Normal Childbearing

Normal childbearing typically represents happy time for expectant clients and their families, and nurses have the privilege of being part of this wonderful experience. In caring for pregnant clients, nurses are responsible for promoting the health and well-being of both the clients and their unborn children, particularly during labor and delivery.

In this learning experience, the learner will acquire knowledge about their role in supporting pregnant clients and their fetuses, both before and throughout labor and delivery.

2.1 Pregnancy

Nurses play a crucial role in the healthcare team, monitoring both the mother and baby during pregnancy, labor, and delivery. Antepartum or prenatal care refers to the support and medical attention provided to a client and their baby before birth (Kaplan Nursing, 2023a). Calculating the expected date of delivery is important for both the mother and the healthcare team. The date is estimated by adding seven days and nine months to the first day of the woman’s last menstrual period (Kaplan Nursing, 2023a). A baby is considered full-term if born between 37 and 42 weeks of the mother’s pregnancy. On the other hand, births before 37 weeks are classified as premature, while those after 42 weeks are considered overdue.

According to Kaplan Nursing (2023a) nurses are advised to gather both current and past medical histories of clients and provide education on the following aspects:

• Blood Pressure: Monitoring is crucial throughout the pregnancy, labor and delivery.
• Weight: Regular measurements are obtained to ensure the client maintains a healthy weight range. An ideal weight gain is around 22 – 27 pounds. Excessive weight gain can increase risks of pre-eclampsia, and post-birth complications like diabetes, high blood pressure and coronary heart disease.
• Lifestyle: The client should adopt a lifestyle conductive to her health and that of the fetus.
• Family and Genetic History: In cases where the client has a significant family and genetic history, or is above 35 years of age, an amniocentesis may be conducted after the 14th week to assess fetal health.
• Support Systems: Understanding the client's support systems allows nurses the need for interventions, such as educating clients about support groups when there is little to no support available.
• Perception of Pregnancy: Understanding how the client perceives the pregnancy can aid in formulating a nursing care plan. It's crucial to address misconceptions, such as viewing pregnancy as an illness.
• Coping Mechanisms: Identifying the client's coping strategies is essential. This understanding helps in educating the client about replacing unhealthy coping mechanisms, like denial or fantasy, with healthier ones.
• Medications: It is essential to inquire about clients' use of prescriptions drugs, alternative therapies, and over-the-counter medications. Certain medications, classified as Category X, are known to be harmful to the fetus. These include:
• Vaccines for measles, mumps, and smallpox.
• Several medications used to treat hyperlipidemia.
• Oral contraceptives pills.
• Warfarin (Coumadin).
• Cytotec.
• Accutane.
• Rh Factor: It is important to determine the Rh status of both parents. This information guides the nurse whether the client needs Rho (D) immune globulin (RhoGAM) at 28 weeks of pregnancy. RhoGAM is necessary if the client is Rh negative, and the father is Rh positive.
• Ultrasound Result: An ultrasound provides crucial details such as the gestational age, location of the placenta, anatomy of the fetus, and the viability of the fetus.
• Fetal Heart Rate: A normal fetal heart rate ranges from 120-160 beats per minute. Nurses should report any heart rates falling below or exceeding this range.

Clients should receive the following education to promote their health and that of their unborn baby (Kaplan Nursing, 2023a):

• Nutrition: It is vital to educate clients about adequate nutrition, especially considering that over half of pregnancies are unplanned, and clients may not have been following balanced diets. Teenagers, in particular, require additional protein, calcium, and phosphorus compared to adults due to their growing bones.
• Information that should be properly discussed with the patient must include:
• Normal events such as:
• Quickening: The first fetal movements felt by clients, typically occurring between 17 – 19 weeks, although they can occur as early as 13 weeks or as late as 25 weeks.
• Braxton-Hicks contractions: Non-labor contractions that usually start after 20 weeks.
• Possible danger signals such as:
• Vaginal bleeding.
• Persistent headaches during the last trimester (three months).
• Edematous extremities during the last trimester.
• Blurred or reduced vision during the last trimester.
• Severe, persistent abdominal pain.
• Decreased fetal movement after 24 weeks.

2.2 Fetal Development

Nursing considerations in fetal development include implementing orders from healthcare providers and other team members, in addition to educating, and supporting clients and their families about the conditions/diseases and their care plans.

Fetal development includes assessment of maternal and genetic considerations, and diagnostic tests (Kaplan Nursing, 2023b):

• Maternal Considerations:
  The assessment of the client covers their age, high-risk group status, environment, medications history (including any taken prior to pregnancy awareness), drug and alcohol use, and nutritional habits.

• Genetic Considerations:
  The ethnicity of clients is important to assess, as certain ethnic groups have higher risks for specific diseases. Other conditions arise from chromosomal abnormalities, autosomal defects, and inborn errors of metabolism.

• Chromosomal Abnormalities:
• Down's Syndrome (Trisomy 21): More common in clients over 35 years.
• Turner Syndrome: Occurs if the female fetus has one X chromosome instead of the usual two.
• Klinefelter Syndrome: Arises in male fetuses with an additional X chromosome.
• Autosomal Defects:
  These defects are found in pairs of chromosomes, excluding the sex chromosomes. Examples include:
• Autosomal Dominant Conditions: These include breast cancer due to BRCA-1 and BRCA-2, polycystic kidney disease, Marfan syndrome, Type 2 diabetes. These conditions manifest in fetuses when a parent passes on the abnormal gene, with a 50 percent likelihood of occurrence.
• Autosomal Recessive Conditions: Conditions like sickle cell disease and cystic fibrosis fall into this category. Here, the abnormal gene is inherited from both parents.
• Sex-linked Transmission Traits: Traits such as color blindness and hemophilia are typically transmitted on one sex chromosome, usually the X chromosome.
• Inborn Errors of Metabolism:
  These errors occur due to the absence or malfunction of enzymes necessary for metabolizing proteins, fats, and carbohydrates. They include:
• Phenylketonuria (PKU): In this condition, the liver enzyme phenylalanine hydroxylase cannot metabolize the amino acid phenylalanine, due to a deficiency caused by an autosomal recessive gene. This leads to a buildup of phenylalanine in the blood and causes toxicity in brain cells.
• Tay-Sachs Disease: This disease results in regression of motor and social development and decreased vision, caused by an autosomal recessive trait due to a deficiency of hexosaminidase A.
• Cystic Fibrosis: Also known as mucoviscidosis or fibrocystic disease of the pancreas, cystic fibrosis is an autosomal recessive trait. It affects the exocrine glands, altering the viscosity of mucus-producing glands.

• Diagnostic Tests: 
  These tests are essential for assessing fetal development, and nurses must be well-versed in the timing and purposes of each test. They should also be prepared to respond appropriately to abnormalities in accordance with their healthcare facility’s policies and procedures. The tests include:

• Alpha-fetoprotein (AFP): This test checks for fetal distress and the potential for miscarriage. It also helps determine the likelihood of neural tube defects or Down syndrome in the fetus, indicated by decreased levels of AFP.
• Chorionic Villus Sampling (CVS):This diagnostic test assists in diagnosing conditions like Down syndrome, Phenylketonuria (PKU), Duchenne muscular dystrophy, sickle-cell anemia, and determining the karyotype of the fetus.
• Amniocentesis: This test is performed at 16 weeks to identify genetic disorders and again at 30 weeks to assess the maturity of the fetus’ lungs.
• Ultrasound: This imaging test provides a visual of the fetus, helping to ascertain measurements, position, the number of fetuses, and other structures such as the client’s placenta.
• Non-stress Test (NST): Conducted after 28 weeks; this test evaluates the fetus’ well-being by recording its movement and heart rate.
• Contraction Stress Test (CST): Administered after 28 weeks, this test involves stimulating the nipple or administered oxytocin to evaluate the fetal response to the stress of simulated labor.
• Estriol Levels:This test evaluates the condition of the placenta, or the fetoplacental status.

2.3 Labor and Delivery

Nurses provide intrapartum care to clients during their labor and childbirth (Kaplan Nursing, 2023a). Clients should be aware that the onset of labor is influenced by hormones, uterine enlargement, and oxytocin release (Kaplan Nursing, 2023a). Additionally, labor can be initiated by the passage of the thick mucus plug in the cervix and the rupture of amniotic membranes. Generally, the duration of labor for first-time babies is approximately 12 to 14 hours, with subsequent labors often being shorter (Kaplan Nursing, 2023a).

According to Kaplan Nursing (2023a) the care provided to clients during labor and delivery encompasses each of the four stages of labor, including:

• During Cervical Dilation from 4 – 10 cm: Assessment of the client's cervix for effacement and dilation along with their need for pain medication.
• From Complete Cervical Dilation to Baby's Delivery: Assessment of the newborn.
• From Baby's Delivery to Placental Expulsion: This stage typically occurs within 5 – 20 minutes after the baby's birth. During this phase, the umbilical cord is examined to ensure it contains one vein and two arteries.
• Immediate Recovery and Observation (About 2 Hours Post-Birth): Monitoring the client’s vital signs, fundal height of the uterus, vaginal discharge, and bladder distension. Efforts at breastfeeding, if chosen by the client, are also assessed.

It is important for nurses to be familiar with their healthcare facilities’ policies and procedures regarding their roles and responsibilities during the labor and delivery process.

To conclude, the learner has gained valuable information, enhancing their understanding of normal childbearing, with a specific emphasis on pregnancy, fetal development, and labor and delivery.

The resources will increase proficiency in these areas and assist with success on the NCLEX examination and in the workplace.

After reviewing the resources, identify areas for improvement and focus on them.

• Kaplan Nursing. (2023a). Next Generation NCLEX-RN Prep 2023-2024: Practice Test + Proven Strategies (9th ed.).  Kaplan Test Prep.
• Kaplan Nursing. (2023b). NCLEX-RN Content Review Guide: Preparation for the NCLEX-RN Examination (9th ed.). Kaplan Test Prep.

Reading

• Burke, A. (2024, January 20). Anti/Intra/Postpartum and Newborn Care: NCLEX-RN. https://www.registerednursing.org/nclex/anti-intra-postpartum-newborn-care/#conception

Video

• Dr. John Campbell. (2022, June 27). Fetal Development [Video]. YouTube. https://youtu.be/N2e02QdzJgg