Maternity

Archer Review Crash Course

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Introduction
● Morgan Taylor, BSN, RN, CCRN
● Pediatric nurse at heart
● Units I’ve worked on:
○ PICU
○ PCICU
○ NICU
○ Mother-Baby
○ ED
○ Bone Marrow Transplant
● Current position: Children’s Resource Unit… a little bit of everything
pediatrics!
● Fun fact: I got married in my backyard this year because….COVID. My
niece and nephew totally stole the show!

Terminology
● Gestation
○ The time between conception and birth.
○ 40 weeks
● Gravida
○ A pregnant woman
● Gravidity
○ Number of pregnancies
● Parity
○ Number of births carried to viability
● Nullipara - never given birth; multipara - given birth multiple times
● LMP
○ Last Menstrual Period
 Naegele's Rule

Naegele's Rule
● Used to estimate the delivery date

First day of
last 7 days 3 months 1 year
menstrual
period

= estimated due
date
May 21st, 2019

7 days 3 months 1 year

5-21-2019
5-28-2019 2-28-2019 2-28-2020

= February 28th,
2020

GTPAL
Gravidity
● G - Gravidity
● The number of pregnancies, including the current one
● Twins only count once! It was ONE pregnancy!

Term
● T - Term
● Number of pregnancies carried to term
● Term - 37+ weeks gestation
● Twins only count once!
Preterm
● P - Preterm
● Number of preterm births
● These are births between 20 and 37 weeks gestation
● Twins only count once!

Abortions
● A - Abortions
● Number of pregnancies ending in abortion
○ Spontaneous
■ Miscarriages
○ Termination
● If the abortion or miscarriage was after 20 weeks gestation, it also counts
for partiy under P.
● If it was before 20 weeks, only count it in A.
Living Children
● L - Living children
● This is the current number of children alive.
● Twins will count twice here.

Determine the GTPAL of the following patient

42 year old female in her second trimester. She has 4 previous pregnancies.
Her first two children were born at 39 and 37 weeks. Her second child was
born at 35 weeks. Her fourth child was miscarried at 22 weeks and did not
survive.
42 year old female in her second trimester. She has 4 previous pregnancies.
Her first two children were born at 39 and 37 weeks. Her second child was
born at 35 weeks. Her fourth child was miscarried at 22 weeks and did not
survive.

G5 T2 P1 A1 L3

Determine the GTPAL of the following patient

A 29 year old patient with a history of 2 miscarriages at 8 and 18 weeks, twins
born at 34 weeks that are still living, and is currently in her 3rd trimester with
a singleton pregnancy.
A 29 year old patient with a history of 2 miscarriages at 8 and 18 weeks, twins
born at 34 weeks that are still living, and is currently in her 3rd trimester with
a singleton pregnancy.

G4 T0 P1 A2 L2

Signs of Pregnancy
Presumptive signs
● Amenorrhea
● Nausea
● Vomiting
● Enlarged breasts
● Urinary frequency
● Fatigue
● Quickening
● Positive home pregnancy test

Probable signs
● Ballottement
● Chadwick’s sign
○ Blue discoloration of cervix
○ Present at 4 weeks
● Goodell’s sign
○ Softening of the cervix
○ Present at 2 months
● Hegar’s sign
○ Softening of the lower uterine segment
○ Present at 4-6 weeks
● Uterine enlargement
● Braxton Hicks
● Positive blood pregnancy test
Positive signs
● Fetal movement detected by health care provider
● Ultrasound
● Fetal heartbeat

Antepartum
Testing
Routine exams done for everyone
● Blood type/Rh factor
● STI testing
● Glucose challenge
● Urinalysis
● Ultrasound
● Nonstress test (NST)
● Group B Strep
● Kick counts

Blood type and Rh Factor

● Important to know the mother's blood type and if she is Rh positive or
negative.
● If the mother is Rh negative, and the baby is Rh positive, this is considered
a ‘set up’ and puts the infant at risk for erythroblastosis fetalis.
● Further testing needed if this is the case - after the baby is born.
○ Direct Coombs test
■ Performed on the newborn's blood sample
○ Indirect Coombs test
■ Performed on the mother’s blood sample
● Treatment = Rhogam
STI Testing
Test for STIs including:

● HIV
● HPV
● Herpes
● Gonorrhea
● Syphilis
● Chlamydia
● Trichomoniasis

Glucose Challenge 3 hour Glucose Tolerance Test

Oral Glucose Tolerance Test
● Done if the 1 hour test is failed or there
● Done at 28 weeks are other risk factors.
● Mother drinks 50 grams of ● It is done fasting; mothers must not eat
glucose in an oral solution or drink for 8 hours prior to the test.
● 1 hour later her blood ● A fasting sugar is checked
● The mother drinks 100 grams of oral
sugar is checked.
glucose.
● If the BG is greater than
● Her BG is rechecked a 1 hour, 2 hours,
140, the 3 hours glucose
and 3 hours.
test is performed.
● A sugar greater than 140 indicates
gestational diabetes.
Urinalysis
● At each prenatal visit urine is dipped to check for:
○ Glucose
○ Protein
● Glucose indicates gestational diabetes and needs further work up
● Protein indicates preeclampsia and needs further work up

Ultrasound
● Each prenatal ultrasounds assess the fetus for:
○ Anatomy
○ If structures developing appropriately
○ Estimated gestational age
○ Blood flow to the placenta and fetus
● Ultrasounds also assess maternal anatomy:
○ Cervix
○ Placenta
Nonstress Test (NST)
● This test assesses fetal well-being and oxygenation of the placenta
● Evaluates if there are changes in the fetal heart rate with movement
○ Increase in fetal heart rate with movement = acceleration = good
○ Decrease in fetal heart rate with movement = deceleration = bad
■ This is a sign that the fetus will not tolerate labor.
● Results
○ Reactive
■ There are at least two accelerations of 15 beats per minutes for 15 seconds in a 20
minute period.
○ Non-Reactive
■ There are NOT at least two accelerations of 15 beats per minutes for 15 seconds in a
20 minute period.
● Further testing required if result is non-reactive
Group B Strep
● Tests for the presence of group beta streptococcus in the vagina
● Many women carry this bacteria and it can put the infant at risk for illness
after a vagnial delivery
● Tested with a simple swab of the vagina
● Usually done around 34 to 36 weeks.

Kick Counts
● Kick counts are performed by
the mother
● She is instructed to lie on her
left side for a 2 hour period and
count how often she feels the
baby kick.
● She is instructed to notify her
health care provider for less
than 10 kicks felt in a 2 hour
period.
Extra testing done if needed
● Contraction stress test
● Percutaneous umbilical blood sampling
● Alpha-fetoprotein screening
● Chorionic villus sample
● Amniocentesis
● Nitrazine test

Contraction Stress Test

● Preformed when the non-stress test is non-reactive.
● Pitocin is administered to induce contractions and the baby is monitored
to evaluate their response to contractions.
● Checking to see if the baby will tolerate labor, or show signs of stress.
● Results
○ Negative
■ Normal
■ The baby did not have decelerations in response to contractives
○ Positive
■ Bad
■ The baby had decelerations indicating distress in response to contractions.
Percutaneous Umbilical Blood Sampling
● Sample of fetal blood
obtained from umbilical cord.
● Blood can be tested for
several different things
○ Fetal anemia
○ Chromosomal defects
Alpha-fetoprotein screening
● This test uses only a sample of the mother's blood between 16 and 18
weeks.
● Measures the level of alpha-fetoprotein
○ This is a protein released by the liver
● High or low levels of alpha-fetoprotein can indicate
○ Neural tube defects - such as spina bifida
○ Down syndrome
○ Chromosomal abnormalities
○ Twins (due to the fact there is more than one baby making the protein)
● Not done on all mothers - done if one of these defects is suspected or
there is a history of it in the family.

Chorionic Villus Sample

● Chorionic villus is the fetal
placental tissue.
● This is an invasive procedure
where a catheter is inserted
through the vagina, into the
uterus, and samples of the
chorionic villus are taken.
● Checks for many different genetic
issues.
● If indicated, done between 11 and
14 weeks.
Amniocentesis
● This invasive procedure uses a
syringe guided by ultrasound to
take a sample of amniotic fluid.
● The amniotic fluid is tested for
genetic and metabolic issues.
● Can also check for issues with the
fetal lungs.
● Not done unless indicated.

Nitrazine Test
● If the mother notes fluid leaking from the vagina, a nitrazine test can be
performed to evaluate if it is simply vaginal secretions, or amniotic fluid
indicated ruptured membranes.
● Stip is dipped in the secretions - color change indicates the pH of the fluid.
● Blue color indicates amniotic fluid.
NCLEX Question
Which of the following are required for a nonstress test to be considered reactive? Select all that
apply.

a. Two increases in the fetal heart rate of 15 beats per minute

b. Two decreases in the fetal heart rate of 15 beats per minute
c. Two increases in the fetal heart rate for 15 seconds
d. Two decreases in the fetal heart rate for 15 seconds

Answer: A and C
A is correct. For a nonstress test to be reactive there must be two accelerations. An acceleration is defined as an
increase in fetal heart rate by 15 beats per minute, for at least 15 seconds with movement.

B is incorrect. Any decrease in fetal heart rate is a deceleration, which is an indicator of fetal distress and a
nonreassuring sign. Decelerations would lead to a nonreactive nonstress test.

C is correct. For a nonstress test to be reactive there must be two accelerations. An acceleration is defined as an
increase in fetal heart rate by 15 beats per minute, for at least 15 seconds with movement.

D is incorrect. Any decrease in fetal heart rate is a deceleration, which is an indicator of fetal distress and a
nonreassuring sign. Decelerations would lead to a nonreactive nonstress test.
NCSBN Client Need:
Topic: Health promotion and maintenance Subtopic: -

Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences.

Subject: Maternal and Newborn Health

Lesson: Antepartum
NCLEX Question
Which of the following are invasive procedures not routinely done on all pregnant women? Select all
that apply.

a. Contraction stress test

b. Amniocentesis
c. Nonstress test
d. Nitrazine test

Answer: A and B
A is correct. In a contraction stress test, contractions are induced with oxytocin. This is only done if a
nonstress test is nonreactive, or there are other concerns.

B is correct. An amniocentesis is a sampling of amniotic fluid that is sent for genetic testing. This is only done
if indicated.

C is incorrect. A nonstress test is noninvasive and done as routine antepartum testing.

D is incorrect. While a nitrazine test is not routinely done on all pregnant women, it is not invasive. This is a
testing of the pH of vaginal secretions to determine if they are amniotic fluid and there have been rupture of
membranes. This is only done if needed. It is non-invasive.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological adaptation

Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. Elsevier Health Sciences.

Subject: Maternal and Newborn Health

Lesson: Antepartum
 Break! Back at...

High Risk Pregnancy Conditions

 Chorioamnionitis

What is Chorioamnionitis?
● A bacterial infection of the amniotic cavity
● Causes
○ Invasive procedures
■ Amniocentesis
■ Cervical exams
■ PROM
● Complications
○ Endometritis
○ Sepsis
Assessment findings
● Temp > 100.4F
● Leukocytosis (WBC > 10,000)
● Tachycardia
● Malodorous amniotic fluid
● Fetal tachycardia

Therapeutic Management
● Blood cultures BEFORE
antibiotics
● Blood cultures from baby if
occurs close to delivery
 Gestational Diabetes

What is Gestational Diabetes?

● GDM - Gestational Diabetes Mellitus
● Diabetes diagnosed during pregnancy
● Pancreas unable to deal with the increased insulin requirements of
pregnancy
○ Increased insulin resistance secondary to hormones released during pregnancy
○ Change in carbohydrate metabolism
Risk Factors

Assessment
● Screen for GDM at prenatal visits
○ Glucose tolerance test at 24-28 weeks
● Screen for ketonuria and proteinuria
Potential complications

Therapeutic Management
● Control with diet and exercise
● Monitor blood glucose
○ Mother should not require insulin after
delivery
○ Neonate at risk for hypoglycemia
● For baby:
○ Fetal pancreas produces its own insulin Macrosomia = >4,000g (8.8 ish lbs)
○ Was used to high levels of glucose in
mothers blood
○ After delivery, no longer has high glucose
levels, but still producing that much insulin.
 Disseminated Intravascular Coagulation
(DIC)

What is DIC?
A serious disorder in which the proteins that control blood clotting become
overactive.
Triggers
● Blood transfusion
● Cancer
● Pancreatitis
● Liver disease
● Severe tissue injury
○ Burns
○ Head injury
● Pregnancy complication

Assessment
Clotting → Where the clot goes
Bleeding
Ecchymosis ● Lungs/Heart
Hematomas ○
○
Chest pain
Dyspnea
Hemoptysis ○ SOB
Melena ● Legs
Pallor ○
○
Pain
Redness
Hematuria ○ Warmth
○ Swelling
● Brain
○ Headache
○ Speech changes
○ Paralysis
○ Dizziness
 Lab Findings

Treatment
● Determine underlying cause and TREAT
● Administer clotting factors
● Administer platelets
● Bleeding precautions
NCLEX Question
The nurse in the Intensive Care Unit notes bleeding from the client’s
transparent dressing over her peripheral intravenous site, gum bleeding, and
frank blood in the urine. The client was originally admitted for Sepsis. What
should be the nurses immediate next action?

a. Assess the client’s hemoglobin and hematocrit level

b. Check the client’s oxygen saturation.
c. Apply pressure to the intravenous site.
d. Call the physician

Answer: D
Choice D is correct. The client is manifesting signs of Disseminated Intravascular Coagulation (DIC). This is a critical complication that often
happens in the intensive care unit and usually is secondary to other serious etiologies such as Sepsis. In this condition, the clotting system is
activated significantly and leads to the consumption of platelets and clotting factors. DIC can manifest with either bleeding or clotting
complications. Thrombocytopenia (low platelet count), coagulopathy (increased prothrombin time, increased partial thromboplastin time,
decreased fibrinogen), and hemolysis are hallmarks of DIC. In the absence of any significant bleeding, transfusing platelets or clotting factors
may fuel the thrombotic process in DIC. Therefore, Platelets, cryoprecipitate, and Fresh Frozen Plasma are not routinely injected in DIC unless
there is significant bleeding. The client is bleeding from multiple sites. The nurse must call the physician first to initiate medical interventions,
which may include ordering labs to confirm DIC, transfusing platelets, or infusing clotting factors.

Choice A is incorrect. DIC is a consumption coagulopathy and also causes intravascular hemolysis. Intravascular small clots (microthrombi)
form due to activation of the coagulation pathway in DIC. Red blood cells may rub against these thrombi leading to hemolysis. Fragmented
red blood cells (schistocytes) can be seen in DIC due to this hemolysis. Hemolysis causes a drop in hemoglobin and hematocrit (Anemia). The
nurse should undoubtedly check the client's Hemoglobin and Hematocrit levels; however, the nurse needs to notify the physician right away
since the client is showing bleeding signs of DIC.

Choice B is incorrect. Assessing the client’s oxygen saturation may also be performed later. The client is not in apparent respiratory distress
based on the information presented. Hypoxia is not the cause of his bleeding complications. DIC should be suspected in this bleeding, septic
patient and the nurse must notify the physician immediately since urgent intervention is needed

Choice C is incorrect. The client is bleeding from multiple sites. The application of pressure to the intravenous site alone will not help stop the
bleeding from other websites. DIC is a consumption coagulopathy. All the clotting factors and platelets are being used up in the clotting
process. Therefore, the bleeding complications of DIC would necessitate platelets and clotting factor infusion.
 Ectopic Pregnancy

What is an Ectopic Pregnancy?!

● Ectopic = out of place
● An egg is fertilized, but impants outside of the uterine cavity
○ Fallopian tube
○ Cervix
○ Abdomen
Therapeutic Management
● PREVENT rupture!!
○ Detect with US
○ Surgically removed
● Methotrexate
○ Stops the embryo from being able to
grow
○ Aborts the fetus
● Rh immune globulin
○ Given to mom if she is Rh negative
○ Prevent erythroblastosis fetalis
■ Don’t know Rh type of fetus
■ Better safe than sorry!

Hyperemesis Gravidarum
What is Hyperemesis
Gravidarum?
● Extreme ‘morning sickness’
● INTENSE, intractable,
nausea AND vomiting
during pregnancy

Risk factors
When to be concerned
● Are they losing weight?
● Are they dehydrated?
○ Skin turgor
○ Mucous membranes
○ HR
● Electrolytes
○ Dehydration → hypernatremia
○ Vomiting excessively → hypokalemia, hypochloremia

Therapeutic management
● Dietary changes
○ Sit up after meals
○ Eat a few crackers before getting out of bed
○ Small portions
○ No liquids with meals; drink in between
○ Nothing spicy, too hot, or too cold…. Keep it simple
● Medications
○ Ondansetron
○ Promethazine hydrochloride
● IVF
● TPN/IL
 Gestational Hypertension

What is gestational hypertension?

● The blood pressure is consistently elevated to greater than 140/90 after
20 weeks gestation.
● Major concern = preeclampsia
Therapeutic Management
● PREVENT progression to preeclampsia
○ Decrease salt intake
○ 8 hours of sleep per night
○ Exercise
○ No alcohol, caffeine, or junk food
○ 6-8 oz water/day
○ Prenatal vitamins
● Monitor closely
○ Check urine for protein
○ Fetal growth/activity

When to call the doctor?

● Headache
● Blurred vision
● Increased swelling
Preeclampsia
What is preeclampsia?
● >20 weeks gestation
● Blood pressure >140/90
○ 2 times
○ 4 hrs apart
● Protein in the urine

Assessment
● Edema
○ Hands
○ Face
● Weight gain
○ Fluid
● Headache
● Abdominal pain
● Blurry vision
● Proteinuria
Therapeutic management
● Delivery
● Prepare for a preterm baby
○ Mag sulfate → prevent seizures in mom
○ Betamethasone → Help develop baby’s lungs
● Antihypertensives…..
Antihypertensives during pregnancy
YES NO
● Labetalol ● ACE- INHIBITORS
● Methyldopa ● ARBs
● Nifedipine ○ Can cause oligohydramnios, fetal
● Hydralazine growth restriction, and more!

HELLP Syndrome
What is HELLP syndrome?
H Hemolysis
E Elevated
L Liver enzymes
L Low
P Platelet count

H Hemolysis
● Rupturing of blood cells
● Can be detected several ways:
○ Abnormal peripheral blood smear
○ Elevated serum bilirubin
○ Low serum haptoglobin
○ Significant drop in H&H (not related to blood loss)
○ Low RBCs
E Elevated L Liver enzymes
● AST or ALT > 2x normal
○ Normal <40

L Low P Platelet count

● <100,000
Assessment
● Low platelets → petechiae
● Anemia → headache, tachycardia
● Elevated liver enzymes → nausea, vomiting

Therapeutic Management
 Obstetrical
Procedures

Induction of Labor
● Using medication to cause labor to begin
● Can only be done if the baby is stable and a vaginal delivery is planned
and safe.
● Medication used to stimulate contractions - oxytocin.
● Must monitor contractions while on oxytocin; if there are too long (greater
than 1.5 minutes) or too close together (less than 2 minutes apart), the
baby is not getting enough oxygen and the oxytocin should be
discontinued.
Amniotomy
● Using a hook or the finger to break
the amniotic sac.
● “Breaking the water”
● This helps stimulate labor and can
make pushing more efficient if the
mother is fully dilated.
● Observe the color, odor, and
condition of the amniotic fluid.
● Malodorous fluid can indicate an
infection.

Episiotomy
● Done if the opening is not large
enough to accomodate the fetus
at the end of a vaginal delivery.
● An incision is made in the vagina
to make the opening larger.
● This allows the fetus to exit the
birth canal.
Forceps-Assisted Delivery
● Forceps are a tool used if there is
difficulty delivering the head of
the baby.
● Manual pressure used to help
pull baby out.
● Must be mindful to monitor for
injury; laceration to skull of baby
or vaginal tissue of mother.
● Also puts the mother at risk for
PPH

Vacuum-Assisted Delivery
● Another technique that can be
used to aid in the delivery of the
head of the baby.
● Suction is applied to the head of
the baby and pulled while the
mother pushes.
● No more than three attempts
○ Called “pop offs”
● Assess skull of infant and monitor
for trauma.
External Version
● This is a technique used when the
baby is not in an appropriate
position for vagnial delivery.
● We want the baby to be cephalic,
or head down.
● If the baby is breach, external
version can be used to try and
more the baby into the cephalic
position for a vaginal delivery.

Caesarean Section
● If vaginal delivery is not safe, infant is unstable or unable to tolerate a
vaginal delivery, a caesarean section will be performed to remove the
fetus surgically.
NCLEX Question
Which of the following obstetrical procedures can be used to assist in the delivery of the head of the
fetus during a vaginal delivery? Select all that apply.

a. Amniotomy
b. Forceps assisted delivery
c. External version
d. Vacuum assisted delivery

Answer: B and D
A is incorrect. An amniotomy is the use of a hook or finger to break the amniotic sac. This helps stimulate
labor but does not assist in the delivery of the head of the fetus.

B is correct. Forceps are tools used to help pull on the head of the baby to assist with the delivery.

C is incorrect. External version is a technique used when the baby is not in an appropriate position for
vagnial delivery. It may help prepare the baby for a vagnial delivery, but does not assist in the delivery of the
head of the fetus.

D is correct. Vacuum assisted delivery is a method where suction is applied to the head of the baby and
pulled while the mother pushes. This helps to deliver the head of the infant.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Risk potential reduction

Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. Elsevier Health Sciences.

Subject: Maternal and Newborn Health

Lesson: Labor and delivery
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