Nursing: Maternal/Newborn

First visit (ideally by 8-12 weeks): complete health history, physical exam, pelvic exam, BMI. Labs: CBC, blood type and Rh, antibody screen, rubella titer, Hep B surface antigen, HIV, syphilis (RPR/VDRL), urinalysis and culture, Pap smear, chlamydia/gonorrhea. Genetic screening offered. Baseline BP and weight. Naegele's rule for EDD: first day of LMP - 3 months + 7 days + 1 year. Fundal height (cm) ≈ gestational age (weeks) after 20 weeks.

First trimester (weeks 1-12): organogenesis (most vulnerable to teratogens, especially weeks 3-8), heart beats by week 6, FHR audible by Doppler at 10-12 weeks. Second trimester (weeks 13-27): quickening (maternal perception of movement) at 16-20 weeks, vernix and lanugo appear, viability at ~24 weeks, fetal lungs begin producing surfactant at 24 weeks. Third trimester (weeks 28-40): rapid weight gain, lungs mature at ~36 weeks (L/S ratio 2:1 indicates maturity), fetus assumes vertex position, lightening (fetal descent) occurs near term.

Call provider for: vaginal bleeding (any amount), gush of fluid from vagina (PPROM), severe headache/visual changes/epigastric pain (preeclampsia), decreased fetal movement (<10 movements in 2 hours), regular contractions before 37 weeks (preterm labor), fever >100.4°F, severe abdominal pain, painful urination with fever (pyelonephritis), persistent vomiting beyond first trimester. Teach patients at every visit. Signs of preeclampsia especially important after 20 weeks.

First trimester: nuchal translucency ultrasound (11-14 weeks) + serum markers (PAPP-A, hCG) = combined first trimester screen (trisomies 21, 18, 13). Cell-free fetal DNA (cfDNA) available from 10 weeks (>99% detection for trisomy 21). Second trimester: quad screen (AFP, hCG, estriol, inhibin A) at 15-20 weeks — elevated AFP: neural tube defects, low AFP: Down syndrome. Anatomy ultrasound at 18-22 weeks. Glucose tolerance test at 24-28 weeks. Group B Strep (GBS) culture at 36 0/7 to 37 6/7 weeks (updated CDC/ACOG 2020). Diagnostic: chorionic villus sampling (CVS) 10-13 weeks, amniocentesis 15-20 weeks. Rh-negative mothers: RhoGAM at 28 weeks and within 72 hrs postpartum.

Stage 1 — Dilation and effacement: Latent phase (0-6 cm): irregular contractions, mild, may last hours.Current ACOG evidence suggests slower progress is normal; the 1 cm/hr expectation is outdated. Transition (8-10 cm): most intense, N/V, irritability, rectal pressure. Nursing: breathing techniques, positioning, hydration, pain management, monitor FHR and contractions. Stage 2 — Pushing/birth: complete dilation to delivery, up to 2 hrs (nullipara). Nursing: coach pushing, monitor FHR after each contraction. Stage 3 — Placenta delivery: 5-30 min, Schultz (shiny/fetal side first) or Duncan (maternal/rough side). Stage 4 — Recovery: first 1-2 hrs postpartum, monitor VS, fundus, lochia, bonding.

Seven movements the fetus makes through the pelvis: 1. Engagement — presenting part enters pelvic inlet (lightening). 2. Descent — downward movement (continues throughout). 3. Flexion — chin to chest (smallest diameter presented). 4. Internal rotation — occiput rotates to anterior position. 5. Extension — head extends under symphysis pubis to deliver. 6. External rotation (restitution) — head realigns with shoulders. 7. Expulsion — anterior then posterior shoulder delivers, followed by body. Understanding helps assess labor progress and anticipate complications.

Normal baseline FHR: 110-160 bpm. Moderate variability (6-25 bpm fluctuation): most reassuring sign — indicates intact autonomic nervous system and adequate oxygenation. Accelerations: ≥15 bpm above baseline for ≥15 seconds (≥32 weeks); ≥10 bpm for ≥10 sec (<32 weeks). Accelerations are REASSURING — indicate fetal well-being. Reactive NST: ≥2 accelerations in 20 minutes. Minimal variability (≤5 bpm): may indicate fetal sleep cycle (up to 40 min), medications (opioids, magnesium), or fetal hypoxia — needs further assessment.

Early decelerations: gradual decrease in FHR that mirrors contractions (onset, nadir, and recovery correspond with contraction). Cause: HEAD compression during contractions — increased vagal tone. Mirror image of contraction. Shape: uniform, smooth, symmetrical. NOT concerning — benign pattern, no intervention needed (reassuring). Usually seen in active labor and transition when head is descending. Continue to monitor. Compare with late decels (uteroplacental insufficiency) and variable decels (cord compression).

Late decelerations: gradual FHR decrease that begins AFTER the contraction starts and returns to baseline AFTER the contraction ends (offset from contraction). Cause: uteroplacental insufficiency — decreased blood flow to placenta. Shape: uniform, smooth, but shifted to the right of contraction. CONCERNING — especially with decreased variability. Interventions: reposition mother (left lateral), IV fluid bolus, administer O2 (10 L non-rebreather), stop oxytocin if infusing, notify provider. If persistent: prepare for emergent delivery. Causes include maternal hypotension, placental abruption, uterine hyperstimulation.

Variable decelerations: abrupt decrease in FHR (onset to nadir <30 sec), ≥15 bpm below baseline lasting 15 sec to 2 min. Cause: CORD compression. Shape: variable in timing, duration, and shape (V, W, or U shaped). Most common deceleration pattern. Interventions: change maternal position (left side, right side, hands and knees, Trendelenburg), IV fluid bolus, O2 by mask, amnioinfusion (for oligohydramnios to cushion cord), discontinue oxytocin, vaginal exam to assess for cord prolapse. If prolonged (>2 min) or severe: prepare for emergency C-section.

Prolonged deceleration: FHR below baseline ≥15 bpm lasting 2-10 min. Causes: cord prolapse, uterine rupture, maternal hypotension, prolonged pushing. Action: emergency interventions, call for help, prepare for delivery. >10 min = terminal bradycardia. Sinusoidal pattern: smooth, undulating sine wave, frequency 3-5 cycles/min, absent variability. Causes: severe fetal anemia (Rh isoimmunization, fetomaternal hemorrhage, vasa previa rupture). OMINOUS — requires immediate delivery. Not to be confused with pseudosinusoidal (medication-related, has normal variability between).

Develops after 20 weeks gestation. Criteria: BP ≥140/90 on 2 occasions 4 hrs apart + proteinuria (≥300 mg/24 hr or protein/creatinine ratio ≥0.3) OR without proteinuria plus any severe feature. Severe features: BP ≥160/110, platelets <100,000, liver transaminases >2x upper normal, creatinine >1.1, pulmonary edema, cerebral or visual symptoms. Assessment: headache (frontal, unrelieved by analgesics), visual disturbances (blurred, scotomata), epigastric/RUQ pain (hepatic edema), hyperreflexia (3+/4+ DTRs, clonus), edema (face, hands — sudden weight gain >2 lbs/week), decreased urine output.

Mag sulfate: first-line for seizure prophylaxis and treatment in preeclampsia/eclampsia. Loading dose: 4-6 g IV over 20-30 min. Maintenance: 1-2 g/hr continuous infusion. Therapeutic level: 4-7 mEq/L. Monitor: DTRs hourly (loss of reflexes = first sign of toxicity), RR (hold if <12), urine output (maintain >30 mL/hr — renally excreted), LOC. Toxicity: absent reflexes → respiratory depression (7-10 mEq/L) → cardiac arrest (>12 mEq/L). Antidote: calcium gluconate 1 g IV push (keep at bedside). Continuous fetal monitoring. Only definitive cure for preeclampsia = DELIVERY. Severe preeclampsia at ≥34 weeks → deliver. <34 weeks: betamethasone for fetal lung maturity if stable, expectant management with close monitoring.

HELLP = Hemolysis (elevated LDH >600, schistocytes on smear), Elevated Liver enzymes (AST/ALT >2x upper normal), Low Platelets (<100,000/mm³). A severe variant of preeclampsia. May present without classic hypertension or proteinuria. Symptoms: malaise, RUQ or epigastric pain, N/V, headache, visual changes. High risk for: DIC, placental abruption, liver rupture, acute renal failure, maternal death. Treatment: stabilize (mag sulfate, antihypertensives), blood products (platelets, FFP), deliver promptly regardless of gestational age. Post-delivery: may worsen for 24-48 hrs before improving. Monitor: CBC, liver panel, coagulation studies q6-12h.

Eclampsia = seizures in a preeclamptic patient not attributable to other causes. Can occur antepartum, intrapartum, or postpartum (up to 6 weeks). Emergency management: maintain airway (turn on side, suction PRN), do NOT restrain, administer O2, magnesium sulfate bolus 4-6 g IV if not already on mag (or 2 g bolus if already infusing), protect from injury (padded side rails). After seizure: assess FHR (transient bradycardia expected), assess for abruption, prepare for delivery. Do NOT give diazepam (less effective, crosses placenta). Monitor mag levels, neuro status. Differential: rule out stroke, intracranial hemorrhage.

Screening at 24-28 weeks: 1-hour glucose challenge test (50 g glucose → ≥130-140 mg/dL is positive). If positive → 3-hour GTT (100 g): fasting ≥95, 1 hr ≥180, 2 hr ≥155, 3 hr ≥140 — need 2 or more abnormal values. Management: nutritional therapy, glucose monitoring (fasting <95, 1 hr postprandial <140, 2 hr <120), exercise, insulin if diet fails (oral agents increasingly used — glyburide, metformin). Risks to fetus: macrosomia (>4000 g — shoulder dystocia risk), neonatal hypoglycemia, jaundice, polycythemia, respiratory distress. Risks to mother: preeclampsia, polyhydramnios, C-section, Type 2 DM later in life (50% risk). Postpartum: glucose usually normalizes; rescreen at 6-12 weeks with 75 g GTT.

Placenta Previa: placenta implanted over cervical os (low-lying, partial, or complete). Presentation: PAINLESS, bright red vaginal bleeding (usually 3rd trimester). Soft, non-tender uterus. NO vaginal exam until ultrasound confirms placental location. FHR usually normal. Diagnosis: transabdominal ultrasound. Management: bed rest, no vaginal exams/intercourse, corticosteroids if <37 weeks, C-section delivery if complete previa. Abruption: premature separation of normally implanted placenta. Presentation: PAINFUL, dark red bleeding (may be concealed — no visible bleeding), rigid/board-like tender uterus, fetal distress, may develop DIC. Risk factors: hypertension, cocaine, trauma, smoking. Treatment: emergent delivery, blood products, large-bore IVs, continuous fetal monitoring.

Indications: failure to progress, non-reassuring FHR, malpresentation (breech, transverse), placenta previa, cord prolapse, prior classical uterine incision, active herpes. Pre-op: informed consent, NPO, Foley catheter, IV fluids, left uterine displacement (prevent aortocaval compression), surgical prep, antibiotics within 60 min of incision. Post-op: monitor VS, fundal firmness, lochia, incision site, I&O, pain management. Assess for complications: hemorrhage, infection (endometritis — fever, foul-smelling lochia), thromboembolism, ileus. Encourage early ambulation, coughing and deep breathing, breastfeeding. Abdominal binder for comfort. Incision care: keep clean and dry, report redness/drainage/separation.

Definition: blood loss ≥1000 mL or signs of hypovolemia. 4 T's: Tone (uterine atony — #1 cause, 70-80%), Trauma (lacerations, hematoma, uterine rupture), Tissue (retained placental fragments), Thrombin (coagulopathy/DIC). Uterine atony management: fundal massage (firm, midline at umbilicus), empty bladder, oxytocin infusion (Pitocin 10-40 units in 1L NS), methylergonovine (Methergine — contraindicated in HTN), carboprost (Hemabate — contraindicated in asthma), misoprostol (Cytotec — rectal). If unresponsive: tamponade balloon, uterine artery embolization, B-Lynch suture, hysterectomy as last resort. Nursing: 2 large-bore IVs, type and crossmatch, continuous VS monitoring, weigh pads (1 g = 1 mL), assess LOC.

B — Breasts: soft, filling, engorged? Nipple condition, latch assessment. U — Uterus: fundal height (should be at or below umbilicus, firm, midline), involution (descends ~1 cm/day). B — Bladder: voiding adequate? Distended bladder displaces uterus → atony risk. B — Bowel: flatus? BM? Hemorrhoid assessment. L — Lochia: rubra (red, 1-3 days) → serosa (pink, 4-10 days) → alba (white/yellow, 10-14 days to 6 weeks). Amount: scant to moderate. Report: saturation of pad in <1 hr, foul odor, return to rubra, large clots (>golf ball). E — Episiotomy/perineum: REEDA (Redness, Edema, Ecchymosis, Drainage, Approximation). Ice packs, sitz baths, witch hazel pads.Homan's sign is no longer recommended for DVT assessment (poor sensitivity/specificity, risk of clot dislodgement). Assess for calf pain, warmth, swelling, redness instead. E — Emotional status: bonding, mood, postpartum depression screening.

Assessed at 1 and 5 minutes after birth. Five components, each scored 0-2: A — Appearance (color): 0 = blue/pale, 1 = acrocyanosis (body pink, extremities blue), 2 = completely pink. P — Pulse: 0 = absent, 1 = <100, 2 = >100. G — Grimace (reflex irritability): 0 = no response, 1 = grimace, 2 = cough/sneeze/cry. A — Activity (muscle tone): 0 = limp, 1 = some flexion, 2 = active motion. R — Respiration: 0 = absent, 1 = slow/irregular/weak cry, 2 = good cry. Interpretation: 7-10 = normal, 4-6 = moderately depressed (stimulation, O2), 0-3 = severely depressed (immediate resuscitation). If 5-min score <7, continue scoring q5 min up to 20 min.

Normal: acrocyanosis (first 24-48 hrs), milia (white papules on nose), Epstein pearls (white cysts on palate), Mongolian spots (blue-gray sacral pigmentation — document), erythema toxicum (newborn rash — benign), molding, caput succedaneum (crosses suture lines, resolves in days). Concerning: central cyanosis, jaundice in first 24 hrs (pathologic), bulging fontanels (increased ICP), sunken fontanels (dehydration), grunting/nasal flaring/retractions (respiratory distress), single palmar crease (Down syndrome association), absent/weak cry, hypotonia, temperature instability (<36.5°C or >37.5°C), absent red reflex (retinoblastoma). Normal VS: HR 120-160, RR 30-60 (periodic breathing normal, apnea >20 sec is not), temp 36.5-37.5°C, BP 60-80/40-50.

Moro (startle): sudden extension then flexion of arms with C-shape of fingers when startled. Present at birth, disappears 3-6 months. Asymmetric = brachial plexus injury (Erb palsy). Rooting: turns head toward stimulus when cheek is stroked. Disappears 3-4 months. Sucking: sucks when finger/nipple placed in mouth. Disappears 4-7 months. Palmar grasp: fingers curl around object placed in palm. Disappears 3-4 months. Plantar grasp: toes curl when sole is stroked. Disappears 8-12 months. Babinski: toes fan out with dorsiflexion of big toe when sole stroked. Normal in infants; disappears by 12-24 months (abnormal in adults = upper motor neuron lesion). Tonic neck (fencer): when head turned, arm/leg extend on that side, flex on opposite. Disappears 3-4 months.

Initiate within first hour. Feed on demand (8-12x/day in newborns). Signs of adequate intake: 6+ wet diapers/day by day 4, 3-4 stools/day, steady weight gain after initial 5-7% loss (regain birth weight by 2 weeks). Proper latch: wide open mouth, flanged lips, areola covered, audible swallowing. Positioning: cradle, cross-cradle, football, side-lying. Common problems: engorgement (warm compresses before feeding, cold after, frequent feeding), sore/cracked nipples (correct latch, lanolin, air dry), mastitis (flu-like symptoms, red wedge-shaped area — continue breastfeeding, antibiotics, warm compresses). Contraindications to breastfeeding: HIV (in developed countries), active TB (until treated), illicit drug use, certain medications (chemotherapy). Breast milk provides IgA antibodies.

Physiologic jaundice: appears after 24 hours, peaks day 3-5 (term) or day 5-7 (preterm), self-resolves by 2 weeks. Cause: immature liver, increased RBC breakdown. Pathologic jaundice: appears within first 24 hours — ALWAYS pathologic (hemolytic disease, ABO/Rh incompatibility, infection, G6PD deficiency). Bilirubin rises >5 mg/dL/day or total exceeds 12 mg/dL (term). Treatment: phototherapy — blue light breaks down unconjugated bilirubin (photoisomerization). Nursing: eyes covered with opaque shields, maximal skin exposure, monitor temp, I&O (increased insensible water loss), assess skin color with lights off, frequent feedings (promotes bilirubin excretion via stool). Exchange transfusion if bilirubin critically high (risk of kernicterus — bilirubin encephalopathy).

Occurs when Rh-negative mother carries Rh-positive fetus. First pregnancy: sensitization occurs at delivery (fetal Rh+ blood enters maternal circulation → mother produces anti-Rh antibodies). Subsequent Rh+ pregnancies: maternal antibodies cross placenta → attack fetal RBCs → hemolytic disease of the newborn (erythroblastosis fetalis) → severe anemia, jaundice, hydrops fetalis. Prevention: RhoGAM (Rh immune globulin) — give at 28 weeks gestation AND within 72 hours postpartum (if newborn is Rh+). Also give after any sensitizing event: miscarriage, abortion, ectopic, amniocentesis, trauma, vaginal bleeding. Indirect Coombs test (maternal): detects antibodies. Direct Coombs test (newborn): detects antibody-coated RBCs.

Baby blues: affects up to 80%, onset 2-3 days postpartum, resolves by 2 weeks. Symptoms: tearfulness, mood swings, irritability, anxiety, fatigue. Self-limiting — reassurance, support, rest. Postpartum depression: affects 10-15%, onset within 4 weeks to 12 months. Symptoms: persistent sadness, hopelessness, guilt, loss of interest, difficulty bonding, appetite/sleep changes, possible suicidal/infanticidal ideation. Screen with Edinburgh Postnatal Depression Scale (EPDS ≥10 indicates possible depression). Treatment: psychotherapy (CBT), SSRIs (sertraline preferred — low breast milk transfer), support groups, brexanolone (IV — FDA-approved for PPD). Postpartum psychosis: rare (1-2/1000), psychiatric EMERGENCY — delusions, hallucinations, disorganized behavior — hospitalize, assess safety of mother and infant.

Cord prolapse: umbilical cord precedes or lies alongside the presenting part → compression → fetal hypoxia. Risk factors: ruptured membranes with unengaged presenting part, polyhydramnios, preterm, malpresentation, multiparity. Assessment: visible or palpable cord in vagina, sudden severe variable decelerations or prolonged deceleration after ROM. EMERGENCY management: call for help, do NOT attempt to push cord back. Examiner's gloved hand in vagina to elevate presenting part OFF cord (maintain until C-section delivery). Position: Trendelenburg or knee-chest (gravity relieves pressure). Wrap any exposed cord in warm, sterile saline-soaked gauze. Continuous fetal monitoring. Prepare for immediate C-section. DO NOT apply traction to cord.

Indication: labor induction or augmentation. Administration: always via IV infusion pump, piggybacked into mainline closest to insertion site (allows immediate discontinuation). Start low, increase gradually per protocol (typically start 1-2 mU/min, increase by 1-2 mU/min q15-30 min). Monitor: continuous FHR and contraction monitoring (IUPC or external toco). Goal: contractions q2-3 min, lasting 40-60 sec, moderate to strong, with ≥60 sec rest between. Complications: uterine hyperstimulation (tachysystole — ≥5 contractions in 10 min) → fetal distress, uterine rupture (rare). If hyperstimulation: stop Pitocin, reposition left lateral, IV fluid bolus, O2, consider terbutaline 0.25 mg SubQ (tocolytic). Antidiuretic effect — monitor for water intoxication with prolonged use.

Definition: regular contractions with cervical change between 20-36+6 weeks. Risk factors: prior preterm birth (#1 predictor), multiple gestation, short cervical length, infections (UTI, BV, chorioamnionitis), PPROM, substance use, stress, low BMI. Assessment: contractions q10 min or less, cervical dilation/effacement, fetal fibronectin (fFN: if negative, 99% will NOT deliver in next 2 weeks — useful to rule out). Tocolytics (goal: delay delivery 48 hrs for corticosteroids): magnesium sulfate (also neuroprotective for fetus <32 weeks), nifedipine (calcium channel blocker — may cause hypotension), indomethacin (NSAID — <32 weeks only, watch for oligohydramnios). Betamethasone: 12 mg IM x2 doses, 24 hrs apart (fetal lung maturity). GBS prophylaxis if status unknown.

Shoulder dystocia: anterior shoulder impacted behind pubic symphysis after delivery of head. Signs: 'turtle sign' (head retracts against perineum), difficulty delivering anterior shoulder with usual traction. EMERGENCY — risk of brachial plexus injury (Erb palsy), clavicle fracture, fetal hypoxia. Maneuvers (mnemonic HELPERR): H — call for Help. E — Evaluate for Episiotomy. L — Legs in McRoberts position (hyperflexion of thighs to abdomen — widens pelvic outlet). P — suprapubic Pressure (NOT fundal pressure). E — Enter vagina for rotational maneuvers (Rubin II, Woods screw). R — Remove posterior arm. R — Roll patient to hands and knees (Gaskin maneuver). Document time of delivery, maneuvers used, outcomes.

Rare, catastrophic emergency — amniotic fluid enters maternal circulation → anaphylactoid reaction. Mortality: 20-60%. Often occurs during labor, delivery, or immediately postpartum. Classic triad: sudden respiratory distress/hypoxia, cardiovascular collapse (hypotension, cardiac arrest), DIC (coagulopathy with hemorrhage). No diagnostic test — clinical diagnosis of exclusion. Management: supportive — immediate intubation, mechanical ventilation, vasopressors, massive transfusion protocol (RBCs, FFP, platelets, cryoprecipitate), ACLS if cardiac arrest (perimortem C-section within 4-5 min if no response). Rapidly assemble multidisciplinary team. High index of suspicion with sudden collapse during/after labor.

GBS (Streptococcus agalactiae): colonizes vagina/rectum in ~25% of women. Leading cause of neonatal sepsis, pneumonia, meningitis. Screening: vaginal-rectal swab at 36 0/7 to 37 6/7 weeks (updated CDC/ACOG 2020). Intrapartum antibiotic prophylaxis (IAP) indicated if: positive GBS culture, GBS bacteriuria during current pregnancy, previous infant with GBS disease, or unknown status with risk factors (preterm <37 weeks, ROM ≥18 hrs, intrapartum fever ≥100.4°F). Treatment: penicillin G 5 million units IV load then 2.5-3 million units q4h until delivery (alternative: ampicillin; if PCN allergy: cefazolin, clindamycin, or vancomycin based on sensitivities). Goal: ≥2 doses (≥4 hrs) before delivery for adequate prophylaxis.

Endometritis: infection of uterine lining — most common postpartum infection. Risk factors: C-section (#1 risk factor), prolonged ROM (>18 hrs), prolonged labor, multiple vaginal exams, chorioamnionitis, retained placental fragments, anemia, GBS colonization. Assessment: fever >100.4°F (38°C) on two occasions 6+ hrs apart (excluding first 24 hrs), uterine tenderness, foul-smelling lochia, tachycardia, malaise. Treatment: broad-spectrum IV antibiotics (clindamycin + gentamicin is standard; add ampicillin if no improvement). Obtain blood and endometrial cultures. Monitor VS, lochia, WBC. Encourage ambulation and adequate hydration.

Fertilized egg implants outside uterus — most commonly fallopian tube (~97%). Risk factors: previous ectopic, PID/STIs, tubal surgery, IUD use, assisted reproduction. Assessment: unilateral lower abdominal/pelvic pain, vaginal bleeding (usually light), amenorrhea, positive pregnancy test with lower-than-expected hCG levels (hCG does not double appropriately q48 hrs). If ruptured: sudden severe pain, referred shoulder pain (diaphragmatic irritation from blood), signs of hemorrhagic shock — surgical emergency. Diagnosis: transvaginal ultrasound (no intrauterine pregnancy + adnexal mass), serial hCG levels. Treatment: methotrexate (if unruptured, <3.5 cm, hCG <5000, no cardiac activity) — folic acid antagonist (avoid alcohol, NSAIDs, prenatal vitamins with folic acid); salpingostomy or salpingectomy if ruptured or methotrexate fails. Follow hCG to zero.

Chronic hypertension: HTN diagnosed before pregnancy or before 20 weeks gestation. BP ≥140/90. Does NOT include proteinuria (unless superimposed preeclampsia develops). Continue antihypertensives (labetalol, nifedipine are safe; avoid ACE/ARBs — teratogenic). Gestational hypertension: new-onset HTN ≥140/90 after 20 weeks WITHOUT proteinuria or severe features. Usually resolves by 12 weeks postpartum. Monitor closely for progression to preeclampsia. Preeclampsia: HTN after 20 weeks WITH proteinuria or severe features (see preeclampsia card). Superimposed preeclampsia: chronic HTN + new proteinuria or worsening HTN + severe features after 20 weeks. Worst prognosis. All: monitor BP closely, fetal surveillance (NST, BPP, growth ultrasound), educate on warning signs.

Abnormal proliferation of trophoblastic tissue. Complete mole: no fetus, 46XX (all paternal), higher malignancy risk. Partial mole: abnormal fetus present, triploid (69 chromosomes). Assessment: vaginal bleeding (dark brown, 'prune juice'), uterus larger than expected for dates, extremely elevated hCG, no FHR (complete mole), severe N/V (hyperemesis from high hCG), preeclampsia before 20 weeks (unusual — suspect mole), 'snowstorm' appearance on ultrasound. Treatment: suction curettage with RhoGAM if Rh-negative. Follow-up: serial hCG levels until undetectable, then monthly for 6-12 months (to detect gestational trophoblastic disease/choriocarcinoma). MUST use reliable contraception during monitoring — pregnancy would elevate hCG and confound monitoring. Do not become pregnant for 1 year (complete) or 6 months (partial).

Four abdominal palpation maneuvers to determine fetal position, presentation, and lie. Performed after 28 weeks. 1st maneuver (fundal grip): palpate fundus — what fetal part is in the upper uterus? (Head = round, firm, ballottable; buttocks = soft, irregular). 2nd maneuver (umbilical grip): palpate sides of abdomen — locate fetal back (smooth, firm, continuous) vs extremities (irregular, small parts). 3rd maneuver (Pawlik's grip): grasp lower abdomen above symphysis — what is the presenting part? Is it engaged? 4th maneuver (pelvic grip): face mother's feet, palpate toward pelvis — determine flexion/attitude and degree of descent. Findings guide auscultation (FHR best heard over fetal back) and labor management.

Amniotomy: artificial rupture of membranes (AROM) using an amnihook. Indications: labor induction/augmentation, application of internal fetal monitor, or to assess amniotic fluid. Prerequisites: vertex presentation, engaged (to reduce cord prolapse risk), cervix dilated. Nursing care: before — document FHR baseline. During/immediately after: assess FHR (rule out cord prolapse — look for variable or prolonged decelerations), note color/amount/odor of fluid (clear = normal; green/brown = meconium; foul odor = infection; bloody = possible abruption or vasa previa). Document time of rupture (prolonged ROM >18 hrs increases infection risk). Monitor maternal temp q1-2 hrs. Expect labor to intensify after amniotomy.

Pre-induction cervical assessment — predicts likelihood of successful induction. Five components (each Dilation, effacement, station scored 0-3; consistency and position scored 0-2; max total 13. Score ≥8: favorable cervix, high likelihood of successful induction (proceed with oxytocin). Score <6: unfavorable cervix — cervical ripening recommended before oxytocin (misoprostol PO/vaginal, dinoprostone insert/gel, Foley bulb). Misoprostol: contraindicated in prior C-section (uterine rupture risk). Foley bulb: mechanical dilation, can use with prior C-section.