Maternal and Newborn Nursing

Maternal and newborn nursing is the care of the childbearing person, the fetus, and the newborn across four phases: antepartum (pregnancy), intrapartum (labor and birth), postpartum (the six weeks after birth), and the neonatal period (birth through 28 days). This article is the shared core content for both the NCLEX-RN and NCLEX-PN tracks. Track-specific practice questions and flashcards are linked from Category:Maternal and Newborn Nursing.

A theme runs through everything below: in obstetrics you are assessing two patients, and normal physiology masks early deterioration. A healthy pregnant person compensates so well that vital signs may stay near normal until roughly 1,500 mL of blood has been lost. That is why maternity nursing depends so heavily on serial, structured, hands-on assessment rather than on waiting for vital signs to change.

Terminology and Obstetric History

• Gravida - number of pregnancies, regardless of outcome. Para - number of pregnancies carried to 20 weeks or beyond, whether the fetus was born alive or not. Para counts pregnancies, not babies, so twins delivered at 36 weeks count as para 1.
• GTPAL - Gravida, Term births (37 0/7 weeks and beyond), Preterm births (20 0/7 through 36 6/7 weeks), Abortions or losses before 20 weeks (spontaneous or induced), Living children.
• Nulligravida never pregnant; primigravida pregnant for the first time; multigravida pregnant more than once. Nullipara, primipara, multipara apply the same way to births at 20 weeks or more.
• Viability is generally discussed around 22 to 24 weeks with neonatal intensive care, though outcomes vary widely by gestational age, weight, and center.

Naegele's rule estimates the due date: take the first day of the last menstrual period, subtract 3 months, add 7 days, and add 1 year. It assumes a regular 28-day cycle with ovulation on day 14, so it is less reliable with irregular cycles. First-trimester ultrasound dating is more accurate than any calculation.

Signs of pregnancy

• Presumptive (subjective, felt by the patient, can have other causes): amenorrhea, nausea and vomiting, breast tenderness, urinary frequency, fatigue, quickening.
• Probable (objective, observed by an examiner, still not conclusive): positive pregnancy test (hCG can also rise with gestational trophoblastic disease), Goodell sign (cervical softening), Chadwick sign (bluish-violet cervix and vagina), Hegar sign (softening of the lower uterine segment), Braxton Hicks contractions, ballottement, uterine enlargement.
• Positive (only explainable by pregnancy): fetal heart tones heard by an examiner, fetal movement palpated by an examiner, and visualization of the fetus on ultrasound.

Application note. A patient can have a positive home test and still not have an intrauterine pregnancy. Any positive test with unilateral pelvic pain, shoulder pain, or bleeding raises concern for ectopic pregnancy and needs urgent evaluation.

Physiologic Adaptations of Pregnancy

Cardiovascular and hematologic

• Blood volume rises roughly 40 to 50 percent; plasma volume rises proportionally more than red cell mass, producing physiologic (dilutional) anemia of pregnancy. Hemoglobin below about 11 g/dL in the first and third trimesters, or below about 10.5 g/dL in the second, suggests true anemia.
• Cardiac output rises about 30 to 50 percent, mostly from increased stroke volume early and heart rate later. Resting pulse increases roughly 10 to 15 beats per minute.
• Blood pressure falls in the first and second trimesters because systemic vascular resistance drops, reaching a nadir near mid-pregnancy, then returns toward the prepregnancy baseline near term. A blood pressure that rises after 20 weeks is never dismissed as normal pregnancy change.
• Pregnancy is a hypercoagulable state (increased fibrinogen and clotting factors, decreased fibrinolysis). This limits hemorrhage at delivery but raises venous thromboembolism risk throughout pregnancy and especially postpartum.
• Supine hypotensive syndrome (aortocaval compression): after about 20 weeks the gravid uterus compresses the inferior vena cava when the patient lies flat, dropping venous return, cardiac output, and uteroplacental perfusion. Signs are dizziness, pallor, nausea, hypotension, and a nonreassuring fetal heart rate. Intervention: turn the patient to a lateral position, classically left lateral. This is the single most common test answer for maternal hypotension or a sudden fetal heart rate change in a supine patient.

Respiratory

Progesterone increases tidal volume and minute ventilation, creating a compensated respiratory alkalosis with a lower normal PaCO2 (roughly 27 to 32 mm Hg). Oxygen consumption rises about 20 percent and functional residual capacity falls, so a pregnant patient desaturates fast during apnea. Dyspnea on exertion and nasal stuffiness are common and benign; dyspnea at rest, orthopnea, or chest pain is not.

Renal and gastrointestinal

Glomerular filtration rate rises about 50 percent, so normal serum creatinine and BUN are lower than in the nonpregnant adult; a creatinine of 1.1 mg/dL that would be unremarkable otherwise is abnormal in pregnancy. Ureteral dilation and urinary stasis raise the risk of pyelonephritis, which is why asymptomatic bacteriuria is treated in pregnancy even though it usually is not outside of pregnancy. Progesterone relaxes smooth muscle, causing decreased gastric motility, constipation, and gastroesophageal reflux from a relaxed lower esophageal sphincter.

Musculoskeletal and integumentary

Relaxin and progesterone loosen pelvic ligaments, and the growing uterus shifts the center of gravity forward, producing lumbar lordosis, low back pain, and a higher fall risk. Skin changes include chloasma (melasma), linea nigra, and striae gravidarum.

Antepartum Care

Visit schedule and routine screening

A common schedule for an uncomplicated pregnancy is every 4 weeks until 28 weeks, every 2 weeks from 28 to 36 weeks, then weekly until birth. Each visit includes weight, blood pressure, urine dipstick for protein and glucose, fundal height, fetal heart rate, fetal movement, and a review of danger signs.

Initial labs typically include blood type and Rh with antibody screen, CBC, rubella and varicella immunity, hepatitis B surface antigen, HIV, syphilis screening, gonorrhea and chlamydia testing, urine culture, and cervical cancer screening as indicated.

• Gestational diabetes screening at 24 to 28 weeks, usually a 50 g 1-hour glucose challenge followed by a 100 g 3-hour oral glucose tolerance test if the screen is elevated.
• Group B Streptococcus (GBS) rectovaginal culture at 36 0/7 to 37 6/7 weeks. A positive culture, GBS bacteriuria in this pregnancy, or a previous infant with GBS disease means intrapartum IV antibiotic prophylaxis, typically penicillin G, ideally at least 4 hours before birth. Treating GBS antepartum does not prevent neonatal disease; the antibiotic must be given in labor.
• Rh-negative patients receive Rho(D) immune globulin at about 28 weeks and again within 72 hours after birth if the newborn is Rh positive. It is also indicated after miscarriage, ectopic pregnancy, elective termination, amniocentesis, chorionic villus sampling, external cephalic version, and abdominal trauma. Rho(D) immune globulin prevents maternal sensitization; it does nothing once antibodies already exist, which is why the antibody screen matters.

Fetal assessment

• Fundal height: the uterus is at the symphysis pubis around 12 weeks and at the umbilicus around 20 weeks. From roughly 18 to 32 weeks, fundal height in centimeters approximates gestational age in weeks within about 2 cm. A height more than about 2 cm larger than dates suggests multiple gestation, polyhydramnios, macrosomia, or wrong dates; smaller suggests fetal growth restriction, oligohydramnios, or wrong dates.
• Fetal heart tones: audible by Doppler around 10 to 12 weeks, by fetoscope around 18 to 20 weeks. Normal baseline is 110 to 160 beats per minute.
• Quickening: first maternal perception of movement, about 18 to 20 weeks in a first pregnancy and 14 to 16 weeks in later pregnancies.
• Fetal movement (kick) counts: a widely taught method is to have the patient rest on her side after a meal and count movements; fewer than 10 distinct movements in 2 hours warrants calling the provider. Teach that a decrease in the baby's usual pattern is always reported, never watched at home.
• Nonstress test (NST): reactive is reassuring and means at least 2 accelerations in 20 minutes, each 15 beats above baseline lasting 15 seconds, in a fetus 32 weeks or more (10 beats for 10 seconds before 32 weeks). Nonreactive requires further testing, not immediate delivery.
• Biophysical profile (BPP): 2 points each for NST, fetal breathing, gross body movement, tone, and amniotic fluid volume. 8 to 10 is reassuring, 6 is equivocal, 4 or less is concerning.
• Contraction stress test: negative (no late decelerations with contractions) is the good result. In this one test the confusing convention is that negative equals normal.
• Amniocentesis after about 15 weeks assesses genetic status and, less often now, fetal lung maturity (lecithin to sphingomyelin ratio of 2:1 or greater, presence of phosphatidylglycerol). Have the patient empty her bladder before a second- or third-trimester procedure, monitor the fetal heart rate afterward, and give Rho(D) immune globulin if the patient is Rh negative.

Nutrition and teaching

• Weight gain guidance by prepregnancy BMI: underweight 28 to 40 lb, normal weight 25 to 35 lb, overweight 15 to 25 lb, obese 11 to 20 lb.
• Folic acid 400 to 800 mcg daily before conception and in early pregnancy prevents neural tube defects; 4 mg daily is recommended with a prior affected pregnancy. Iron requirement is about 27 mg daily. Calcium about 1,000 mg daily.
• Avoid alcohol entirely (no known safe amount; fetal alcohol spectrum disorders), avoid tobacco and cannabis, limit caffeine, avoid high-mercury fish (shark, swordfish, king mackerel, tilefish), avoid unpasteurized dairy, deli meats unless steaming hot, and raw or undercooked meat, fish, and eggs (Listeria, Toxoplasma, Salmonella). Avoid changing cat litter and wear gloves when gardening (toxoplasmosis).
• Avoid live vaccines in pregnancy (MMR, varicella). Inactivated influenza vaccine and Tdap (given at 27 to 36 weeks for infant pertussis protection) are recommended during pregnancy.
• Common discomforts and nursing responses: nausea (small dry carbohydrate before rising, small frequent meals), heartburn (small meals, upright after eating, avoid lying flat), constipation (fiber, fluids, activity; docusate rather than stimulant laxatives), varicosities and edema (elevate legs, avoid crossing legs, support hose), and back pain (pelvic tilt, good body mechanics, low-heeled shoes).

Danger signs the patient must report immediately

Vaginal bleeding; leaking of fluid; severe or persistent headache; visual changes such as blurring, spots, or photophobia; right upper quadrant or epigastric pain; sudden swelling of the face and hands; persistent vomiting; fever; painful urination; decreased fetal movement; regular contractions before 37 weeks.

Antepartum Complications

Hypertensive disorders

• Chronic hypertension: present before pregnancy or before 20 weeks.
• Gestational hypertension: new hypertension after 20 weeks without proteinuria or severe features.
• Preeclampsia: after 20 weeks, blood pressure of 140/90 mm Hg or higher on two occasions at least 4 hours apart, plus proteinuria (300 mg or more per 24 hours, protein to creatinine ratio of 0.3 or more, or 2+ dipstick when other methods are unavailable). Preeclampsia can also be diagnosed without proteinuria if new hypertension is accompanied by thrombocytopenia, elevated liver enzymes, renal insufficiency, pulmonary edema, or new cerebral or visual symptoms. The underlying problem is abnormal placental development with widespread endothelial dysfunction and vasospasm, which is why it affects the brain, liver, kidneys, lungs, platelets, and placenta all at once.
• Severe features include systolic 160 mm Hg or higher or diastolic 110 mm Hg or higher, platelets below 100,000/mm3, transaminases roughly twice normal or severe persistent right upper quadrant pain, creatinine above 1.1 mg/dL or doubled, pulmonary edema, and new cerebral or visual disturbance.
• Eclampsia: generalized seizure in a patient with preeclampsia, not explained by another cause.
• HELLP syndrome: Hemolysis, Elevated Liver enzymes, Low Platelets. It may present with malaise and right upper quadrant pain and can occur with only mildly elevated blood pressure, so it is missed if the nurse anchors on blood pressure alone.

Nursing care. Definitive treatment is birth. Until then: quiet low-stimulation environment, seizure precautions with suction and oxygen at the bedside, strict intake and output, deep tendon reflexes and clonus, serial blood pressures, daily weights, fetal surveillance, and teaching the patient to report headache, visual change, and epigastric pain.

Magnesium sulfate is given for seizure prophylaxis, not to lower blood pressure. It is a central nervous system depressant and a smooth muscle relaxant, typically a loading dose followed by a continuous infusion on a pump. Monitor deep tendon reflexes, respiratory rate, level of consciousness, urine output, and fetal heart rate.

• Earliest reliable sign of toxicity: loss of deep tendon reflexes. Then respiratory depression (respirations below 12 per minute), then decreased level of consciousness, then cardiac arrest.
• Urine output below 30 mL/hour is a red flag because magnesium is cleared renally and will accumulate.
• Antidote: calcium gluconate IV, kept immediately available whenever magnesium is infusing.
• Expect flushing, warmth, and sedation; these are effects, not toxicity. Newborns of mothers on magnesium may be hypotonic and sleepy with respiratory depression.

Acute severe hypertension is treated with IV labetalol, IV hydralazine, or oral immediate-release nifedipine. ACE inhibitors and ARBs are contraindicated in pregnancy because of fetal renal injury and death.

Bleeding disorders

	Placenta previa	Placental abruption
Bleeding	Painless, bright red, sudden onset	Painful, often dark red; may be concealed with little visible blood
Uterus	Soft, nontender, relaxed	Rigid, board-like, tender; frequent low-amplitude contractions
Key risk factors	Prior cesarean or uterine surgery, prior previa, multiparity, multiple gestation, advanced age, smoking	Hypertension and preeclampsia, cocaine use, abdominal trauma, smoking, prior abruption, PPROM
Critical nursing rule	No vaginal or digital cervical exam	Monitor for DIC and hypovolemic shock; prepare for possible emergency birth

Other first-trimester bleeding causes include spontaneous abortion, ectopic pregnancy (unilateral pelvic pain, missed period, positive hCG, possible referred shoulder pain and syncope from hemoperitoneum; a surgical emergency if ruptured), and gestational trophoblastic disease (molar pregnancy: markedly elevated hCG, uterus larger than dates, grape-like vesicles, hyperemesis, early-onset hypertension; requires hCG follow-up and strict contraception because of choriocarcinoma risk).

Preterm labor and PPROM

Preterm labor is regular contractions with cervical change between 20 0/7 and 36 6/7 weeks. Teach patients that preterm labor can feel like low dull backache, pelvic pressure, menstrual-like cramping, increased or changed vaginal discharge, and vague abdominal tightening, not necessarily classic painful contractions.

• Tocolytics (nifedipine, indomethacin before 32 weeks, terbutaline for short-term use only) buy roughly 48 hours, and that time is the point.
• Antenatal corticosteroids (betamethasone 12 mg IM in two doses 24 hours apart, or dexamethasone) accelerate fetal lung maturity and reduce respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis. Benefit is greatest 24 hours to 7 days after the first dose.
• Magnesium sulfate before about 32 weeks is given for fetal neuroprotection (reduced cerebral palsy), a different indication from seizure prophylaxis.

PPROM (preterm premature rupture of membranes) is rupture before 37 weeks and before labor. Priorities are avoiding infection (limit vaginal exams, monitor temperature, pulse, and uterine tenderness for chorioamnionitis) and watching for cord prolapse. Confirm rupture by pooling on sterile speculum exam, nitrazine paper turning blue (alkaline amniotic fluid), and ferning on microscopy. Blood, semen, and vaginal infection cause false-positive nitrazine results.

Other antepartum conditions

• Hyperemesis gravidarum: intractable vomiting with weight loss above about 5 percent, dehydration, ketonuria, and electrolyte imbalance. Care is IV fluids, electrolyte correction, antiemetics, and thiamine before glucose-containing fluids in prolonged vomiting.
• Gestational diabetes: target values commonly taught are fasting below 95 mg/dL, 1 hour postprandial below 140 mg/dL, and 2 hours postprandial below 120 mg/dL. Insulin is the traditional first-line pharmacologic agent because it does not cross the placenta. Insulin requirements rise through pregnancy as placental hormones create insulin resistance, then drop sharply immediately after the placenta is delivered, which is when postpartum hypoglycemia occurs. Fetal and neonatal risks include macrosomia, shoulder dystocia, birth injury, neonatal hypoglycemia, hyperbilirubinemia, and respiratory distress syndrome.
• Anemia, infection, cardiac disease, and substance use all raise risk. TORCH infections (toxoplasmosis, other such as syphilis and parvovirus B19, rubella, cytomegalovirus, herpes simplex) cause congenital injury. Active genital herpes lesions at the onset of labor are an indication for cesarean birth.

Intrapartum Care

Onset and the five P's

Premonitory signs include lightening, increased Braxton Hicks contractions, cervical ripening, bloody show, a small weight loss, a burst of energy (nesting), and rupture of membranes. True labor produces regular contractions that increase in frequency, duration, and intensity, are usually felt in the back radiating to the abdomen, are not relieved by walking or rest, and produce cervical dilation and effacement. False labor is irregular, felt mostly in the abdomen, often relieved by walking, position change, or hydration, and does not change the cervix. Cervical change is the deciding criterion.

The five P's are passenger (fetal size, lie, presentation, attitude, position), passageway (pelvis and soft tissues), powers (contractions and maternal pushing), position (maternal position), and psyche (emotional state and support). Fetal station is the relationship of the presenting part to the ischial spines: 0 is engaged, negative numbers are above the spines, positive numbers are below.

Stages of labor

• First stage - onset of true labor to full dilation (10 cm).
  • Latent phase (0 to about 5 or 6 cm): contractions mild to moderate, patient talkative and sociable. Nursing focus is orientation, ambulation, hydration, and teaching.
  • Active phase (about 6 cm to 10 cm): contractions every 2 to 5 minutes, strong, patient inwardly focused, may become irritable, nauseated, and shaky in transition. Nursing focus is comfort, coaching, and closer fetal and maternal monitoring.
• Second stage - full dilation to birth of the infant. Encourage pushing with the urge; support spontaneous rather than prolonged breath-holding pushing when possible.
• Third stage - birth of the infant to delivery of the placenta, usually within 5 to 30 minutes. Signs of placental separation are a gush of blood, lengthening of the cord, and a globular firming uterus. Do not pull on the cord; traction risks uterine inversion.
• Fourth stage - the first 1 to 4 hours after delivery of the placenta, the highest-risk window for postpartum hemorrhage. Assess fundus, lochia, vital signs, bladder, and perineum on a frequent schedule per facility protocol (a common pattern is every 15 minutes for the first hour).

Cardinal movements: engagement, descent, flexion, internal rotation, extension, external rotation (restitution), and expulsion.

Contraction assessment

• Frequency: beginning of one contraction to the beginning of the next.
• Duration: beginning to end of one contraction.
• Intensity: by palpation (mild feels like the tip of the nose, moderate like the chin, firm like the forehead) or in Montevideo units with an intrauterine pressure catheter.
• Resting tone: the uterus must relax fully between contractions; that is when the placenta refills and the fetus is oxygenated.
• Tachysystole is more than 5 contractions in 10 minutes averaged over 30 minutes. If oxytocin is infusing and tachysystole or a nonreassuring fetal heart rate occurs, stop or decrease the oxytocin as the first action.

Electronic fetal monitoring

Interpret in this order: baseline rate, variability, accelerations, decelerations, and uterine activity.

• Baseline 110 to 160 bpm. Above 160 for 10 minutes or more is tachycardia (maternal fever, infection, dehydration, medications, fetal hypoxia). Below 110 is bradycardia (cord compression or prolapse, rapid descent, maternal hypotension, abruption).
• Variability is the most important single indicator of fetal central nervous system oxygenation. Absent (undetectable), minimal (5 bpm or less), moderate (6 to 25 bpm, the reassuring finding), marked (more than 25 bpm). Fetal sleep cycles, narcotics, and magnesium reduce variability without necessarily meaning hypoxia.
• Accelerations are reassuring and essentially rule out fetal acidemia at that moment.
• Decelerations:
  • Early - gradual, mirror the contraction, nadir with the peak. Cause is head compression. Benign; no intervention.
  • Variable - abrupt drop of 15 bpm or more for 15 seconds or more, variable in shape and timing. Cause is cord compression. Interventions: reposition, and consider amnioinfusion for repetitive variables.
  • Late - gradual, begin after the contraction starts, nadir after the peak, return after the contraction ends. Cause is uteroplacental insufficiency. Always concerning.
  • Prolonged - 15 bpm or more below baseline lasting 2 minutes to less than 10 minutes.
• Memory aid VEAL CHOP: Variable = Cord compression, Early = Head compression, Accelerations = OK, Late = Placental insufficiency.
• Category I is normal (baseline 110 to 160, moderate variability, no late or variable decelerations, early decelerations and accelerations may be present or absent). Category III is abnormal and requires prompt intervention: absent variability with recurrent late decelerations, recurrent variable decelerations, or bradycardia; or a sinusoidal pattern. Category II is everything in between, is the most common category, and requires evaluation and continued surveillance.

Intrauterine resuscitation for a nonreassuring pattern: reposition the patient to a lateral position (usually the first and fastest action), stop oxytocin, give an IV fluid bolus of isotonic solution, give oxygen by nonrebreather mask as indicated by facility protocol, perform a vaginal exam to rule out cord prolapse and assess rapid descent, correct maternal hypotension, and notify the provider. Consider terbutaline for tachysystole and amnioinfusion for recurrent variables.

Obstetric emergencies

• Umbilical cord prolapse - suspect with sudden prolonged deceleration or variable decelerations right after rupture of membranes, especially with a high presenting part, malpresentation, polyhydramnios, or a long cord. Actions: call for help, place a gloved hand in the vagina and hold the presenting part off the cord, place the patient in knee-chest or steep Trendelenburg or exaggerated Sims position, give oxygen, stop oxytocin, and prepare for emergency cesarean birth. Do not attempt to push the cord back in. If the cord is visible, keep it moist with warm sterile saline gauze. The nurse's hand stays in place until delivery.
• Shoulder dystocia - the head delivers and retracts against the perineum (turtle sign). McRoberts maneuver (hyperflex the maternal thighs sharply onto the abdomen) plus suprapubic pressure. Never apply fundal pressure, which worsens impaction and risks uterine rupture. Watch for postpartum hemorrhage and for neonatal brachial plexus injury or clavicle fracture.
• Uterine rupture - sudden severe abdominal pain often described as tearing, loss of fetal station, an abnormal fetal heart rate or loss of tracing, cessation of contractions, and signs of shock. Highest concern with a prior classical uterine incision or trial of labor after cesarean. Immediate surgical delivery.
• Amniotic fluid embolism - abrupt hypoxia and respiratory distress, cardiovascular collapse, and DIC, typically in labor or just after birth. Care is immediate cardiopulmonary resuscitation and support, oxygen, and massive transfusion.
• Chorioamnionitis - maternal fever, maternal and fetal tachycardia, uterine tenderness, foul-smelling fluid. Antibiotics and delivery.

Comfort and anesthesia

Nonpharmacologic measures include position changes and ambulation, hydrotherapy, counterpressure to the sacrum for back labor, breathing techniques, effleurage, heat and cold, and continuous labor support.

Epidural analgesia: the most common serious immediate complication is maternal hypotension with resulting decreased uteroplacental perfusion and fetal heart rate change. Nursing care: IV access with a fluid bolus per protocol before placement, position the patient sitting or side-lying with the back curved, monitor blood pressure frequently (a common pattern is every 2 to 5 minutes for the first 15 to 20 minutes), have the patient void or place a catheter because bladder sensation is lost, keep the patient off her back, and implement fall precautions. Treat hypotension with lateral positioning, a fluid bolus, oxygen, and a vasopressor such as ephedrine or phenylephrine per order. Other risks are pruritus, fever, urinary retention, and postdural puncture headache.

Opioids given close to birth can cause neonatal respiratory depression; naloxone should be available, and it is not given to a newborn of an opioid-dependent mother because it can precipitate withdrawal and seizures.

Induction, augmentation, and cesarean birth

Oxytocin is titrated to an adequate contraction pattern with a full resting tone. Nursing responsibility is continuous fetal monitoring, watching for tachysystole and Category II or III patterns, monitoring intake and output (oxytocin has an antidiuretic effect and high-dose prolonged infusion risks water intoxication), and knowing that the nurse independently stops or decreases the infusion for tachysystole or a nonreassuring tracing. Cervical ripening agents include prostaglandins (dinoprostone, misoprostol) and mechanical methods such as a Foley balloon. Bishop score estimates readiness for induction; a higher score predicts success.

Amniotomy: assess and document the fetal heart rate immediately before and after, note fluid color, odor, and amount, and watch for cord prolapse. Meconium-stained fluid warrants readiness for neonatal resuscitation. Time from rupture matters for infection risk.

Cesarean birth care includes the standard perioperative sequence plus a wedge under the right hip to displace the uterus off the vena cava, and postoperatively the same fundal, lochia, incision, and VTE assessments as vaginal birth. Cesarean patients still have lochia and still need fundal assessment.

Postpartum Care

Systematic assessment: BUBBLE-HE

Breasts, Uterus, Bladder, Bowel, Lochia, Episiotomy or perineum, Homan sign and lower extremities or VTE risk, Emotional status. Many facilities add pain and Rh or rubella status.

• Uterus: the fundus should be firm, midline, and at or near the umbilicus within a few hours of birth, then descend about 1 fingerbreadth (1 cm) per day, becoming nonpalpable by roughly 10 to 14 days. A boggy fundus is massaged first. A fundus that is high and deviated to the right almost always means a full bladder, which prevents contraction and causes bleeding; have the patient void, then reassess. Afterpains are stronger in multiparas, with breastfeeding, and with an overdistended uterus.
• Lochia: rubra (dark red, days 1 to 3), serosa (pinkish-brown, days 4 to 10), alba (creamy white or yellow, day 11 through about 4 to 6 weeks). Small clots can be normal early. Abnormal: saturating a perimeter pad in 1 hour or less, a foul odor, large clots, bright red bleeding that returns after progressing to serosa, or lochia that is heavier when the fundus is firm (suggesting a laceration rather than atony). Always check underneath the patient; blood pools under the buttocks.
• Breasts: assess for engorgement, nipple integrity, and mastitis (usually unilateral, localized redness, warmth, tenderness, fever, and flu-like symptoms). Mastitis is treated with antibiotics and continued emptying of the breast; the patient keeps breastfeeding or pumping.
• Bladder: postpartum diuresis is normal and large. Watch for urinary retention with overflow (frequent small voids) especially after an epidural. Aim for voiding within about 6 to 8 hours of birth.
• Bowel: constipation is very common. Fluids, fiber, ambulation, and a stool softener; a third- or fourth-degree laceration is a contraindication to suppositories and enemas.
• Perineum: assess with the REEDA framework - Redness, Edema, Ecchymosis, Discharge, Approximation. Ice for the first 24 hours, then sitz baths, peri-bottle rinsing front to back, topical anesthetics, and a donut cushion as needed. A hematoma presents as severe unrelieved perineal or rectal pain with a bulging bluish discolored area, and it can hide significant blood loss.
• Extremities: assess for unilateral calf swelling, warmth, redness, and pain. Homan sign is unreliable and is no longer recommended as a diagnostic maneuver, but it appears in older material. Early ambulation and prophylaxis reduce VTE risk, which is elevated for weeks after birth.

Normal postpartum physiology

• Bradycardia of 50 to 70 beats per minute in the first days is normal from increased stroke volume and mobilized blood volume. Tachycardia is the abnormal finding and suggests hemorrhage, pain, infection, or anxiety.
• Temperature up to 100.4 degrees F (38 degrees C) in the first 24 hours may reflect dehydration and normal exertion. A temperature of 100.4 degrees F or higher on two occasions after the first 24 hours suggests puerperal infection.
• Profuse diuresis and diaphoresis occur in the first days as the extra plasma volume is excreted.
• A chill and shaking right after birth is common and benign if the patient is afebrile.
• Hemoglobin and hematocrit are unreliable in the first 24 hours because of fluid shifts.

Postpartum hemorrhage

Commonly defined as cumulative blood loss of 1,000 mL or more, or blood loss with signs or symptoms of hypovolemia, within 24 hours of birth regardless of route. Older thresholds of 500 mL after vaginal and 1,000 mL after cesarean birth still appear in test material. Early (primary) hemorrhage occurs within 24 hours; late (secondary) occurs from 24 hours to 12 weeks and is most often from retained placental fragments or subinvolution.

The four T's: Tone (uterine atony, the cause in roughly 70 to 80 percent), Trauma (lacerations, hematoma, uterine inversion or rupture), Tissue (retained placenta), Thrombin (coagulopathy, including DIC).

Nursing sequence for a boggy uterus with heavy bleeding: massage the fundus first (an independent nursing action that often works), have the patient empty the bladder or catheterize, then anticipate uterotonics, large-bore IV access, isotonic fluids, oxygen, type and crossmatch, quantitative blood loss measurement, and provider notification. Reassess after every intervention.

Uterotonics and their key contraindications (a very high-yield set):

• Oxytocin (Pitocin) - first line; watch blood pressure and, with prolonged high-dose use, water intoxication.
• Methylergonovine (Methergine) - contraindicated in hypertension and preeclampsia; check the blood pressure before every dose.
• Carboprost tromethamine (Hemabate) - contraindicated in asthma; commonly causes diarrhea, nausea, and fever.
• Misoprostol (Cytotec) - can be given by several routes; causes fever and shivering.
• Tranexamic acid is used as an adjunct within 3 hours of birth.

Classic early signs of hypovolemia in a healthy young obstetric patient are tachycardia, narrowing pulse pressure, restlessness or anxiety, and cool clammy skin; a falling blood pressure is a late sign.

Psychosocial and discharge issues

• Postpartum blues: tearfulness, mood lability, and fatigue affecting a majority of patients, beginning within days and resolving by about 2 weeks. Care is reassurance, rest, and support.
• Postpartum depression: persists beyond 2 weeks or begins later within the first year, with impaired function, anhedonia, guilt, and possible thoughts of harming self or the infant. Screening with a validated tool such as the Edinburgh Postnatal Depression Scale is standard. Treatment is effective; the nurse screens, refers, and follows up rather than reassuring the patient that it will pass.
• Postpartum psychosis: a psychiatric emergency with hallucinations, delusions (often about the infant), disorganized thinking, and elevated risk of infanticide and suicide. It requires immediate evaluation and usually hospitalization, and the infant must not be left alone with the parent.
• Rubella-nonimmune patients receive MMR before discharge, with teaching to avoid pregnancy for 28 days. Rh-negative patients with an Rh-positive newborn receive Rho(D) immune globulin within 72 hours.
• Teach the patient to report fever, foul-smelling lochia, bleeding that soaks a pad in an hour, severe headache or visual changes (preeclampsia can present or worsen after birth, including up to 6 weeks postpartum), chest pain or dyspnea, unilateral leg pain and swelling, and thoughts of harming self or baby.
• Ovulation can return before the first menses, so contraception counseling happens before discharge. Estrogen-containing contraception is generally avoided in the early postpartum period because of VTE risk and is timed with lactation and risk factors in mind.

Newborn Care

Immediate transition and the Apgar score

At birth the newborn must clear lung fluid, establish spontaneous respiration, and shift from fetal to neonatal circulation as pulmonary vascular resistance falls and the ductus arteriosus, foramen ovale, and ductus venosus close. The first priorities in the delivery room are, in order, warmth, airway, and breathing: dry the infant, remove wet linens, provide skin-to-skin contact or a radiant warmer, position the airway, and stimulate.

The Apgar score is assigned at 1 and 5 minutes (and every 5 minutes to 20 minutes if the score stays below 7). Five parameters scored 0, 1, or 2: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A total of 7 to 10 is reassuring, 4 to 6 indicates moderate difficulty, and 0 to 3 indicates severe distress. The Apgar score describes transition; it does not dictate resuscitation. Resuscitation is started based on respirations, heart rate, and tone, not on waiting for a score.

Normal newborn values and assessment

• Heart rate 110 to 160 bpm awake (may drop to about 90 in deep sleep and rise to 180 when crying); respiratory rate 30 to 60 per minute, irregular, with periodic breathing and short pauses under 20 seconds; axillary temperature 97.7 to 99.5 degrees F (36.5 to 37.5 degrees C); blood pressure roughly 60 to 80 over 40 to 50.
• Weight roughly 2,500 to 4,000 g at term. A weight loss of up to about 7 to 10 percent in the first days is expected, regained by 10 to 14 days.
• Normal findings often mistaken for problems: acrocyanosis (blue hands and feet) in the first 24 to 48 hours, milia, erythema toxicum, congenital dermal melanocytosis (formerly Mongolian spots), vernix caseosa, lanugo, molding, pseudomenstruation and breast engorgement from maternal hormones, transient tachypnea, and epstein pearls.
• Abnormal findings requiring report: central cyanosis or circumoral cyanosis, grunting, nasal flaring, retractions, sustained respiratory rate above 60, apnea longer than 20 seconds, temperature instability, jitteriness, a single umbilical artery (normal cord has two arteries and one vein), and jaundice in the first 24 hours.
• Caput succedaneum is scalp edema that crosses suture lines, is present at birth, and resolves in days. Cephalhematoma is subperiosteal bleeding that does not cross suture lines, appears hours after birth, resolves over weeks, and increases the risk of hyperbilirubinemia as the blood breaks down.
• Fontanels: anterior (diamond) closes at 12 to 18 months; posterior (triangle) closes by about 2 to 3 months. They should be soft and flat. Bulging suggests increased intracranial pressure; sunken suggests dehydration.
• Reflexes: Moro (startle), rooting, sucking, palmar and plantar grasp, Babinski (fanning is normal in infants), tonic neck (fencing), and stepping. An asymmetric Moro suggests clavicle fracture or brachial plexus injury.
• Elimination: first void within 24 hours and first meconium stool within 24 to 48 hours; failure to pass either is reported. Stools progress from meconium to transitional to yellow seedy (breastfed) or pale yellow to tan and firmer (formula fed).
• Gestational age is estimated with the New Ballard score; infants are classified as small, appropriate, or large for gestational age.

Thermoregulation

Newborns lose heat rapidly because of a large surface area to mass ratio, thin subcutaneous fat, and thin skin, and they cannot shiver. They generate heat by nonshivering thermogenesis, metabolizing brown adipose tissue located around the neck, scapulae, axillae, mediastinum, and kidneys.

Four mechanisms of heat loss and their nursing countermeasures:

• Evaporation (moisture on skin): dry immediately after birth and after baths; remove wet linens.
• Conduction (contact with a cooler surface): prewarm the scale, mattress, stethoscope, and hands.
• Convection (moving air): keep away from drafts, air vents, doorways, and open portholes.
• Radiation (heat transfer to a nearby cooler surface without contact): move the crib away from cold exterior walls and windows.

Cold stress is a cascade, not just a low temperature: increased oxygen consumption and metabolic rate leads to hypoglycemia, anaerobic metabolism leads to metabolic acidosis, which causes pulmonary vasoconstriction, worsening respiratory distress, and can impair bilirubin binding. Preterm, small-for-gestational-age, and infants of diabetic mothers are at highest risk. Skin-to-skin contact is both effective and preferred; delay the first bath until the temperature is stable.

Hypoglycemia

Institutional thresholds vary, but blood glucose below about 40 to 45 mg/dL in the first hours is commonly used as the treatment trigger. At-risk infants include those who are large for gestational age, small for gestational age, preterm or late preterm, infants of diabetic mothers, and any infant with cold stress, sepsis, or asphyxia. Signs are nonspecific and easy to miss: jitteriness or tremors, poor feeding, lethargy, hypotonia, weak or high-pitched cry, temperature instability, apnea, cyanosis, and seizures. Management for an asymptomatic at-risk infant is usually early feeding and a repeat glucose; symptomatic or very low values require IV dextrose. Jitteriness in a newborn is checked with a glucose level, not reassured away.

Routine prophylaxis and screening

• Vitamin K (phytonadione) IM in the vastus lateralis shortly after birth to prevent vitamin K deficiency bleeding. Newborns are deficient because the gut is sterile at birth and little vitamin K crosses the placenta.
• Erythromycin ophthalmic ointment to both eyes to prevent gonococcal ophthalmia neonatorum. It may be delayed up to about an hour to allow initial bonding and eye contact.
• Hepatitis B vaccine; if the mother is HBsAg positive, the infant also receives hepatitis B immune globulin, ideally within 12 hours of birth.
• Newborn metabolic screening by heel stick, typically at 24 to 48 hours of age, for conditions such as phenylketonuria, congenital hypothyroidism, galactosemia, sickle cell disease, and cystic fibrosis. Adequate feeding before the screen matters for accuracy. Use the lateral heel to avoid the calcaneus, and warm the heel first.
• Hearing screening and pulse oximetry screening for critical congenital heart disease (right hand and either foot, usually after 24 hours).

Jaundice

Physiologic jaundice appears after 24 hours of age, peaks around days 3 to 5, and resolves without treatment. It results from a high red cell mass with a short red cell lifespan and an immature hepatic conjugating system. Pathologic jaundice appears within the first 24 hours, rises rapidly, or persists, and suggests hemolysis such as Rh or ABO incompatibility, infection, or metabolic disease. Unconjugated bilirubin is fat soluble and can cross the blood-brain barrier, causing acute bilirubin encephalopathy and kernicterus, which is permanent.

Nursing care: plot bilirubin against age in hours on a risk nomogram, promote frequent feeding (8 to 12 times in 24 hours) because bilirubin is excreted in stool and delayed passage increases enterohepatic reabsorption, and for phototherapy maximize skin exposure, provide eye protection, monitor temperature and hydration, and monitor for loose green stools and rash. Water supplementation does not lower bilirubin and is not given.

Feeding

• Breastfeeding: colostrum comes first (high in protein and immunoglobulin A, laxative effect that promotes meconium passage); mature milk typically comes in at about 2 to 5 days. Feed 8 to 12 times per 24 hours on demand, watching for early hunger cues (rooting, hand to mouth, lip smacking) rather than waiting for crying, which is a late cue.
• Signs of an effective latch: a wide open mouth taking in the nipple and a good portion of the areola, flanged lips, the chin touching the breast, audible swallowing, and comfort for the mother. Nipple pain and cracking usually mean a shallow latch, not too much feeding. Break suction with a clean finger in the corner of the mouth before removing the infant.
• Signs of adequate intake: at least 6 wet diapers per day by about day 4 to 5, 3 or more stools per day in the early weeks, appropriate weight gain, and audible swallowing.
• Engorgement care differs by goal: for a breastfeeding mother, use warmth before feeding to promote letdown, feed or pump frequently, and use cold compresses after feeding for comfort. For a mother who is not breastfeeding, avoid all nipple stimulation, wear a supportive bra, use cold compresses, and do not pump.
• Formula feeding: hold the infant semi-upright with the nipple full of formula, never prop the bottle, and never microwave formula. Prepared formula follows manufacturer dilution exactly; overdilution causes water intoxication and hyponatremia, and underdilution stresses immature kidneys. No cow's milk, honey (botulism risk), or solids before the recommended ages.
• Contraindications to breastfeeding are limited but include maternal HIV in settings where safe replacement feeding is available, active untreated tuberculosis (until treated, though expressed milk may be given), certain medications and chemotherapy, active herpes lesions on the breast, and infant galactosemia.

Discharge teaching

• Safe sleep: always on the back, on a firm flat surface, in the infant's own space, with no pillows, bumpers, blankets, or soft toys. Room sharing without bed sharing is recommended. Avoid overheating and secondhand smoke.
• Car seat: rear-facing in the back seat, never in front of an active airbag.
• Cord care: keep clean and dry, fold the diaper below the cord, expect it to detach in about 7 to 14 days, and report redness spreading onto the abdomen, purulent drainage, or foul odor.
• Circumcision: after a Plastibell, do not remove the ring (it falls off in about 5 to 8 days); after other methods apply petroleum gauze as ordered. A yellowish exudate on the glans after a day or two is normal healing and is not wiped off. Report bleeding more than a few drops or failure to void within 6 to 8 hours.
• When to call: axillary temperature at or above 100.4 degrees F (38 degrees C) in an infant under about 3 months is an emergency requiring immediate evaluation; also report poor feeding, lethargy, fewer wet diapers, persistent vomiting, jaundice that worsens or reaches the abdomen and legs, and any breathing difficulty.

High-Yield Priority Rules

1. Supine pregnant patient with hypotension or a fetal heart rate change: turn her onto her side first.
2. Boggy fundus: massage it. Firm fundus that is high and displaced to the right: have her empty the bladder.
3. Firm fundus with heavy bright red bleeding: think laceration, not atony, and notify the provider.
4. Nonreassuring fetal heart rate with oxytocin running: stop the oxytocin.
5. Cord prolapse: relieve pressure on the cord with a gloved hand and reposition, do not replace the cord.
6. Shoulder dystocia: McRoberts and suprapubic pressure, never fundal pressure.
7. Magnesium sulfate: absent deep tendon reflexes is the first sign of toxicity; calcium gluconate is the antidote.
8. Methylergonovine is withheld in hypertension; carboprost is withheld in asthma.
9. Newborn jitteriness: check the glucose.
10. Jaundice in the first 24 hours is pathologic until proven otherwise.
11. Postpartum tachycardia is a warning sign; bradycardia is expected.
12. A patient reporting headache, visual changes, or epigastric pain after 20 weeks or postpartum is evaluated for preeclampsia immediately.

See Also

• Maternal and Newborn Nursing – RN Practice Questions
• Maternal and Newborn Nursing – LPN Practice Questions
• Maternal and Newborn Nursing – RN Flashcards
• Maternal and Newborn Nursing – LPN Flashcards

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