5.1 Antepartum, Intrapartum & Postpartum Nursing Care

5.1 Antepartum, Intrapartum & Postpartum Nursing Care

Antepartum Care & Obstetrical Calculations

During the antepartum period, nursing care focuses on optimizing maternal and fetal health through regular monitoring, extensive education, and early identification of potential complications. One of the foundational clinical skills in obstetrics is calculating the estimated date of delivery (EDD) using Naegele's Rule. This standardized formula is vital for monitoring fetal growth and scheduling necessary interventions. To apply Naegele's rule, determine the first day of the client's last menstrual period (LMP), subtract 3 months, add 7 days, and adjust the year if necessary. For example, if the LMP was September 10, 2025, subtracting 3 months gives June 10, and adding 7 days yields an EDD of June 17, 2026. This calculation allows healthcare providers to properly time ultrasound screenings, glucose tolerance tests, and Group B Streptococcus (GBS) swabbing.

Another critical assessment tool utilized in the initial prenatal visit is the GTPAL system, which provides a comprehensive obstetrical history:

• G (Gravida): Total number of pregnancies, including the current one, regardless of outcome.
• T (Term): Number of pregnancies carried to 37 weeks gestation or beyond.
• P (Preterm): Number of pregnancies delivered between 20 weeks and 36 weeks and 6 days.
• A (Abortions): Number of pregnancies ending before 20 weeks (either spontaneous miscarriages or induced abortions).
• L (Living): Number of currently living children. Understanding a patient's GTPAL helps identify risks. For instance, a history of preterm births may warrant closer cervical monitoring or progesterone therapy to prevent recurrent preterm labor.

Routine prenatal visits generally occur every 4 weeks until 28 weeks, every 2 weeks until 36 weeks, and weekly thereafter until delivery. Key routine assessments include maternal blood pressure, weight gain tracking, fundal height measurement, fetal heart rate assessment, and urinalysis for protein and glucose. Fundal height in centimeters should roughly correlate with gestational age in weeks between 20 and 36 weeks. A discrepancy of more than 2 centimeters may indicate oligohydramnios, polyhydramnios, intrauterine growth restriction (IUGR), or a multiple gestation, necessitating an ultrasound evaluation.

High-risk conditions during the antepartum period require vigilant nursing management. Preeclampsia is characterized by new-onset hypertension (blood pressure >= 140/90 mmHg) and proteinuria after 20 weeks of gestation. Severe features may include unremitting headaches, visual disturbances (scotomata), right upper quadrant or epigastric pain (indicating liver involvement), and thrombocytopenia. The definitive cure is delivery of the fetus and placenta. However, management often includes antihypertensives (like Labetalol or Hydralazine) and Magnesium Sulfate for seizure prophylaxis. When administering Magnesium Sulfate, the nurse must closely monitor for signs of magnesium toxicity: loss of deep tendon reflexes, respiratory depression (respiratory rate < 12 breaths/min), and decreased urine output (< 30 mL/hr). The antidote, calcium gluconate, must be readily available at the bedside.

Gestational diabetes mellitus (GDM) is another common complication, typically screened for between 24 and 28 weeks using a 1-hour glucose challenge test. Management focuses on strict glycemic control through medical nutrition therapy, exercise, and sometimes pharmacological interventions like insulin or metformin. Poorly controlled GDM can lead to fetal macrosomia, increasing the risk of birth trauma (e.g., shoulder dystocia) and profound neonatal hypoglycemia postpartum.

Intrapartum Care & Fetal Monitoring

The intrapartum period, commonly known as labor and delivery, is clinically divided into four distinct stages.

• First Stage: Begins with the onset of true, regular contractions leading to complete cervical dilation (10 cm). It consists of three progressive phases: Latent phase (0-3 cm dilation, mild contractions), Active phase (4-7 cm, stronger and closer contractions), and Transition phase (8-10 cm, intense contractions, often accompanied by maternal nausea, trembling, and an urge to push).
• Second Stage: Spans from complete cervical dilation to the delivery of the neonate. Nursing priorities include coaching maternal pushing efforts, positioning for optimal pelvic opening, and continuously monitoring the fetal heart rate (FHR) to ensure the fetus tolerates the descent.
• Third Stage: Begins after the delivery of the neonate and ends with the delivery of the placenta. Signs of placental separation include a sudden gush of dark blood, lengthening of the umbilical cord, and the uterus becoming firm and globular.
• Fourth Stage: Encompasses the first 1-4 hours postpartum. This is a critical period for maternal stabilization, promoting bonding, and monitoring closely for postpartum hemorrhage.

Continuous or intermittent electronic fetal monitoring is employed to assess fetal well-being and oxygenation during labor. Nurses must quickly and accurately interpret FHR patterns. The baseline should be 110-160 beats per minute with moderate variability. The VEAL CHOP mnemonic is essential for interpreting periodic changes:

• V (Variable decelerations) correlate with C (Cord compression). These are abrupt drops in FHR, often V or W shaped. Nursing Interventions: Change maternal position, administer oxygen, stop oxytocin if infusing, and potentially assist with an amnioinfusion.
• E (Early decelerations) correlate with H (Head compression). These mirror the contraction. Intervention: None required; they are a normal physiological response. Prepare for imminent delivery.
• A (Accelerations) correlate with O (Okay/Reassuring). These indicate an intact fetal central nervous system and adequate oxygenation. Intervention: Document and continue monitoring.
• L (Late decelerations) correlate with P (Placental insufficiency). These drop after the peak of the contraction. Intervention: This is an emergency requiring intrauterine resuscitation! Turn the patient to the left lateral position to optimize blood flow, administer an IV fluid bolus, provide oxygen via non-rebreather mask at 8-10 L/min, stop oxytocin immediately, and notify the healthcare provider.

Pain management during labor is individualized. Non-pharmacological methods include breathing techniques, hydrotherapy, counterpressure (especially for back labor caused by an occiput posterior fetal position), and effleurage. Pharmacological options include systemic opioid analgesics (which should be avoided close to delivery due to neonatal respiratory depression) and regional anesthesia (epidural). If an epidural is administered, the nurse must closely monitor for maternal hypotension, a common and potentially dangerous side effect that can lead to decreased placental perfusion and fetal distress. Pre-hydration with an isotonic IV fluid bolus is standard proactive practice to mitigate this risk.

Postpartum Nursing Care & Complications

The postpartum period involves significant physiological, hormonal, and psychological adaptations. The primary immediate complication to monitor for is Postpartum Hemorrhage (PPH), traditionally defined as blood loss greater than 500 mL for a vaginal delivery or 1,000 mL for a cesarean section.

The most common cause of PPH is uterine atony (failure of the uterus to contract). Nursing interventions for a boggy (soft) uterus include immediate, vigorous fundal massage until the uterus becomes firm, ensuring the bladder is empty (a distended bladder displaces the uterus up and to the right, preventing effective contraction), and administering prescribed uterotonic medications. Common uterotonics include Oxytocin (Pitocin), Methylergonovine (Methergine), Misoprostol (Cytotec), or Carboprost (Hemabate). Crucially, Methergine is contraindicated in patients with hypertension or preeclampsia, and Hemabate is contraindicated in patients with asthma.

Lochia, the postpartum vaginal discharge consisting of blood, tissue, and mucus, progresses through three distinct stages:

1. Lochia rubra: Dark red, containing small clots, lasts 3-4 days.
2. Lochia serosa: Pinkish-brown, indicating healing, lasts 4-10 days.
3. Lochia alba: Yellowish-white, mostly leukocytes and decidua, lasts up to 6 weeks. Saturating a perineal pad in less than 1 hour or passing clots larger than a golf ball requires immediate medical evaluation as it indicates excessive bleeding.

Nurses must also assess the perineum, especially if an episiotomy or laceration occurred, using the REEDA acronym: Redness, Edema, Ecchymosis, Discharge, and Approximation of wound edges. Comfort measures include applying ice packs for the first 24 hours to reduce swelling, followed by warm sitz baths to promote circulation and healing, topical anesthetic sprays, and oral analgesics like ibuprofen.

Breastfeeding education and support are vital nursing roles. Educate mothers on establishing a proper latch (incorporating the nipple and much of the areola) to prevent painful nipple trauma, and encourage frequent feeding (every 2-3 hours) on demand to stimulate prolactin and milk production. For non-breastfeeding mothers, education focuses on lactation suppression: wearing a tight, supportive bra continuously for 72 hours, avoiding any breast stimulation (including warm water in the shower), and applying cold cabbage leaves or ice packs to reduce engorgement.

Psychological assessments are equally important. Nurses should screen for postpartum blues (a common, transient condition of mood lability resolving within 2 weeks), postpartum depression (persistent sadness and inability to care for oneself or the infant, requiring intervention), and postpartum psychosis (a rare psychiatric emergency characterized by delusions and thoughts of harming the infant). Comprehensive discharge teaching must encompass warning signs of infection (fever, foul-smelling lochia), deep vein thrombosis (DVT) precautions, and contraception planning, as ovulation can return before the resumption of the first menstrual period.