5.2 Maternal, Child & Family-Centred Healthcare
Key Takeaways
- Postpartum Hemorrhage (PPH) is defined as blood loss ≥500 mL following vaginal delivery or ≥1000 mL following cesarean; immediate management prioritizes fundal massage, uterine tonics (oxytocin, ergometrine, misoprostol), and fluid replacement according to the 4 Ts (Tone, Tissue, Trauma, Thrombin).
- Preeclampsia is diagnosed by hypertension (BP ≥140/90 mmHg after 20 weeks) with proteinuria or end-organ dysfunction; severe features require magnesium sulfate seizure prophylaxis with mandatory monitoring of deep tendon reflexes, respiratory rate (≥12/min), and urine output (≥30 mL/h).
- The Well Child Tamariki Ora framework provides universal health screening, immunization, and growth monitoring for children in New Zealand from birth to 5 years, supporting whānau-centred health outcomes.
- Pediatric initial assessment utilizes the Pediatric Assessment Triangle (PAT) evaluating Appearance, Work of Breathing, and Circulation to Skin to rapidly identify severity of illness without physical contact.
- Under the Oranga Tamariki Act 1989, registered nurses in New Zealand have a professional duty to recognize indicators of child abuse/neglect, document objective findings, and escalate child protection concerns to multidisciplinary safety teams.
5.2 Maternal, Child & Family-Centred Healthcare
Maternal & Obstetric Nursing Care
Antenatal & Intrapartum Assessment
Maternal nursing care requires a deep understanding of pregnancy-induced anatomical and physiological adaptations, alongside vigilance for obstetric emergencies. Physiological changes during pregnancy include a 40–50% increase in circulating blood volume, increased cardiac output, physiological anemia of pregnancy due to hemodilution (plasma volume expands faster than red cell mass), elevated diaphragm reducing functional residual capacity, and increased glomerular filtration rate (GFR). Antenatal care involves systematic maternal assessment and fetal surveillance. Electronic fetal monitoring via Cardiotocography (CTG) evaluates fetal well-being during labor. Normal baseline fetal heart rate ranges between 110–160 beats per minute (bpm) with moderate baseline variability (5–25 bpm). Accelerations (abrupt increases ≥15 bpm lasting ≥15 seconds) indicate fetal reactivity and oxygenation. Decelerations are categorized into: Early decelerations (mirror uterine contractions, caused by fetal head compression, benign); Variable decelerations (abrupt drop in FHR, caused by umbilical cord compression, relieved by maternal position change); and Late decelerations (gradual drop in FHR starting after contraction peak and returning to baseline after contraction ends, indicating uteroplacental insufficiency and fetal hypoxia). Late decelerations require immediate resuscitation: position mother on left side, administer high-flow oxygen, stop oxytocin infusion, give IV fluid bolus, and prepare for emergency delivery.
Postpartum Hemorrhage (PPH) Management
Postpartum Hemorrhage (PPH) is one of the leading causes of maternal mortality worldwide. Primary PPH occurs within 24 hours of delivery and is defined as blood loss ≥500 mL following vaginal delivery or ≥1000 mL following cesarean section (or any blood loss causing hemodynamic instability). Secondary PPH occurs between 24 hours and 6 weeks postpartum. Nursing assessment and management follow the "4 Ts" framework:
- Tone (Uterine Atony - accounts for 70% of PPH): Assessed by palpable soft, boggy uterus above the umbilicus. Immediate action: fundal massage (rubbing the fundus until firm) and continuous uterine expression of clots.
- Tissue (Retained placenta or membranes): Inspected by examining the placenta for missing cotyledons; requires manual exploration or surgical curettage.
- Trauma (Genital tract lacerations or uterine rupture): Characterized by a firm fundus with continuous trickle of bright red blood; requires surgical repair.
- Thrombin (Coagulopathy): Characterized by oozing from IV sites or failure of blood to clot; requires blood products (packed red blood cells, fresh frozen plasma, platelets, cryoprecipitate). First-line pharmacological management for PPH includes: Oxytocin 10 units IM or 20–40 units in 1 L 0.9% NaCl IV infusion; Ergometrine 250–500 mcg IM (contraindicated in preeclampsia/hypertension); Misoprostol 800–1000 mcg rectally; and IV Tranexamic Acid (TXA) 1 g over 10 minutes administered within 3 hours of birth. Nursing priorities include calling for emergency assistance, inserting two 16-gauge IV cannulas, administering oxygen, inserting a Foley catheter to empty the bladder (a full bladder prevents uterine contraction), and monitoring blood pressure and pulse every 5 minutes.
Preeclampsia & Eclampsia
Preeclampsia is a multisystem hypertensive disorder diagnosed after 20 weeks of gestation, characterized by new-onset systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg on two occasions at least 4 hours apart, accompanied by proteinuria (≥300 mg in 24-hour urine or urine protein:creatinine ratio ≥0.3) or end-organ dysfunction (thrombocytopenia <100,000/mcL, elevated liver transaminases, serum creatinine >90 mcmol/L, pulmonary edema, or visual/neurological symptoms). Severe features include BP ≥160/110 mmHg, severe persistent headache, epigastric or right upper quadrant pain, hyperreflexia with clonus, and visual disturbances. Magnesium Sulfate (MgSO4) is the drug of choice for eclampsia seizure prophylaxis and treatment. The regimen comprises a loading dose of 4 g IV over 15–20 minutes, followed by a continuous infusion of 1 g/hour. The nurse must perform mandatory safety monitoring before and during MgSO4 administration: patellar (deep tendon) reflexes must be present, respiratory rate must be ≥12 breaths/minute, and urine output must be ≥30 mL/hour. The first sign of magnesium toxicity is loss of deep tendon reflexes (occurs at serum level 3.5–5.0 mmol/L), followed by respiratory depression (>6.0 mmol/L) and cardiac arrest (>12 mmol/L). If toxicity occurs, stop the infusion immediately and administer the antidote: Calcium Gluconate 1 g (10 mL of 10% solution) IV over 10 minutes.
Neonatal Care & The Well Child Tamariki Ora Framework
Neonatal Assessment & Resuscitation
Immediate neonatal care focuses on establishing respiratory gas exchange and thermoregulation. The APGAR score evaluates neonatal transition at 1 and 5 minutes post-birth across 5 parameters scored 0–2: Appearance (color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (respiratory effort). A score of 7–10 indicates good transition; 4–6 indicates moderate depression requiring tactile stimulation and oxygen; 0–3 indicates severe distress requiring immediate neonatal resuscitation. Neonatal Resuscitation Protocol: Keep infant warm under radiant warmer, dry thoroughly, reposition head into "sniffing position", clear airway if obstructed, and provide tactile stimulation. If heart rate is <100 bpm or gasping/apneic, initiate positive pressure ventilation (PPV) with room air (21% O2) at 40–60 breaths/minute using a T-piece resuscitator or bag-valve-mask. If heart rate remains <60 bpm despite 30 seconds of effective PPV, increase O2 to 100%, initiate chest compressions at a 3:1 ratio (90 compressions and 30 breaths per minute), and prepare IV epinephrine.
Well Child Tamariki Ora Framework (New Zealand)
The Well Child Tamariki Ora (WCTO) framework is New Zealand's universal child health and development service provided to all children from birth to 5 years of age. Delivered collaboratively by Lead Maternity Carers (LMCs), Tamariki Ora nurses (such as Plunket and Iwi health providers), and General Practice, the framework ensures equitable access to growth monitoring, developmental screening, immunization, and family health education. The WCTO schedule mandates 8 core contacts: birth to 6 weeks (LMC transition), 6 weeks (GP & Tamariki Ora nurse check, 6-week immunizations), 3–5 months, 5–7 months, 9–12 months, 15–18 months, 3 years, and the B4 School Check at 4 years. Assessment components include: WHO growth chart monitoring (weight, height/length, head circumference), screening for developmental delay, vision (photoscreening) and hearing (swept-frequency audiometry) checks, oral health risk screening, maternal mental health evaluation using the Edinburgh Postnatal Depression Scale (EPDS), and promoting the National Immunisation Schedule (including DTaP-IPV-HepB-Hib at 6 weeks, 3 months, 5 months; PCV13; MMR at 12 months and 15 months; and Rotavirus).
Pediatric Nursing Assessment & Child Protection
Pediatric Assessment Triangle (PAT)
Pediatric assessment begins with the Pediatric Assessment Triangle (PAT), a rapid non-touch observational tool that allows nurses to evaluate a child's clinical acuity within 30 seconds:
- Appearance: Evaluated using the TICLS mnemonic—Tone (active vs limp), Interactivity (alert vs lethargic), Consolability (soothed by caregiver vs inconsolable), Look/Gaze (fixed gaze vs eye contact), Speech/Cry (strong vs weak/moaning).
- Work of Breathing: Observed for tachypnea, nasal flaring, intercostal/subcostal retractions, head bobbing, grunting, or stridor.
- Circulation to Skin: Observed for pallor, mottling, or central cyanosis. Anatomical and physiological differences in children include: smaller airway diameter (1 mm of mucosal edema reduces airway cross-sectional area by 75% in infants), higher metabolic rate requiring higher oxygen consumption (6–8 mL/kg/min vs 3–4 mL/kg/min in adults), compliant chest wall leading to early intercostal retractions, and blood volume of ~80 mL/kg (meaning small absolute blood loss causes severe hypovolemic shock).
Developmental Milestones (0–5 Years)
- 2–3 Months: Holds head up, tracks objects past midline, coos, social smile.
- 6 Months: Rolls front to back, sits with support, transfers objects hand-to-hand, babbles.
- 9–12 Months: Pulls to stand, pincer grasp, says "mama/dada", plays peek-a-boo.
- 18–24 Months: Runs, kicks ball, builds tower of 4–6 blocks, 20–50 words, 2-word phrases.
- 3–4 Years: Rides tricycle, uses scissors, speaks in complete sentences, cooperative play.
Child Protection & Oranga Tamariki Act 1989
Child Protection under the Oranga Tamariki Act 1989 & Children's Act 2014 obligates New Zealand registered nurses to safeguard vulnerable children. Nurses must recognize physical abuse indicators (unexplained bruises on non-ambulatory infants, pattern burns, multiple fractures in various stages of healing), neglect (severe diaper dermatitis, failure to thrive, unaddressed medical needs), and emotional/sexual abuse. When child maltreatment is suspected, nurses must record objective, verbatim statements and detailed wound measurements/diagrams, report concerns to the hospital child protection team, and make a formal notification to Oranga Tamariki (Ministry for Children) or the New Zealand Police.
| Developmental Stage | Key Gross & Fine Motor Milestones | Language & Social Milestones |
|---|---|---|
| 2–3 Months | Holds head steady, lifts head 45° when prone, tracks objects past midline | Coos, vocalises response to voice, social smile |
| 6 Months | Rolls front-to-back, sits with support, transfers objects hand-to-hand | Babbles consonant sounds, responds to own name, laughs |
| 9–12 Months | Pulls to stand, cruises on furniture, 2-finger pincer grasp | Says 'mama/dada' specifically, plays peek-a-boo, waves bye-bye |
| 18–24 Months | Runs smoothly, kicks ball, builds tower of 4-6 blocks | 20-50 words, 2-word phrases ('want milk'), parallel play |
| 3–4 Years | Rides tricycle, jumps off step, cuts with scissors, holds pencil with tripod grip | 3-4 word sentences, asks 'why', cooperative play, dresses self |
A midwife and nurse are managing a primary Postpartum Hemorrhage (PPH) following a normal vaginal delivery. Upon abdominal palpation, the nurse notes that the fundus is soft, boggy, and located 2 cm above the umbilicus. What is the single most important immediate nursing action?
A pregnant woman at 34 weeks gestation with severe preeclampsia is receiving a continuous IV infusion of Magnesium Sulfate (MgSO4) for eclampsia prophylaxis. During safety monitoring, the nurse notes: BP 148/92 mmHg, Heart Rate 78 bpm, Respiratory Rate 10 breaths/minute, Patellar reflexes absent, Urine output 20 mL in the last hour. What is the priority nursing action?
At what post-delivery time intervals is the APGAR score systematically calculated to evaluate a newborn's initial physiological transition?
A nurse is conducting a rapid initial assessment of a 2-year-old child using the Pediatric Assessment Triangle (PAT). Which three distinct components form the PAT framework?