8.1 Antenatal Assessment, Normal Labor, Delivery & Postpartum Care
Key Takeaways
Presumptive signs are subjective maternal symptoms, probable signs are objective examiner findings, and positive signs definitively confirm fetal existence via ultrasound, fetal heart tones, or palpated movement.
Naegele's rule calculates the EDD by subtracting 3 months and adding 7 days to the first day of the last menstrual period (LMP), adjusting the calendar year forward as appropriate.
The GTPAL system quantifies Gravidity, Term births (>=37 weeks), Preterm births (20–36.6 weeks), Abortions (<20 weeks), and Living children.
Magnesium sulfate for preeclampsia requires strict monitoring of patellar DTRs (+2), respirations (>=12/min), and urine output (>=30 mL/hr), with calcium gluconate immediately available.
Postpartum haemorrhage (500 mL or more within 24 hours, WHO) is managed through the 4 Ts with fundal massage, bladder emptying, uterotonics and tranexamic acid within 3 hours of birth.
Antenatal Assessment, Normal Labor, Delivery & Postpartum Care
Clinical Overview: Maternal and newborn nursing is a central pillar of Caribbean healthcare delivery. Registered nurses must master antenatal surveillance, intrapartum monitoring, and postpartum care. Rapidly identifying obstetric emergencies—such as preeclampsia, cord prolapse, and postpartum hemorrhage—and initiating immediate interventions is critical for safeguarding maternal and neonatal outcomes on the RENR.
Antenatal Diagnostic Indicators & Assessment
Diagnostic indicators of pregnancy are categorized into three distinct clinical tiers:
- Presumptive Signs (Subjective): Amenorrhea, nausea/vomiting, breast tenderness, urinary frequency, fatigue, and quickening (first fetal flutter felt at 16–20 weeks).
- Probable Signs (Objective): Positive hCG tests, Goodell's sign (cervical softening), Chadwick's sign (purplish cervix/vagina), Hegar's sign (softening of the uterine isthmus), uterine enlargement, ballottement, and Braxton Hicks contractions.
- Positive Signs (Definitive): Doppler fetal heart tones (10–12 weeks) or fetoscope detection (18–20 weeks), ultrasound visualization, and active fetal movements palpated by an experienced clinician.
Naegele's Rule & The GTPAL System
- Naegele's Rule for EDD: Assumes a 28-day cycle: EDD = First day of LMP - 3 months + 7 days + 1 year. Example: LMP November 18, 2025: subtract 3 months (August 18), add 7 days (August 25), advance year = August 25, 2026.
- GTPAL Obstetric Classification: Standardized record of Gravidity (total pregnancies), Term deliveries (>=37 weeks), Preterm deliveries (20–36.6 weeks), Abortions (<20 weeks), and Living children. Example: A currently pregnant client with one term birth, one surviving preterm child at 31 weeks, and one miscarriage at 8 weeks is G4-T1-P1-A1-L2.
Routine Antenatal Screening Protocols
- Blood Group & Rh Status: Unsensitized Rh-negative mothers receive Rho(D) immune globulin (RhoGAM) at 28 weeks and within 72 hours postpartum if the newborn is Rh-positive, preventing maternal alloimmunization.
- Sickle Cell Screen: Universal in Caribbean practice to identify sickle cell trait (HbAS) or disease (HbSS/HbSC) requiring specialized maternal surveillance.
- Infectious Disease Serology: VDRL/RPR for syphilis (treated with IM benzathine penicillin), rubella immunity, Hepatitis B surface antigen (HBsAg), and opt-out HIV screening to initiate prevention of mother-to-child transmission (PMTCT).
- Gestational Diabetes (GDM): Screen at 24–28 weeks. WHO and many Caribbean services use a one-step 75 g, 2-hour OGTT, diagnosing GDM if fasting glucose is 5.1 mmol/L or more, 1-hour 10.0 or more, or 2-hour 8.5 or more. Some services use a two-step 50 g challenge first, where 7.8 mmol/L (140 mg/dL) or more leads to a diagnostic OGTT.
Gestational Hypertensive Disorders & Magnesium Sulfate Protocol
- Gestational Hypertension: BP >=140/90 mmHg after 20 weeks gestation without proteinuria.
- Preeclampsia: BP >=140/90 mmHg after 20 weeks with proteinuria (>=1+ dipstick or protein/creatinine ratio >=0.3) or systemic signs: persistent severe headache, visual scotomata, hyperreflexia, thrombocytopenia (<100,000/μL), or epigastric/RUQ pain indicating hepatic capsule distension.
- Eclampsia: Tonic-clonic seizures in a preeclamptic client. Nursing priorities: Turn client to left lateral position, clear secretions, give oxygen via face mask, and call for emergency obstetric assistance. Never insert a tongue blade or restrain during convulsions.
Magnesium Sulfate Protocol & Toxicity Surveillance
Intravenous Magnesium Sulfate (4–6 g loading dose over 15–20 minutes, then 1–2 g/hour maintenance) prevents and controls eclamptic convulsions by depressing neuromuscular transmission:
| Assessment Parameter | Target Normal Finding | Manifestation of Magnesium Toxicity |
|---|---|---|
| Deep Tendon Reflexes (DTRs) | +2 (brisk, active) | Loss of patellar reflex (0 or +1) — earliest sign |
| Respiratory Rate | >=12 breaths/minute | Bradypnea (<12 breaths/min) or respiratory arrest |
| Urinary Output | >=30 mL/hour | Oliguria (<30 mL/hr) — causes rapid toxic drug accumulation |
| Neurological / Cardiac | Alert, oriented | Slurred speech, severe hypotension, cardiac arrest |
Emergency Toxicity Intervention: Stop infusion immediately, give high-flow oxygen, and administer antidote: Calcium gluconate 10% (1 g in 10 mL IV push over 3 minutes).
Intrapartum Care, FHR Monitoring & Cord Emergencies
Labor progresses through four physiological stages: First Stage (cervical dilation: latent 0–5 cm, active 6–10 cm); Second Stage (full dilation to infant birth; pushing); Third Stage (placental expulsion, 5–30 minutes); Fourth Stage (postpartum stabilization, 1–4 hours).
Electronic Fetal Monitoring: VEAL CHOP
Baseline FHR is 110–160 bpm with moderate variability (6–25 bpm). Decelerations are interpreted via VEAL CHOP:
- Variable Decelerations -> Cord Compression: Abrupt FHR drop. Action: Reposition client (left lateral or knee-chest), stop oxytocin, give oxygen.
- Early Decelerations -> Head Compression: Symmetrical FHR dip mirroring contraction peak. Action: Benign physiological event; continue observation.
- Accelerations -> OK / Well-Oxygenated: Transient rise >=15 bpm lasting >=15 seconds. Reassuring.
- Late Decelerations -> Placental Insufficiency: Symmetrical FHR drop starting after contraction peak and recovering late. Intrauterine resuscitation: Stop oxytocin immediately, turn client to left side, give oxygen at 8–10 L/min, bolus IV fluids, notify physician.
Amniotomy & Umbilical Cord Prolapse
Assess fetal heart rate immediately after rupture of membranes (AROM/SROM) to detect cord compression. In overt prolapse: insert a sterile gloved hand into the vagina and apply continuous upward pressure on the presenting part to relieve cord compression; assist mother into knee-chest or steep Trendelenburg position; cover exposed cord with warm sterile saline gauze; and prepare for immediate emergency Cesarean delivery.
Postpartum Assessment (BUBBLE-HE) & Hemorrhage
Postpartum assessment follows BUBBLE-HE: Breasts, Uterus (firm, midline at umbilicus, descending 1 cm/day; displaced right indicates urinary retention), Bladder, Bowels, Lochia, Episiotomy/Perineum (REEDA scale), Homans/DVT check (calf swelling, warmth or pain; Homans' sign itself is unreliable), and Emotions.
- Lochia Progression: Rubra (dark red, days 1–3), Serosa (pink-brown, days 4–10), Alba (yellowish-white, days 11–28+). Danger signs: Pad saturated in <=15 minutes, large clots, foul odor.
- Postpartum Hemorrhage (PPH): WHO defines PPH as blood loss of 500 mL or more within 24 hours of birth; 1,000 mL or more is severe. Many texts use more than 1,000 mL after caesarean. Visual estimates underestimate loss, so measure it and watch vital signs. Causes follow the 4 Ts: Tone (uterine atony, 70–80%), Trauma (lacerations/hematomas), Tissue (retained placenta), and Thrombin (coagulopathy).
- Uterine Atony Protocol:
- Call for help and massage the uterine fundus until firm.
- Empty the bladder with a catheter.
- Give uterotonics as prescribed: oxytocin (first-line, IV or IM), ergometrine/methylergonovine (IM; contraindicated in hypertension and pre-eclampsia), misoprostol (sublingual or rectal) or carboprost (IM; contraindicated in asthma).
- WHO also recommends IV tranexamic acid 1 g within 3 hours of birth for all PPH, alongside IV fluids and close monitoring.
- If bleeding continues, apply bimanual uterine compression while further treatment is prepared.
A client presents to the antenatal clinic for her first visit. She reports that the first day of her last normal menstrual period (LMP) was November 18, 2025. Applying Naegele's rule, what is her estimated date of delivery (EDD)?
August 11, 2026
September 25, 2026
August 25, 2026
August 18, 2026
A client with severe preeclampsia is receiving an intravenous infusion of magnesium sulfate at 2 g/hour. During hourly surveillance, the nurse notes absent patellar deep tendon reflexes (0), a respiratory rate of 10 breaths/minute, and a urine output of 18 mL over the past hour. Which action must the nurse take FIRST?
Administer a prescribed intravenous dose of hydralazine to lower blood pressure
Discontinue the magnesium sulfate infusion immediately and prepare calcium gluconate
Increase the primary intravenous infusion rate to flush the kidneys
Assist the client into a knee-chest position to optimize renal blood flow
A client in active labor at 39 weeks gestation receiving an oxytocin infusion displays recurring fetal heart rate decelerations that begin well after the peak of each uterine contraction and return to baseline after the contraction ends. What is the priority nursing intervention?
Administer a subcutaneous dose of terbutaline and encourage the client to ambulate
Assist the client into the lithotomy position and instruct her to bear down with contractions
Perform an immediate amniotomy to check for the presence of meconium-stained fluid
Discontinue the oxytocin infusion immediately and reposition the client onto her left side
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