أساسيات الأمومة والولادة
Naegele, GTPAL, fundal height, labor, Apgar, postpartum.
الأمومة والولادة
Pregnancy basics
- Naegele's rule: first day of LMP + 7 days − 3 months + 1 year. LMP 10 Aug → EDD 17 May.
- GTPAL: Gravida (all pregnancies, including the current one), Term (≥ 37 wk), Preterm (20–36⁶⁄₇ wk), Abortions (< 20 wk), Living children. Twins count as one birth.
- Fundal height: 12 wk just above the symphysis · 16 wk halfway to the umbilicus · 20 wk at the umbilicus · 36 wk at the xiphoid. From 20–36 wk, cm ≈ weeks.
- Visits: every 4 weeks until 28 wk, every 2 weeks from 28–36 wk, weekly from 36 wk.
- Screening: GDM glucose challenge at 24–28 wk; Group B strep swab at 35–37 wk; anti-D (RhoGAM) at 28 wk and within 72 h of delivery or any bleeding, abortion or trauma in Rh-negative mothers.
- Folic acid 400 mcg daily before conception (4 mg if there was a previous neural tube defect).
- Live vaccines (MMR, varicella) are not given in pregnancy; Tdap and inactivated influenza are recommended. Rubella-non-immune mothers are vaccinated postpartum.
Recommended weight gain
| Pre-pregnancy BMI | Total gain |
|---|---|
| Underweight (< 18.5) | 12.5 – 18 kg |
| Normal (18.5 – 24.9) | 11.5 – 16 kg |
| Overweight (25 – 29.9) | 7 – 11.5 kg |
| Obese (≥ 30) | 5 – 9 kg |
Labor
| Stage | From → to | Nursing focus |
|---|---|---|
| First — latent | Onset → about 3–6 cm | Support, ambulation, hydration |
| First — active / transition | About 4–6 cm → 10 cm | Pain relief, FHR monitoring, bladder, position changes |
| Second | Full dilation → birth of the baby | Coach pushing; FHR every 5–15 min |
| Third | Birth → delivery of the placenta | Signs of separation; check the placenta is complete |
| Fourth | First 1–4 h after the placenta | Fundus, lochia and vital signs every 15 min (hemorrhage risk) |
- True labor: regular contractions that get stronger, start in the back and radiate forward, and change the cervix. False (Braxton Hicks): irregular, felt in the abdomen, relieved by walking, no cervical change.
- Contraction frequency is timed from the start of one contraction to the start of the next.
- Normal FHR is 110–160 bpm. VEAL CHOP: Variable decelerations = Cord compression (reposition); Early = Head compression (normal); Accelerations = OK; Late = Placental insufficiency (left side, O₂, stop oxytocin, IV fluids, notify).
- Tachysystole on oxytocin (more than 5 contractions in 10 min): stop the oxytocin first.
- Epidural: the main complication is maternal hypotension — check BP often.
Apgar score (1 and 5 minutes)
| Sign | 0 | 1 | 2 |
|---|---|---|---|
| Heart rate | Absent | < 100 | ≥ 100 |
| Respiratory effort | Absent | Slow, irregular, weak cry | Good, strong cry |
| Muscle tone | Limp | Some flexion | Active motion |
| Reflex irritability | None | Grimace | Cry, cough, sneeze |
| Color | Blue or pale | Body pink, extremities blue | Completely pink |
Postpartum
- Lochia: rubra (red) days 1–3 → serosa (pink-brown) days 4–10 → alba (white) from day 10. A fleshy odor is normal; a foul odor suggests infection.
- The fundus is at the umbilicus after birth, descends about 1 cm/day, and is not palpable by 10–14 days.
- Boggy uterus → massage the fundus first. Fundus high and deviated to the right → full bladder → help her void.
- Bleeding with a firm uterus → laceration. PPH causes: the 4 Ts — Tone (atony, most common), Trauma, Tissue (retained placenta), Thrombin.
- REEDA for the perineum: Redness, Edema, Ecchymosis, Discharge, Approximation.
- Puerperal fever: ≥ 38 °C on 2 of the first 10 days, excluding the first 24 h. Up to 38 °C in the first 24 h is usually dehydration.
- Rubin's phases: taking-in (days 1–2, dependent) → taking-hold (independent, eager to learn) → letting-go.
- Blues (days 3–10, resolves within 2 weeks) vs depression (> 2 weeks) vs psychosis (hallucinations — emergency).
- Mastitis: usually Staph aureus. Antibiotics (full course) and CONTINUE breastfeeding. Engorgement: frequent feeding every 2–3 h, day and night.
Complications
| Condition | Key signs | Key nursing points |
|---|---|---|
| Placenta previa | Painless, bright red bleeding, soft uterus | No vaginal exams; ultrasound |
| Placental abruption | Painful, rigid, board-like abdomen; bleeding may be concealed | Emergency; monitor for shock and fetal distress |
| Preeclampsia | BP ≥ 140/90 after 20 wk, proteinuria, headache, visual changes, edema | Left lateral rest, magnesium sulfate for seizure prevention |
| Magnesium toxicity | RR < 12, absent deep tendon reflexes, urine < 30 mL/h | Stop the infusion; antidote calcium gluconate |
| Hydatidiform mole | Uterus larger than dates, very high hCG, dark bleeding, hyperemesis | Avoid pregnancy for about 1 year while hCG is followed |
| Ectopic pregnancy | Unilateral pain, spotting, uterus smaller than dates | Rupture → shock (emergency) |
| Gestational diabetes | Found at 24–28 wk | Diet and exercise first; baby at risk of macrosomia and hypoglycemia |
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