Drugs Used in Obstetrics

Objectives

1 Describe nursing assessments and nursing interventions needed for the pregnant patient.

2 Identify potential obstetric complications and appropriate nursing assessments.

3 Summarize the care needs of the pregnant woman during labor and delivery and the immediate postpartum period, including the patient education needed before discharge to promote safe self-care and care of the newborn.

4 State the actions, primary uses, nursing assessments, and monitoring parameters for uterine stimulants, uterine relaxants, clomiphene citrate, and magnesium sulfate.

5 Describe specific nursing concerns and appropriate nursing actions when uterine stimulants are administered for induction of labor, augmentation of labor, and postpartum atony and hemorrhage.

6 Identify what tocolysis means and what the nursing responsibilities are related to the management of preterm labor.

7 Identify the action and proper timing of the administration of Rho(D) immune globulin.

Key Terms

pregnancy hypertension disorders ( ) (p. 623)

lochia () (p. 625)

precipitous labor and delivery () (p. 630)

augmentation () (p. 630)

dysfunctional labor () (p. 630)

http://evolve.elsevier.com/Clayton

Obstetrics

Nursing Implications for Obstetrics

Assessment

Prenatal Assessment.

Obtain basic historical information about the woman and family concerning acute or chronic conditions, surgeries, and deaths.

• Has the patient been treated for kidney or bladder problems; high blood pressure; heart disease; rheumatic fever; hypothyroidism or hyperthyroidism; diabetes mellitus; allergies to any foods, drugs, or environmental substances; or sexually transmitted infections (STIs)?

• Has the patient been exposed to any communicable diseases since becoming pregnant?

• Has the patient received blood or blood products?

• Does the patient smoke or use any substances of abuse (e.g., illicit drugs, alcohol)?

If the woman answers yes to any of these questions, find out which health care provider made the diagnosis, when the disorder occurred, and how the disorder was treated. Request the approximate date of the last Papanicolaou (Pap) test and results.

Gather data about menstrual pattern (e.g., age of initial onset, duration and frequency of monthly periods, date of last full menstrual cycle, any bleeding since the last full menstrual period), and contraceptive use (e.g., condoms, foam, diaphragm, sponge, oral contraceptives, intrauterine devices).

Take an obstetric history. Ask the woman if she has had any previous live births, stillbirths, or spontaneous or therapeutic abortions. If any of the deliveries were premature, obtain additional information about the infant’s gestational age, survival of the child, suspected causes of prematurity, and infections. Ask whether any of the births required a cesarean delivery. If yes, ask why. Ask if Rho(D) immune globulin (RhoGAM) has been given for Rh factor incompatibility.

Nutritional History

• What is the patient’s usual or prepregnant weight? How much weight has she gained or lost in the past 3 months?

• What are the woman’s favorite foods? Are there any foods that she avoids? How often does she eat? What has she eaten in the past 3 days? Does she normally take daily vitamins, minerals, or herbal products?

• Are there any cultural food practices to be maintained during the pregnancy?

Elimination Pattern

• What is the patient’s elimination pattern?

• How often does she have bowel movements?

• What is the stool consistency and color?

• Is there any bleeding?

• Are laxatives ever needed? If so, how often?

Psychosocial Culture History

• Determine how the woman feels about this pregnancy (e.g., excited, nervous, or if the baby is not intended).

• Determine cultural patterns regarding prenatal care (e.g., language spoken, activities that she cannot do while pregnant, whether she prefers a female caregiver). Ask the pregnant woman what specific cultural practices she would like to follow during the pregnancy.

• Who makes up her support group: husband, boyfriend, friends, partner, family, tribal healer?

• Ask about her employment status and what type of work she performs.

• Determine the woman’s level of education, economic status, and general interest in learning more about effective management of the pregnancy. Will referral to social services agencies be necessary?

Medication History.

Ask the woman if she takes any prescribed medications, over-the-counter (OTC) medications, or herbal remedies. If she is not currently taking any medications, ask whether she has taken any over the past 6 months. Determine which have been prescribed and for what purpose.

Determine the use of alcohol and street or recreational drugs of any type, including what, how much, and how frequently.

Physical Examination.

Assist the woman to undress and prepare for examination, including a pelvic examination and Pap smear.

• Height and weight: Record height and weight. (See an obstetric textbook for a detailed guide to all aspects of a prenatal visit and the initial assessments performed.)

• Hypertension: Take the blood pressure. Ask if any treatment has been given for high blood pressure. If so, inquire about the onset, treatment, and degree of control achieved.

• Heart rate: At prenatal visits, count the pulse for 1 full minute. Report irregularities in rate, rhythm, or volume. On subsequent visits, anticipate an increase in rate of approximately 10 beats/min during the course of the pregnancy.

• Respirations: Record the rate of respirations. As the pregnancy progresses, observe for hyperventilation and thoracic breathing.

• Temperature: If the temperature is elevated, ask about any signs of infection or exposure to people with known communicable diseases.

• Laboratory and diagnostic studies: Obtain a urine specimen using the clean-catch method.

• Blood tests: Testing for complete blood count (CBC), hemoglobin, hematocrit, hemoglobin electrophoresis, rubella titer, Rh factor, and STIs (e.g., syphilis, gonorrhea, chlamydia) may be ordered at this initial visit. These may include antibody, sickle cell, and thalassemia screen, folic acid level, and, as appropriate, purified protein derivative, human immunodeficiency virus (HIV), hepatitis B screen, and toxicology screen. With a history of diabetes, hypertension, or renal disease, additional laboratory testing may be ordered (e.g., 1-hour glucose tolerance, creatinine clearance, total protein excretion).

Assessment During First, Second, and Third Trimesters.

Assessment done at routine visits during the pregnancy includes weight; measurement of blood pressure, pulse, and respirations; and examination of the abdomen, with measurement of fundal height and fetal heart sounds. Any problems or concerns should be discussed. Hemoglobin and hematocrit may be periodically rechecked.

The pregnant woman who does not experience complications is usually examined monthly for the first 6 months, every 2 weeks in the seventh and eighth months, and weekly during the last month. Vaginal examinations are usually performed on the initial visit and are not repeated until 2 to 3 weeks before the estimated date of delivery or estimated date of birth, or due date, at which time the cervical status, degree of engagement, and fetal presentation are evaluated. A sonogram may be obtained in early pregnancy.

Assessment of the Pregnant Patient at Risk.

Assess for signs and symptoms of potential obstetric complications (see an obstetrics text for further details of each complication): infection, hyperemesis gravidarum, abortion, preterm labor, premature rupture of membranes (PROM), gestational diabetes, preeclampsia, HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, and intrauterine fetal death.

• Infection: Record the patient’s temperature. Report any elevations to the health care provider immediately for further evaluation. As appropriate, obtain urine for urinalysis.

• Hyperemesis gravidarum: Obtain details of persistent, severe vomiting.

• Early pregnancy loss, placental separation, abortion: Assess for signs of bleeding. Gather specific information about the onset, duration, volume (number of pads used), and color, and report any clots or tissue.

• Ask the patient to describe any pain experienced using a scale of 0 to 10. Has she had any backache or pelvic cramping, sharp abdominal pain, faintness, or pain in the shoulder area?

• Vital signs should be taken and compared with baseline data whenever bleeding is suspected. Assess for development of shock—restlessness, perspiration, pallor, clammy skin, dyspnea, tachycardia, and blood pressure changes. Record fetal heart tones at regular intervals.

• Preterm labor: Preterm labor is defined as:

• Labor occurring after 20 and before 37 completed weeks of gestation plus

• Clinically documented uterine contractions (4/20 minutes or 6/60 minutes) plus

• Ruptured membranes or

• Intact membranes and cervical dilation greater than 2 cm or

• Intact membranes and cervical effacement greater than 80% or

• Intact membranes and cervical change during observation.

These can be measured by changes in dilation or effacement, or by changes in cervical length measured clinically, or by ultrasound.

A fetal fibronectin test (FFN) may be ordered to assess the presence of preterm labor in patients whose presenting symptoms are questionable so that early intervention (e.g., tocolytic therapy, corticosteroids, transport to a tertiary center) can be initiated when indicated or, if negative, unnecessary interventions can be avoided. This test is for women with intact membranes and cervical dilation of less than 3 cm. This test may detect the probability of preterm labor from 24 to 34 weeks’ gestation. If the test is negative, the patient is unlikely to experience preterm delivery in the next 7 to 14 days (Figure 40-1). Home uterine activity monitoring using a tocodynamometer may be used to detect excessive uterine contractions.

• Premature rupture of membranes: Assess for and obtain specifics of any signs of leakage of amniotic fluid from the vagina.

• Gestational diabetes: Review urinalysis reports for glycosuria. Review history of symptoms, especially during previous pregnancies. Review 1- and 3-hour glucose tolerance blood test results.

• Pregnancy hypertension disorders: Assess for and report sudden hypertension (an elevation of systolic pressure 30 mm Hg or more above prior readings, systolic blood pressure of 140 mm Hg or more, or diastolic pressure of 90 mm Hg or more). Pregnancy hypertension disorders include preeclampsia (elevated blood pressure, proteinuria due to hypoperfusion secondary to a vasospastic process that affects the fetus, the placenta, and maternal organs and vasculature) and eclampsia (convulsions accompanying preeclampsia).

• Assess for edema of any body parts (e.g., fingers, hands, face, legs, ankles). Assess hydration status, and, in particular, obtain daily weights.

Life Span Considerations

The status of the fetus may be assessed by fetal movement counts, contraction stress testing, biophysical profile, and ultrasonography for placental placement and measurement of maturity indicators. Amniocentesis may be performed to assess fetal lung maturity and detect fetal disorders.

Review laboratory reports for indications of abnormal electrolytes, elevated uric acid or hematocrit levels, thrombocytopenia, and the presence of red blood cells (RBCs) and protein in the urine.

• Assess for signs and symptoms of seizure activity.

• Monitor fetal heart rate and movements.

• Assess for start of labor or signs of other complications such as pulmonary edema, disseminated intravascular coagulation (DIC), heart failure, abruptio placentae, or cerebral hemorrhage.

When giving magnesium sulfate for preeclampsia, assess deep tendon reflexes, respiratory status (report depression), sedation level, intake and output, seizure precautions, and cardiac status. (Always have calcium gluconate, the antidote for magnesium sulfate, available.)

Assessment During Normal Labor and Delivery

History of Pregnancy.

On admission to the hospital, obtain the following information:

• Name and age

• Obstetric history (gravida, para, abortions, fetal deaths, birth weight of previous children, and complications during previous deliveries)

• Estimated due date, estimated gestational age, and day of last menstrual period

• Prenatal care (type and amount, any significant problems)

• Prenatal education (type and extent of childbirth preparation)

• Plan for infant feeding

• Status of membranes (intact, ruptured, time ruptured, amount, and color of fluid that escaped)

• Status of labor (time of onset of contractions, frequency, duration and intensity, how patient is coping with contractions)

• Time of last meal

Physical Examination.

The physical examination should include the following:

• Height, weight, vital signs (temperature, blood pressure, pulse, and respirations)

• State of hydration, including presence of edema

• Size and contour of abdomen and fundus

• Frequency of contractions

• Fetal heart rate

• Vaginal examination: cervical dilation and effacement, status of membranes, and presentation and position of fetus

Assessment After Delivery and During Postpartum Care

• The vital signs should be checked every 15 minutes during the first hour or until the woman is stable, then every 30 minutes for the next 2 hours.

• Inspect the perineum and note any abnormal swelling or bruising.

• Assess fundal height and firmness every 15 minutes for 1 hour, then every 30 minutes for the next 4 hours. Continue to assess fundal height and position until the woman is discharged.

• Describe the amount of lochia (vaginal discharge after delivery) and the color and the presence of clots every 15 minutes for 1 hour, every 30 minutes for 4 hours, and at least every 4 hours for the next 12 hours or as needed (PRN).

• Assess breasts for redness, softness, and nipple condition. Encourage early feedings with normal newborns as allowed. Check for breast engorgement and discomfort.

Assessment of the Neonate

• Ensure a patent airway.

• Observe umbilical cord until pulsations cease, then clamp or ligate it.

• Assess neonate’s health status at 1 minute and 5 minutes after delivery using the Apgar scoring system (Table 40-1).

• Perform rapid estimation of gestational age (Table 40-2).

Table 40-1

Apgar Scoring System

SIGN	SCORE
SIGN	0	1	2
Heart rate (beats/min)	Absent	Slow (below 100)	Over 100
Respiratory effort	Absent	Slow, irregular	Good, crying
Muscle tone	Flaccid	Some flexion of extremities	Active motion
Reflex irritability	No response	Grimace	Cry
Color	Blue, pale	Body pink, extremities blue	Completely pink

Table 40-2

Gestational Age

SITES	FEATURES
SITES	36 WEEKS OR LESS	37-38 WEEKS	39 WEEKS OR MORE
Sole creases	Anterior transverse creases only	Occasional creases, anterior two thirds	Sole covered with creases
Breast nodule diameter (mm)	2	4	7
Scalp hair	Fine, fuzzy	Fine, fuzzy	Coarse and silky
Earlobes	Pliable, no cartilage	Some cartilage	Stiffened by thick cartilage
Testes and scrotum	Testes in lower canal, scrotum small, few rugae	Intermediate	Testes pendulous, scrotum full, extensive rugae

From Cunningham FG, MacDonald PC, Grant NF: Williams’ obstetrics, ed 18, Norwalk, CT, 1989, Appleton & Lange.

Implementation

Prenatal

• Collect information relating to the person’s health status and the pregnancy. Observe for signs of potential complications of pregnancy.

• Assist with routine prenatal examinations and diagnostic procedures.

• Review laboratory and diagnostic studies performed; report abnormal findings to the health care provider.

• During the first trimester, initiate discussion of infant feeding options available; provide information needed for parents to make a decision.

Complications of Pregnancy

• Infection: Monitor for infections and intervene according to the health care provider’s orders when an infection is confirmed.

• Hyperemesis gravidarum (see Chapter 34): Monitor hydration status, daily weight, and vital signs. Provide for dietary needs through intravenous (IV) therapy, nutritional supplements, and gradual progression of diet as tolerated.

• Bleeding, spontaneous abortion: Ensure that the patient adheres to bed rest, and give sedatives as prescribed. Monitor maternal vital signs, fetal heart rate and activity, and the volume (frequency of change and number of pads used) of bleeding present. When bleeding is present, blood studies for hemoglobin, hematocrit, white blood cells (WBCs), human chorionic gonadotropin titer, and blood type and crossmatch may be ordered. Other diagnostic procedures, such as culdoscopy, sonography, laparoscopy, fetoscopy, and pregnancy tests, may be performed.

Preterm Labor

• Monitor uterine contractions, and continue external fetal and uterine monitoring.

• Position the mother on her side, increase fluid intake, and start an IV infusion as ordered. Monitor hydration, maintain accurate intake and output records, and take daily weights.

• Assist with obtaining cervical and vaginal cultures, as ordered.

• Perform cervical examination to determine dilation and effacement. Assess for leakage of amniotic fluid.

• Take maternal vital signs. Record fetal heart rate and frequency and intensity of uterine contractions.

• Administer prescribed uterine relaxants, for example, nifedipine, indomethacin, magnesium sulfate, or terbutaline. (See individual drug monographs for administration information and monitoring parameters.) Glucocorticoids, usually betamethasone or dexamethasone, may be administered by the intramuscular (IM) route to accelerate lung maturation to minimize fetal respiratory distress syndrome. It may be used in cases in which it is anticipated that premature labor should be stopped for only 36 to 48 hours, such as with premature rupture of the membranes. Usual dosage for betamethasone is 12 mg IM, repeated in 24 hours. Dexamethasone is usually administered 6 mg IM every 12 hours for a total dose of 24 mg.

• Review available laboratory studies and report findings to the health care provider (e.g., fetal fibronectin, electrolyte studies, CBC with differential, thrombocytopenia, uric acid level, hematocrit, serum estriol, lecithin-to-sphingomyelin [L/S] ratio).

• All patients in preterm labor are considered to be at high risk for neonatal group B streptococcal infection and therefore often receive prophylactic antibiotics. Antibiotics frequently used are penicillin G, ampicillin, or clindamycin for patients allergic to penicillins.

• Provide appropriate psychological support. Involve supportive pastoral care appropriately.

Premature Rupture of Membranes

• Check fetal heart tones and fetal activity.

• Describe the color, characteristics, and amount of amniotic fluid leakage.

• Check maternal vital signs; report elevated temperature, chills, or malaise immediately.

• Continue to monitor for any leakage of fluid.

Gestational Diabetes Mellitus (GDM)

• Assist with the performance of glucose tolerance testing.

• Perform blood glucose testing four times daily, and assist the patient in administering prescribed insulin. While reviewing the self-monitoring blood glucose levels, ensure that the patient understands her individualized insulin dosage adjustment.

• Encourage adherence to diet and exercise prescribed to achieve tight glucose control to maintain desired weight gain during the pregnancy and to prevent complications (e.g., neonatal hypoglycemia or stillbirth).

• Women with GDM have twice the risk of developing hypertension than other pregnant women, so the blood pressure should be monitored regularly.

• Monitor for development of hypoglycemia and hyperglycemia. Consult current American Diabetes Association guidelines for monitoring GDM.

• During labor, monitor glucose level every 2 hours; maintain adequate hydration.

• During the postpartum period, continue to monitor glucose levels. (Usually with GDM, the mother’s glucose reverts to normal during the postpartum period. Therefore, careful monitoring of glucose and adjustment of insulin dosages are required.)

The patient with diabetes should have multiple laboratory tests, including glycosylated hemoglobin (A1C), serum creatinine, urine microalbumin, and other tests consistent with the history. The woman with diabetes must understand the importance of having a sustained record of preconception glycemic control to prevent maternal and fetal complications.

Pregnancy Hypertension Disorders (Preeclampsia, Eclampsia)

• Monitor maternal vital signs, fetal heart tones, and fetal movement at appropriate intervals consistent with presenting symptoms. Maintain the patient on bed rest in a lateral position to promote uteroplacental circulation and to reduce compression of the vena cava.

• Maintain hydration by the oral or IV route (usually 1000 mL plus the amount of urine output over the past 24 hours). Maintain accurate intake and output, and obtain daily weights. Salt intake is generally maintained at a normal level, although heavy use should be discouraged.

• Test the urine for protein and specific gravity every hour. Report a steady decrease in hourly output or output of less than 30 mL/hr.

• Review available laboratory studies and report findings to the health care provider (e.g., electrolyte levels, CBC with differential, thrombocytopenia, liver enzyme levels, uric acid level, hematocrit, serum estriol, L/S ratio).

• Monitor deep tendon reflexes and for signs of seizure activity (e.g., increased drowsiness, hyperreflexia, visual disturbances, and development of severe pain). If symptoms are present, report immediately.

• If seizures occur, give supportive care, provide a nonstimulating environment, and have oxygen and suction available. Institute seizure precautions.

• Be alert for complications (e.g., start of labor, pulmonary edema, DIC, heart failure, abruptio placentae, cerebral edema).

• Administer prescribed drugs (e.g., diazepam or phenobarbital, antihypertensives). The vasodilator hydralazine is usually administered to control blood pressure. It may be administered orally or IV, depending on the severity of the condition. If given IV, monitor the maternal and fetal heart rates and the mother’s blood pressure every 2 to 3 minutes after the initial dose and every 10 to 15 minutes thereafter. The diastolic pressure is usually maintained at 90 to 100 mm Hg. Anticonvulsants such as magnesium sulfate or phenytoin may be given for seizure activity (see drug monograph regarding administration and monitoring of the patient during drug therapy).

Termination of Pregnancy

• If bleeding occurs near the estimated date of delivery, the infant may be delivered by cesarean birth. If it appears that a spontaneous abortion (i.e., miscarriage) is occurring, the woman may be hospitalized for observation and bed rest, diagnosis for possible causes (e.g., infection), and fluid replacement.

• If a pregnancy is to be terminated (i.e., induced abortion), the following methods may be used:

• Before 12 weeks’ gestation: Suction curettage or dilation and evacuation

• From 12 to 20 weeks’ gestation: Intra-amniotic instillation of hypertonic saline (20% solution) or prostaglandin administered intra-amniotically, intramuscularly, or by vaginal suppository

• Intrauterine fetal death after 20 weeks’ gestation: Prostaglandin suppositories with or without oxytocin augmentation (see the section on uterine stimulants, p. 630)

• Encourage the persons involved in the loss of an infant to talk about their feelings of grief, sadness, or anger. Create memories of the experience through photographs and mementos as appropriate. Have pastoral care involved in supportive processes as appropriate. Listen and allow feelings to be vented. Give answers (if known) regarding future pregnancies. Refer for other counseling as appropriate. Anticipate that depression may develop over the next few weeks and that patient may need treatment for depression.

• Administer Rho(D) immune globulin to an Rh-negative mother within 72 hours of the termination of pregnancy (see p. 638). Also check the patient’s rubella titer; if low, obtain an order for inoculation immediately after pregnancy.

Normal Labor and Delivery

• Perform routine admission procedures (e.g., vital signs, fetal heart rate monitoring, birth plan). Determine if there will be someone present during the delivery process that will provide emotional support.

• Follow institutional guidelines regarding activity level of the mother; some permit ambulation during early stages of labor.

• During labor, provide pain relief, alternate side-to-side positioning (avoid lying flat on back), and intervene with comfort measures (e.g., back rub, pelvic rocking, effleurage, warm shower, music). Encourage leg extension and dorsiflexion of the foot to relieve spasms and cramping.

• Provide privacy, and support the woman and coach when necessary.

• Check for bladder distention. Have patient void every 2 hours.

• Maintain adequate hydration by giving ice chips or clear liquids. Check hydration status throughout labor by observing mucous membranes, dryness of lips, and skin turgor. Give oral hygiene frequently. Do not give solid foods unless specifically approved by the health care provider.

• As labor progresses, continue to monitor the maternal and fetal vital signs and the frequency, duration, and intensity of uterine contractions.

• Report contractions of 90 seconds or more and those not followed by complete uterine relaxation. Report abnormal patterns on the fetal monitor, such as decreased variability, late decelerations, and variable decelerations.

• Continue to coach when necessary.

• As vaginal discharge increases, wash the perineum with warm water, then dry the area. Change the bed sheets, pad, and gown when necessary.

• Monitor the temperature every 4 hours while membranes are intact and temperature remains within normal range. Monitor every 2 hours if the temperature is elevated or if the membranes have ruptured.

• After delivery, record the time of delivery and position of the infant, the type of tear or episiotomy and type of suture used in repair, if appropriate, any anesthetic or analgesic used during repair, the time of placental delivery, and any complications (e.g., additional bleeding, postpartum hemorrhage, or neonatal distress).

• Administer and record oxytocic agent, as ordered.

Immediate Neonatal Care.

Before delivery, the maternal history through the current stage of labor should be reviewed to identify potential complications that may arise for the neonate. Although a complete physical examination of the neonate will be performed later, a preliminary assessment and recording of data must be completed at the time of birth. The following procedures must be completed by the health care provider or nurse immediately after delivery.

Airway.

Ensure that the airway remains open. As soon as the head is delivered, suction the oropharynx and nasal passages with a small bulb syringe. Immediately after delivery, hold the newborn with the head lowered at a 10- to 15-degree angle to help drain amniotic fluid, mucus, and blood. Resuction with the bulb syringe as necessary.

Clamping the Umbilical Cord.

Consult with the mother before delivery if she is participating in cord blood banking. If so, special containers must be used for blood storage and registration. When the airway is opened and the respirations have stabilized, the neonate should be held at the same level as the uterus until cord pulsations cease. The cord is then clamped or ligated.

Health Status.

The health status of the neonate is estimated at 1 minute and 5 minutes after delivery using the Apgar scoring system (see Table 40-1). Rapid estimation of gestational age is also performed (see Table 40-2).

Temperature Maintenance.

The neonate should be dried immediately and body temperature maintained with the use of prewarmed blankets, a heated bassinet, or radiant warmer. If the neonate is term and in stable condition as assessed by the Apgar score, temperature may be maintained by skin-to-skin contact with the mother.

Eye Prophylaxis.

It is a legal requirement that every newborn baby’s eyes be treated prophylactically for Neisseria gonorrhoeae. Another rapidly emerging neonatal conjunctival infection is chlamydial ophthalmia neonatorum, which is caused by Chlamydia trachomatis. The neonate may have become infected during birth if the mother is infected. Ophthalmic erythromycin or tetracycline is used for prophylactic treatment of neonatal conjunctivitis caused by N. gonorrhoeae or C. trachomatis. Instillation of the ophthalmic agent may be delayed up to 2 hours to facilitate parent-child bonding.

Other Procedures.

While the parents are bonding with the newborn infant, the nurse should prepare an infant identification bracelet and place it on the baby, as well as a duplicate one on the mother. Examine the placenta and cord for anomalies and verify the presence of one vein and two arteries. Samples of cord blood may be collected for analysis of the Rh factor, blood grouping, and hematocrit. The baby may be held by the parents as long as the infant’s condition is stable. Breastfeeding should be initiated. The newborn is cared for in the presence of the family in most institutions while the weight, measurements, and physical examinations are completed. Some health care providers also order an IM injection of vitamin K as prophylaxis against hemorrhage along with an IM injection of hepatitis B vaccine. Evaluation of the infant’s vital signs and color is performed on a continuum. Alterations from baseline are evaluated and reported.

Postpartum Care.

Postpartum is defined as the time between delivery and return of the reproductive organs to prepregnancy status.