This area focuses on the nursing care of the childbearing family. Health care needs and problems that occur during the antepartal, intrapartal, postpartal, and neonatal periods are included.
A. Theoretical framework - basis of care
1. The childbearing woman
a. Antepartal period
1) Signs and symptoms of pregnancy
Presumptive and probable
Subjective and objective
Subjective:
Nausea and vomiting (morning sickness), urinary frequency, absence of expected menses, weight gain
Objective
HCG (Human Chorionic Gonadotropin) present and detectable in urine and blood, a hormone created by the chorionic villi of the placenta (all laboratory tests are only 95% to 98% accurate) (home pregnancy tests accuracy of about 97% if instructions followed exactly)
Goodell's sign - softening of the cervix at about 6 weeks. Change from harder like the tip of nose to that of the earlobe.
Hegar's sign - softening of the lower part of the uterus at about 6 weeks.
Chadwick's sign - colour change of the vagina and cervix from pink to a bluish purple. NB: only reliable with first pregnancy
Positive Signs
Fetal heart separate from the mothers, although heart beating by day 24, it is detectable by stethoscope at 18 to 20 weeks. Ultrasound may detect heart beat as early as 10th week.
Fetal movements felt by examiner, felt as early as 16 to 20 weeks.
Ultrasound - fetal sack detectable in uterus as early as 6 weeks, fetal heart detectable at 12 weeks, movement at 12 weeks.
2) Physiological changes (for example: uterine growth, cardiovascular changes, lungs, gastrointestinal/genitourinary [GI/GU] system, hormonal alterations)
Uterine growth - the growth of the fetus requires enlargement; however, the uterus muscle wall increases in thickness. Growth is mainly through stretching of the muscle fibers, thus allowing for the ease of return to the prepregnant size.
Rate of growth - A constant, steady and predictable rate of growth is the hallmark, with the uterus is easily palpable above the symphysis pubis, and at 20 to 22 week be at the umbilicus, with 36 weeks reaching the xyphoid process.
Ovation stops with pregnancy through estrogen-progesterone feedback.
Changes in the Breasts -breast size increases through hyperplasia (excessive cell formation) of the mammary alveoli and fat tissue. Darkening of the areola occurs, and the overall diameter increases to double.
Uterine growth causes displacement of other organs and structures. This displacement will cause effects upon the other systems
Cardiovascular changes - total blood volume increases 30% to 50%; however, a pseudoanemia may result as the plasma increases first, followed by the red blood cells. Iron needs increase but digestive absorption may be impaired thus true anemia may occur. The heart rate is increased about 10%. Overall clotting factors increase.
Lungs are crouded vertically by the expanding uterus pusing the diaphramg up as much as 4 inches, but expand in circumferance resulting in the same vital capacity. The hypothalamus sets a lower PCO2 at 32 mm Hg rather than the normal 40 mm HG, producing a hyoerventilation to blow of the CO2. Overall a feeling of shortness of breath is experienced.
Gastrointestinal/genitourinary [GI/GU] system
hormonal alterations
3) Psychosocial changes in the expectant family (for example: emotional responses, role transition, alterations in sexuality, differences based on age and culture)
4) Health maintenance (for example: calculation of date of conception; obstetrical history; lab tests such as serology for syphilis, smear for gonorrhea, test for chlamydia, herpes, Pap smear; patient education regarding nutrition, activities of daily living [ADLs], and symptoms to be reported)
5) Childbirth education (for example: birthing options, childbirth exercises, sibling participation)
6) Minor discomforts of pregnancy
Bathing
Breast Care - Breast Tenderness
Perineal hygiene
Sexual activity
Sleep, Exercise, Work
Palmar erythema
Constipation, nausea, vomiting, pyrosis
Muscle cramps
Hypotension and Heart palpitations
Varicosities
Hemorrhoids
Urinary frequency
Abdominal discomfort
Leukorrhea
Ankle edema
Backache, headache
Striae gravidarum
Linea nigra
Melasma
7) Complications of pregnancy
(a) Pregnancy-specific complications (for example: gestational diabetes, spontaneous abortion, ectopic pregnancy, pregnancy-induced hypertension [PIH], incompetent cervix, placenta previa, abruptio placenta)
(b) Coexisting medical conditions (for example: diabetes mellitus, infection, anemia, cardiac disease)
(c) Coexisting psychosocial problems (for example: substance abuse, adolescent pregnancy, advanced maternal age, low socioeconomic status)
b. Intrapartal period
1) Process of labour (for example: stages and phases of labour, fetal presentation and positions)
2) Complications of labour (for example: fetal malposition, pattern of late decelerations, primary and secondary inertia, premature rupture of membranes, prolapsed cord)
3) Medical interventions (for example: amniotomy, episiotomy, induction of labour, forceps, cesarean section)
4) Medications (for example: oxytocics, prostaglandins, anesthesia, analgesics)
Oxytocics
c. Postpartal period
1) Anatomical and physiological changes (for example: uterine involution, breast changes, body system changes)
2) Psychosocial adaptation
3) Role adaptation
4) Family planning
5) Postpartal complications (for example: hemorrhage, puerperal infections, lacerations, mastitis)
6. Medications (for example: Rho[D] immune globulin [RhoGAM], lactation suppressants, rubella vaccine)
2. The fetus/neonate
a. Conception
b. Embryonic/fetal development
1) Patterns of development (for example: cephalocaudal, proximal-distal)
2) Fetal circulation patterns
c. Functions of the placenta (for example: waste elimination, oxygen exchange, endocrine)
d. Factors influencing fetal growth and well-being (for example: genetic makeup, nutrition, oxygen supply, medications, teratogens, maternal diabetes, maternal substance abuse)
e. Physiology of the neonate: normal transition to extrauterine life (for example: respiratory changes, circulatory changes, temperature regulation, newborn reflexes, GI/GU function)
f. Nutritional needs of the neonate
g. Complications of the neonate (for example: prematurity, postmaturity, large of small for gestation, respiratory distress syndrome, hemolytic disease, infection, fetal alcohol syndrome, hypoglycemia)
B. Nursing care related to theoretical framework - the childbearing woman
1. Assessment - gather and synthesize data about the patient's functional health patterns
a. Gather assessment data
1) Obtain the patient's health history (for example: obstetric-gynecologic history, expected date of delivery, history of bleeding, substance abuse, fetal movement patterns)
2) Assess factors influencing the patient's response to childbearing (for example: preparation for childbirth, cultural factors, socioeconomic status, patient age, lifestyle, psychological factors, nutrition, bonding)
3) Obtain objective data (for example: fetal heart rate, fetal movement, weight gain, amount and colour of lochia, colour of amniotic fluid, location and contraction of the fundus)
4) Review laboratory and other diagnostic data (for example: sonogram, fetal heart monitor, amniocentesis, estriol levels, alpha-fetoprotein level, nonstress test, stress test)
b. Synthesize assessment data (see IIIB1a [1-4] above)
2. Analysis - identify the nursing diagnosis (patient problem) and determine the expected outcomes (goals) of patient care
a. Identify actual or potential nursing diagnoses (for example: fluid volume deficit related to inadequate fluid intake during labour; impaired skin integrity related to episiotomy; urinary retention related to urethral trauma; knowledge deficit: care of the perineum)
b. Set priorities (for example: based on Maslow's hierarchy of needs, based on the patient's developmental level)
c. Establish expected outcomes (patient-centered goals) for care (for example: patient will correctly demonstrate childbearing exercises, patient will perform care of perineum correctly)
3. Planning - formulate specific strategies to achieve the expected outcomes
a. Consider factors influencing the patient's response to childbearing (see IIIB1a[2]) and involve the patient's family in planning patient care (for example: plan sibling visits, consider low socioeconomic status, consider ethnicity, consider patient age)
b. Plan nursing measures on the basis of established priorities to help the patient achieve the expected outcomes (for example: provide feedback on the progress of labour to reduce anxiety, monitor the patient for urinary retention)
4. Implementation - carry out nursing plans designed to move the patient toward the expected outcomes
a. Use nursing measures to enhance positive outcomes for the childbearing family (for example: provide instructions regarding the effects of nutrition, lifestyle, drugs, medications, and infections; manipulate the environment to foster rest, nutrition, and reduction of stress)
b. Use nursing measures to promote optimal fetoplacental blood flow (for example: position to prevent vena caval syndrome, monitor fetal heart rate during labour and delivery)
c. Use nursing measures to ensure a safe environment (for example: safety measures for the patient with preeclampsia, maintain bed rest prior to fetal engagement)
d. Use nursing measures to facilitate the progress of labour (for example: positioning, coaching, encourage ambulation)
e. Use nursing measures to facilitate involution and healing (for example: episiotomy care, nipple care, fundal massage)
f. Use nursing measures to provide emotional support (for example: assist with role transition, foster bonding)
g. Use nursing measures to ensure optimal nutrition (for example: provide instruction regarding antepartal weight gain, provide postpartal dietary instruction)
h. Use nursing measures to relieve patient discomfort (for example: instruction in breathing patterns, application of heat and cold)
I. Use nursing measures specific to prescribed medications during the childbearing cycle (for example: monitor uterine contractions for a patient receiving oxytocin [Pitocin]; keep calcium gluconate at the bedside of a patient receiving magnesium sulfate; check the blood pressure of a patient receiving ergonovine maleate; monitor the blood pressure of a patient receiving anesthesia)
j. Use nursing measures to assist the patient in making educated choices throughout the childbearing cycle (for example: birthing options, family planning)
k. Provide information and instruction (for example: home health care, signs and symptoms of impaired involution, self-care needs, infant care, referrals)
5. Evaluation - appraise the effectiveness of the nursing interventions relative to the nursing diagnosis and the expected outcomes
a. Assess and report the patient's response to nursing actions (for example: chart colour and amount of lochia, condition of nipples, condition of episiotomy; report tetanic contractions)
b. Revise the plan of care (for example: coach the patient in progressive levels of breathing during labour, monitor vital signs with increased frequency as labour progresses)
C. Nursing care related to theoretical framework - the fetus/neonate
1. Assessment - gather and synthesize data about the patient's health status in relation to the patient's functional health patterns
a. Gather assessment data
1) Obtain the fetus/neonate's health history (for example: length of labour, type of delivery, exposure to teratogens, maternal history of substance abuse)
2) Obtain objective data related to the fetus/neonate's health status (for example: vital signs, Apgar score, reflexes, condition of umbilical cord stump, hyperexcitability, high-pitched cry)
3) Review laboratory and other diagnostic data (for example: tests for fetal maturity, bilirubin, Coombs' test, screening for phenylketonuria [PKU], galactosemia, and hypothyroidism)
b. Synthesize assessment data (see IIIC1a [1-3])
2. Analysis - identify the nursing diagnosis (patient problem) and determine the expected outcomes (goals) of patient care
a. Identify actual or potential nursing diagnoses (for example: ineffective breast-feeding related to poor sucking reflex; ineffective thermoregulation related to newborn transition to the extrauterine environment)
b. Set priorities (for example: based on Maslow's hierarchy of needs, based on the patient's development level)
c. Establish expected outcomes (patient-centered goals) for care (for example: axillary temperature will be stable, mother will use the rooting mechanism to initiate feeding, circumcision will show no signs of infection)
3. Planning - formulate specific strategies to achieve the expected outcomes
a. Plan for anticipated needs of the fetus/neonate on the basis of established priorities (for example: plan to facilitate bonding)
b. Plan nursing measures on the basis of established priorities to help the patient achieve the expected outcomes (for example: swaddle the neonate to promote security and maintain body temperature, provide a dark quiet environment for a neonate with drug addiction, increase fluid volume for a neonate who is undergoing phototherapy)
4. Implementation - carry out nursing plans designed to move the patient toward the expected outcomes
a. Use nursing measures to ensure a safe environment (for example: provide warmth for the neonate, encourage rest, cover the eyes of a neonate undergoing phototherapy, complete newborn identification procedure)
b. Use nursing measures to increase the fetus/neonate's oxygen supply (for example; suction the neonate's airway, administer oxygen at no more than 60%)
c. Use nursing measures to ensure optimal nutrition (for example: assist with neonate feeding, facilitate breast-feeding)
d. Use nursing measures to relieve fetal/neonate discomfort (for example: provide a quiet environment for the neonate with drug addiction, care of circumcision site)
e. Use nursing measures to provide emotional support (for example: foster bonding)
f. Use nursing measures specific to prescribed medication (for example: administer prophylactic eyedrops, administer vitamin K)
g. Use nursing measures to facilitate healing (for example: cord care, circumcision care)
h. Use nursing measures to maintain physiological stability (for example: care during phototherapy,, positioning, maintain cord clamp)
5. Evaluation - appraise the effectiveness of the nursing interventions relative to the nursing diagnosis and the expected outcomes
a. Assess and report the fetus/neonate's response to nursing actions (for example: chart daily weight, chart colour and consistency of stool, chart response to feeding and bonding, report elevated bilirubin levels)
b. Revise the plan of care (for example: provide fluid in response to temperature elevation, refer mother to a home health care agency if the neonate's weight gain is poor)