another
Fetal flexion: chin flexed to chest, extremities flex into
torso
Fetal extension: chin extended away from chest,
extremities extended
Fetopelvic or fetal position: The relationship of the
presenting part of the fetus, preferably the occiput, in
reference to its directional position as it relates to 1 of the 4
maternal pelvic quadrants. Labelled with 3 letters
First letter- either R or L side of maternal pelvis
Second letter- references the presenting part of the
fetus, O (occiput), S (sacrum), M (mental), or scapula
(Sc)
Third letter either A (anterior), P (posterior), or T
(transverse) part of maternal pelvis
Station: measurement of fetal descent in cm with
station 0 being at the level of an imaginary line at the
level of the ischial spines, minus stations superior to
the ischial spines, and plus stations inferior to the
ischial spines
o Passageway: The birth canal that is composed of the bony pelvis,
cervix, pelvic floor, vaginal, and introitus (vaginal opening). The size

and shape of the bony pelvis must be adequate to allow the fetus to
pass through it. The cervix must dilate and efface in response to
contractions and fetal descent
o Powers: uterine contractions cause effacement and dilation of the
cervix and descent of the fetus. Involuntary urge to push and
voluntary bearing down in the second stage of labor helps in
expulsion of the fetus.
o Position: of the woman who is in labor. The client should engage in
frequent position changes during labor to increase comfort, relieve
fatigue, and promote circulation. Position during the second stage
is determined by maternal preference, provider preference, and the
condition of the mother and fetus.
Gravity can aid in the fetal descent in upright, sitting,
kneeling, and squatting positions.
o Psychological responses: maternal stress, tension, and anxiety can
produce physiologic changes that impair progress of labor
Nursing Interventions for Labor and Birth
Preprocedure
o Leopold maneuvers: abdominal palpation of the number of fetuses,
the fetal presenting part, lie, attitude, descent, and the probably
location where fetal heart tones may be best ausculatated on the
womans abdomen
o External electronic monitoring (tocotransducer): separate
transducer applied to the maternal abdomen over the fundus that
measures uterine activity
Displays uterine contraction patterns
Easily applied by nurse but must reposition with maternal
movement to ensure proper placement
o External fetal monitoring (EFM): transducer applied to the abdomen
of the client to assess FHR patterns during labor and birth
o Labs
Group B Strep 36-37 weeks
If + IV prophylaxis antibiotic is prescribed
Urinalysis (clean catch)
Hydration status via specific gravity
Nutritional status via ketones
Proteinuria, indicative of gestational hypertension
UTI via bacterial count
Blood tests
Hct level
ABo typing and Rh if not done
Intraprocedure
o Assess maternal VS
Maternal membranes every 1-2 hours if ruptured

o Assess FHR to determine fetus well being. May be performed with

use of EFM of spiral electrode applied to scalp.
Prior to electrode placement, cervical dilation and ROM must
occur
o Assess uterine labor contraction characteristics by palpation (hand
over fundus to assess contraction frequency, duration, and
intensity) or by the use of external or internal monitoring
Frequency: beginning of one contraction to beginning of next
Duration: time between beginning of a contraction to end of
that same contraction
Intensity: strength of contraction at its peak (mild, moderate,
strong)
Resting tone of uterine contraction: tone of uterine muscle
between contractions
A prolonged contraction duration (longer than 90
seconds) or too frequent (more than 5 in 10 min
period) withoutsufficient time for uterine relaxation
(less than 30 seconds) can reduce blood flow to
placenta. This can result in fetal hypoxia or decreased
FHR.
o Insert sold, sterile, water-filled intrauterine pressure catheter inside
uterus to measure intrauterine pressure
Uterine contractions displayed on monitor
Requires ROM and cervix sufficiently dilated
o Vag exam- performed digitally to assess:
Cervical dilation (stretching of cervical os adequate to allow
fetal passage) & effacement (cervical thinning and
shortening)
Descent of fetus through birth canal as measured by fetal
station in cms
Fetal position, presenting part, lie
Membranes intact or ruptured
Mechanisms of Labor: adaptions fetus makes as it progresses through birth
canal
o Engagement: when presenting part, usually biparitetal (largest)
diameter of the fetal head passes the pelvic inlet at the level of the
ischial spines. Referred to as station 0.
o Descent: the progress of the presenting part (preferably occiput)
through the pelvis. Measured by station during vag exam as either
negative station measured in cms if superior to station 0 and not
yet engaged, or + station measured in cms if inferior to station 0.
o Flexion: when the fetal head meets resistance of the cervix, pelvic
wall, or pelvic floor. The head flexes, bringing the chin close to the
chest, presenting a smaller diameter to pass through the pelvis.

o Internal rotation: the fetal occiput ideally rotates to a lateral anterior

position as it progresses from the ischial spines to the lower pelvis
in a corkscrew motion to pass through the pelvis
o Extension: the fetal occiput passes under the symphysis pubis, and
then the head is deflected anteriorly and is born by extension of the
chin away from the fetal chest
o Restitution and external rotation: after the head is born, it rotates to
the position it occupied as it entered the pelvic inlet (restitution) in
alignment with the fetal body and completes a quarter turn to face
transverse as the anterior shoulder passes under the symphysis
o Expulsion: after birth of head and shoulders the trunk of the
neonate is born by flexing it toward the symphysis pubis

Stages of Labor

o First Stage
Duration: 12.5 hr
Begins with: Onset of labor
Ends with: Complete dilation
Maternal characteristics: Cervical dilation 1 cm/hr for
primigravida, and 1.5 cm/hr multigravida (on average)
o Latent Phase
Duration:
Primigravida: 6 hr
Multigravida: 4 hr
Begins with:
Cervix 0 cm
Irregular, mild to moderate contractions
Frequency 5-30 min
Duration 30-45 seconds
Ends with: Cervix 3 cm
Maternal characteristics: Some dilation and effacement,
talkative and eager
o Active Phase
Duration:
Primigravida: 3 hr
Multigravida: 2 hr
Begins with:
Cervix: 4 cm
More regular, moderate to strong contractions
Frequency 3-5 min
Duration 40-70 seconds
Ends with:
Cervix dilated 7 cm
Maternal characteristics:
Rapid dilation and effacement
Some fetal descent
Feelings of helplessness
Anxiety and restlessness increase as contractions
stronger
o Transition
Duration:
20-40 min
Begins with:
Cervix 8 cm
Strong to very strong contractions
Frequency 2 to 3 min

 Duration 45-90 seconds

Ends with: Complete dilation at 10 cm
Maternal characteristics:
Tired, restlessness, irritable
Feeling out of control, cannot continue!
N/V
Urge to push
Increased rectal pressure and feelings of needing to
have a BM
Increased bloody show
Most difficult part of labor
Sources of pain:
Internal visceral pain that may be felt as back or leg
pain, caused by
o Dilation, effacement, and stretching of cervix
o Distention of lower segment of uterus
o Contractions of uterus with resultant uterine
ischemia
o Second Stage
Duration:
Primigravida: 30 min-2 hr
Multigravida: 5-30 min
Begins with:
Full dilation
Progresses to intense contractions every 1-2 min
Ends with: Birth
Maternal characteristics: Pushing results in birth of fetus
Pain:
Somatic and occurs with fetal descent and expulsion.
Caused by
o Pressure and distension of vagina and
perineum described as burning, splitting, and
tearing
o Pressure and pulling on pelvic structures
(ligaments, fall tubes, ovaries, bladder, and
peritoneum)
o Laceratons of soft tissue
o Third Stage
Duration: 5-30 min
Begins with: Delivery of neonate
Ends with: Delivery of placenta
Maternal characteristics:
Placental separation and expulsion

Schultze presentation: shiny fetal surface of placenta

emerges first
Duncan presentation: dull maternal surface of
placenta emerges first

Pain:
Pain with expulsion of placenta is similar to pain
experienced during the first stage. Caused by
o Uterine contractions
o Pressure and pulling of uterine structures
o Fourth Stage
Duration: 1-4 hour
Begins with: Delivery of placenta
Ends with: Maternal stabilization of VS
Maternal characteristics:
Achievement of VS homeostasis
Lochia scant to moderate rubra
Pain:
Caused by distention and stretching of vagina and
perineum incurred during the second stage with a
splitting, burning, and tearing sensation
Maternal VS q 15 min for first hour then according to
protocol
Assess fundus and lochia q 15 min for first hr.
Massage uterine fundus and or administer oxytocies as
prescribed to maintain uterine tone to prevent hemorrhage
Assess perineum and provide comfort measures as needed
Encourage voiding to prevent bladder distension
bonding

Pain Control
non pharmalogical
o Gate control theory of pain
Sensory strategies
Cutaneous strategies
Effleurage: light gentle circular stroking of pts
abdomen with fingertips in rhythm with breathing
during contractions
Sacral counterpressure: consistent pressure applied
by support person using heel of hand or fist against
sacral area to counteract pain in lower pact
Hydrotherapy increases endorphin levels
o Frequent maternal position changes to promote relaxation and pain
relief: semi-sitting, squatting, kneeling, kneeling and rocking back

and forth, supine position only with placement of wedge under one
of hips to tilt uterus and avoid hypotension
Pharmacological
o Analgesia
Opiod analgesics
Sedatives (barbituates) such as secobarbitual,
pentobarbitual, and phenobaritual, NOT USED
DURING BIRTH, BUT DURING ACTIVE OR LATENT
PHASE TO RELIEVE ANXIETY AND INDUCE SLEEP
Adverse effects of sedatives:
o Neonate respiratory depression secondary to
med crossing plcenta and affecting fetus.
Should not give 12-24 hr
o Unsteady walking
o Inhibition of ability to cope with labor
Meperidine hydrochloride (Demerol), fentanyl
(sublimaze), butorphanol (stadol), and nalbuphine
(Nubain) act in CNS to decrease perception of pain
without loss of consciousness. IV or IM.
o Butorphanol and nalbuphine provide pain releft
without causing significant respiratory
depression
o Adverse effects:
Prior to administering, ensure labor is established,
perform V exam and cervical dilation at least 4 cm
and fetus well engaged
Administer antiemetics
Monitor maternal VS, uterine contraction pattern, and
continue FHR monitoring
Naloxone (Narcan)
Opioid antagonist for reversal of opioid reduced
respiratory depression
Ondansetron (Zofran)
o Epidural and spinal regional analgesia
Consist of Fentanyl (Sublimaze) and sufentanil (Sufenta)
which are short acting opiods that are administered as a
motor block into the epidural or intrathecal space without
anesthesia. Produce regional anagsic providing rapid pain
relief while allowing pt to sense contractions and maintain
ability to bear down
Adverse effects
Pharmacological Anesthesia
o Regional blocks
Most common

Pudendal block
Consists of local anesthetic administered
transvaginally into the space in front of the pudendal
nervea

Additional
Urine output should exceed 30 mL/hr
Serum magnesium maintenance level is 4-7 mEq
Uric acid range 2-6.6mg/dl
Fetal heart tones of fetus in L sacrum anterior position- LUQ
FHT R sacrum anterior position - Right upper quadrant
FHT of fetus in left occipital anterior best heard LLQ
FHT of fetus n right occipital anterior position RLQ