Two patients, one of whom cannot speak
Most maternal deaths in the world are preventable, and most of them are prevented by somebody at the bedside noticing something early. This subject is where nursing observation translates most directly into survival, and it is the subject where the gap between what is known and what is delivered costs the most lives each year.
Every assessment in obstetric nursing concerns two people whose interests are usually aligned and occasionally are not, and one of whom cannot report a symptom. This shapes everything. A nurse assessing a pregnant woman is simultaneously assessing a fetus whose only available signals are heart rate, movement and growth, all of which must be read through the mother. It also means the woman's own account carries extra weight, because reduced fetal movement reported by a mother is frequently the only warning that exists, and dismissing it is a recognised cause of preventable stillbirth.
Pregnancy and birth are normal processes for the overwhelming majority of women, and treating them as illness causes its own harm. But the transition from normal to life-threatening can take minutes, particularly around delivery, and the same nurse must be capable of both supporting a normal process without interfering and recognising a catastrophe immediately. Holding both dispositions at once is the central skill of the subject and it is what examinations are really testing when they give you a scenario that begins ordinarily.
The World Health Organization's assessment is that the great majority of maternal deaths are preventable, and the leading direct causes are few: severe bleeding, infection, high blood pressure disorders including eclampsia, complications of delivery, and unsafe abortion. This short list is the most useful thing a student can memorise in the whole subject, because it tells you where to look. Almost everything that kills a woman in childbirth falls into one of those groups, and almost every one of them announces itself before it becomes fatal, to somebody who is paying attention.
The World Health Organization reframed antenatal care around a positive pregnancy experience, not because experience is a luxury but because women who are treated badly stop attending, and women who stop attending are the ones who die. Disrespect, roughness, being left alone, and being spoken to as though they were a nuisance are documented reasons that women avoid facilities in many countries. A nurse who is kind is not being soft; they are removing the largest barrier to the care that keeps women alive.
Blood volume rises substantially, plasma rising more than red cell mass, which produces the dilutional fall in haemoglobin that is normal in pregnancy and that a nurse must not mistake for anaemia without interpretation. Cardiac output rises, resistance falls, and blood pressure typically dips in the middle of pregnancy before returning towards baseline. This matters practically: a blood pressure that would be unremarkable in a non-pregnant woman may be abnormal here, and a pregnant woman can lose a great deal of blood before her observations change, because she started with more.
The diaphragm is displaced upward, tidal volume increases, and breathlessness on exertion is common and usually normal. Smooth muscle relaxes throughout, which slows gastric emptying and gut transit and produces reflux and constipation, and which also increases aspiration risk under anaesthesia. Ligaments soften, the centre of gravity shifts, and back pain and altered balance follow. Each of these has a nursing consequence: positioning, advice, fall risk, and the recognition that a complaint which sounds trivial has a physiological basis.
Pregnancy is a hypercoagulable state, which protects against haemorrhage at delivery and raises the risk of venous thromboembolism throughout pregnancy and especially afterwards. Immune modulation makes some infections more likely and some more severe. A nurse should carry both facts as warnings: calf pain, chest pain or sudden breathlessness in a pregnant or recently delivered woman is never to be dismissed, and an infection in pregnancy is watched more closely than the same infection would be otherwise.
From around the middle of pregnancy the uterus compresses the inferior vena cava when the woman lies flat on her back, reducing the blood returning to the heart. The result can be a fall in blood pressure, faintness, and reduced blood flow to the placenta. The correction is simple and constantly forgotten: tilt her to the left, or place a wedge under the right hip. It applies during examination, during transport, during anaesthesia and during resuscitation, and remembering it is one of the highest-value habits in this subject.
Antenatal contacts exist to detect the conditions that kill, to provide the interventions that prevent them, and to prepare the woman for birth and for her newborn. The World Health Organization's model increased the number of contacts because more contact detects more, and reframed them as contacts rather than visits to signal that the purpose is engagement rather than attendance. For a nurse, each contact has a structure: how is she, how is the baby, what has changed, what is due today, and what does she need to know before the next one.
Previous pregnancies and how they ended, previous caesarean section, previous postpartum haemorrhage, previous stillbirth, existing medical conditions, medicines, and the dates that establish gestation. Obstetric history is the strongest predictor available of what will happen this time, and a woman who bled heavily after her last birth is at raised risk of doing so again. A history taken properly at the first contact is what allows every subsequent contact to be interpreted.
Blood pressure and urine testing at every contact, because pre-eclampsia is detected by nothing else and produces no symptoms until it is advanced. Fundal height to track growth. Fetal heart and, later in pregnancy, presentation. Assessment for anaemia, for oedema of a concerning kind, and for anything the woman raises. The routine is unglamorous and it is the whole mechanism by which silent conditions are caught.
Programmes vary by country and this manual will not list them, but the structure is consistent: screening for anaemia, for infections that affect the fetus, for diabetes, and for conditions with local prevalence; supplementation according to national policy; and immunisation, most universally against tetanus, which remains a major cause of newborn death where coverage is poor. A nurse should know their own national schedule thoroughly, because they are usually the person delivering it.
The danger signs that mean come back immediately: bleeding, severe headache, visual disturbance, severe upper abdominal pain, swelling of face and hands, fever, reduced fetal movement, fluid loss, and convulsions. Where she should go, how she will get there, and who will go with her. A birth plan that survives contact with reality is one that names a facility and a means of transport, and in many settings arranging that in advance is the single most effective thing done in an antenatal clinic.
Hypertensive disorders are among the leading direct causes of maternal death worldwide, and pre-eclampsia is the reason blood pressure and urine are checked at every single antenatal contact. It is a disorder of the placenta with effects throughout the body, it produces no symptoms in its early stages, and it can progress to seizures, stroke, liver rupture, clotting failure and death. The only thing that reliably detects it early is routine measurement in a woman who feels perfectly well.
Rising blood pressure and protein in the urine are the screening findings. The symptoms that signal advancing disease are severe headache that does not settle, visual disturbance such as flashing lights or blurring, pain below the ribs usually on the right, vomiting, and sudden swelling of the face, hands or feet. The NHS guidance lists these because women themselves can recognise them, and teaching them to a woman at an antenatal contact turns her into a monitor who is present every day between visits.
A nurse's role is recognition, immediate escalation, and supportive care: quiet environment, left lateral positioning, close observation, accurate recording, and preparation for whatever the protocol requires next. Treatment is prescribed under protocol and delivery is the only definitive resolution. What matters for a student is knowing that this is a condition where the nurse's contribution is speed, and that a woman with severe features is not left alone, not sent home, and not asked to come back tomorrow.
A seizure in a pregnant or recently delivered woman is eclampsia until proven otherwise. The immediate actions are the general ones for any seizure — protect from injury, do not restrain, nothing in the mouth, time it — plus left lateral positioning, airway protection, oxygen where available, and an emergency call. This is one of the small number of obstetric events where the first few minutes of nursing care visibly change the outcome, and where hesitating to call for help is the error that costs most.
Bleeding in early pregnancy has several causes, and one of them — ectopic pregnancy — can kill quickly and can present with pain more than with visible bleeding, because the blood is inside the abdomen. Any woman of reproductive age with abdominal pain and collapse is treated as a possible ectopic pregnancy until that is excluded, and this is a rule worth carrying out of this manual permanently because it saves lives in emergency departments where nobody thought to ask about a period.
Bleeding after the midpoint of pregnancy is an emergency. The two classical causes behave differently: bleeding from a low-lying placenta is characteristically painless, while separation of a normally sited placenta characteristically causes pain and a tense uterus, and may conceal much of the blood inside. The practical instruction for a nurse is the one that matters most: do not perform a vaginal examination on a woman bleeding in later pregnancy, because if the placenta is covering the cervix the examination can provoke catastrophic haemorrhage. Escalate, position, monitor, and prepare.
Visible loss underestimates true loss, sometimes enormously, because blood collects in bed linen, on the floor, inside the uterus and within the abdomen. Pregnant women compensate well and then fail suddenly. The findings to act on are pulse, peripheral perfusion, capillary refill, conscious level and the woman's own sense that something is wrong; blood pressure falls late. Weighing swabs and linen where the service does it is far more accurate than estimating by eye, and estimating by eye is what most people do.
Call for help specifically and early. Lie her flat with a left tilt and raise the legs. Give oxygen if available. Establish intravenous access where that is within your scope and your service's protocol. Keep her warm, because cold blood clots badly. Record times and observations. Do not leave her. In a setting where transfusion or surgery is hours away, begin organising transport at the same moment you begin resuscitating, not after.
The first stage runs from the onset of established labour to full dilatation of the cervix, and the nursing work is observation, support, hydration, position and pain relief. The second stage runs to the birth of the baby, and the work is support, protection of the perineum by whoever is conducting the birth, and close monitoring of the fetal heart. The third stage is delivery of the placenta, and it is the stage with the highest immediate risk to the mother. Knowing which stage you are in tells you what you are watching for.
The mother's observations, her contractions, her progress and her state of mind on one side; the fetal heart rate and its pattern on the other. Fetal heart monitoring is interpreted in the context of what the uterus is doing, which is why contractions are recorded alongside it. A student should understand the principle rather than attempt to learn pattern interpretation from a page: what is being looked for is whether the fetus is tolerating labour, and any deterioration is escalated to whoever interprets and decides in your service.
Women who are able to move and to adopt upright positions in labour generally do better, and confining a labouring woman to a bed on her back is both uncomfortable and physiologically unhelpful. Pain relief ranges from presence, breathing, massage and water through to regional anaesthesia, and what is available differs enormously. The nursing contribution that is available everywhere and is consistently undervalued is continuous companionship: a woman who is not left alone has shorter labour and better outcomes, and this is one of the best-evidenced findings in the whole of maternity care.
Labour that is not progressing is a warning, because obstructed labour causes uterine rupture, fistula and death, and it is a major cause of maternal harm where surgical delivery is not quickly available. What a nurse records — timing, progress, the woman's condition, the fetal heart — is what allows delay to be recognised rather than absorbed. In settings where referral takes hours, recognising delay early is the difference between a transfer and a catastrophe.
The immediate priorities at birth are keeping the newborn warm, drying and stimulating, and assessing breathing. Most babies need nothing more than drying, warmth and their mother. A baby who does not establish breathing needs resuscitation, and every birth attendant must be able to begin it, which is why newborn resuscitation training is a requirement wherever births happen. Delayed cord clamping is recommended in most current guidance where the baby is well, and the specific timing is the one your national guideline states.
Severe bleeding after childbirth is the leading direct cause of maternal death globally, and most of it happens in the first hours after delivery. This single fact should determine how a nurse allocates attention: the period immediately after birth, when the room is relaxing and the baby is the centre of attention, is the period of highest risk to the mother, and she must still be being watched.
Bleeding after delivery comes from a uterus that has not contracted, from retained placental tissue, from trauma to the genital tract, or from a failure of clotting. They are taught as a group because the assessment that distinguishes them is quick and because the immediate action differs. A soft, high uterus points to poor contraction; a firm, well-contracted uterus with continuing bleeding points to trauma; and a woman who continues to ooze from everywhere points to a clotting problem. A nurse who can make that distinction at the bedside gives the arriving team a starting point.
Call for help. Rub up a contraction by massaging the uterine fundus. Empty the bladder, because a full bladder prevents the uterus contracting and is an extremely common and reversible contributor. Keep the woman flat with legs raised and keep her warm. Establish access and monitor continuously. Encourage the baby to the breast where that is possible, because suckling stimulates the natural contraction of the uterus. Record everything, particularly times and losses.
Active management of the third stage is recommended in most national guidance and substantially reduces the incidence of haemorrhage. Identifying women at higher risk in advance — previous haemorrhage, prolonged labour, multiple pregnancy, a large baby, many previous births — allows them to be delivered where help is available. In settings with limited resources, this kind of anticipation is the intervention that is always affordable.
Maternal sepsis kills quickly, is often missed because the signs are attributed to normal postnatal changes, and occurs in a population who are young, fit and expected to recover. The combination is dangerous: everybody assumes she will be fine, and she is deteriorating. Any woman who has recently given birth and becomes unwell is assessed for sepsis explicitly rather than reassured.
Fever or an abnormally low temperature, rapid pulse, rapid breathing, offensive discharge, abdominal pain, a uterus that is tender or not reducing in size as expected, breast infection, wound infection, and — the sign that outranks all of the others — a woman who feels very unwell or seems confused. Rapid breathing is frequently the earliest measurable change and is frequently not counted.
Clean birth practices, hand hygiene, aseptic technique for any procedure, minimising vaginal examinations in labour, careful perineal and wound care, and prompt attention to retained products. Much of the global burden of maternal infection is the result of birth in unclean conditions, which makes basic infection prevention one of the highest-yield things a nurse does in a maternity setting.
Sepsis is treated by protocol with urgency, and the nursing contribution is speed of recognition, early observations, obtaining cultures where that is the plan, giving prescribed treatment without delay, and repeating observations frequently enough to see the trend. A single set of observations tells you almost nothing; a trend over an hour tells you a great deal.
Most maternal and newborn deaths occur in the days immediately after birth, and yet postnatal care is the most neglected part of maternity services in most countries. The World Health Organization's postnatal guidance exists precisely to correct this. For a nurse, the implication is direct: the woman who has delivered safely is not finished, and the contacts scheduled in the first days and weeks are not a courtesy.
Bleeding and the involution of the uterus, blood pressure, temperature, the perineum or wound, bladder and bowel function, legs for signs of thrombosis, breasts and feeding, pain, sleep, and mood. The newborn is assessed alongside her: feeding, weight, colour, temperature, cord, and behaviour. In practice these two assessments interleave, and a nurse who assesses only the baby has missed half the patients in the room.
Early initiation of breastfeeding and exclusive breastfeeding for the first months are recommended globally on strong evidence, and the support that makes them succeed is practical rather than motivational: positioning, attachment, recognising effective feeding, managing engorgement and sore nipples, and not undermining the mother's confidence. Where a woman cannot or chooses not to breastfeed, she is supported to feed safely rather than made to feel judged, and in settings without clean water the risks of formula feeding are discussed honestly.
Perinatal mental illness is common, under-detected and sometimes fatal. Low mood in the first days is frequent and usually settles; depression that persists, anxiety that is disabling, and any thought of harming herself or the baby are different and require action. Asking directly about mood at every postnatal contact is what detects it, and a nurse who is uncomfortable asking will not detect it. Psychosis after birth is rare, develops rapidly and is an emergency.
Spacing between pregnancies affects the outcome of the next one, and the postnatal period is when the conversation is most likely to happen. What is offered depends on national programmes, on feeding, and on the woman's own wishes, which are hers to determine. A nurse's job is accurate information, respect for her decision, and ensuring she knows how to obtain what she chooses.
Dry, keep warm, assess breathing, and keep mother and baby together unless there is a reason not to. Hypothermia in a newborn is common, harmful and easy to prevent, and skin-to-skin contact with the mother is the best available warming method as well as supporting feeding and bonding. A cold baby is a baby whose blood sugar falls and whose breathing worsens, and a wet baby in a cool room becomes cold within minutes.
Newborns have few ways of showing illness and the signs are non-specific: poor feeding, lethargy, irritability, temperature instability in either direction, fast or laboured breathing, grunting, colour change, jaundice appearing very early or very deep, a bulging fontanelle, convulsions, and reduced movement. Any of these warrants urgent assessment. A mother who says her baby is not feeding as before is giving you a clinical sign, not an anxiety.
Jaundice appearing in the first day, or deepening rapidly, or persisting, needs assessment rather than reassurance, because untreated severe jaundice causes permanent brain injury and the treatment is simple. Cord care follows national guidance, with the universal principles being clean hands, keeping it clean and dry, and recognising redness or discharge as infection. Eye discharge in the first days is assessed rather than wiped away.
A minority of babies need help to establish breathing, and the initial steps are drying, stimulation, positioning the airway, and ventilation. Newborn resuscitation differs from adult resuscitation in ways that matter, and it is a separate structured course that every person attending births should complete. This manual introduces it so that a student knows it exists and knows it is not optional; it does not attempt to teach it.
Stillbirth is common enough that every nurse in maternity will encounter it, and the care given in those hours is remembered by the family for the rest of their lives. What helps is consistent: honest information given plainly, choices offered about seeing and holding the baby rather than decisions made for the parents, memories created if they want them, the baby referred to by name if one has been given, and the avoidance of phrases intended to comfort that minimise the loss.
Early pregnancy loss is frequently dismissed as minor by everyone except the woman experiencing it. Care that acknowledges the loss as a loss, provides accurate information about what is happening physically, and does not moralise, is the standard. Termination of pregnancy is legally and culturally contested in many of the countries this manual will be read in, and a nurse's professional obligation everywhere is to provide safe care and accurate information within the law where they practise, and to treat the woman with respect regardless of their own view.
When a woman dies, the care of the family and of the newborn continues, and so does the obligation to review honestly what happened. Maternal death reviews exist in most countries and they work only where staff can describe events without fear. A student should know that being part of such a review is not an accusation.
People who work in maternity carry these events. Services that acknowledge this and provide support retain staff and make fewer errors; services that expect people to continue as though nothing happened lose both. Knowing what support exists before you need it is worth doing in your first week on any unit.
Pregnancy in adolescence carries higher risks of obstructed labour, pre-eclampsia, and preterm birth, and it is common in many of the countries where this manual will be read. The clinical response is closer monitoring and delivery where help is available. The nursing response also includes not compounding the situation with disapproval, because a girl who feels judged does not return, and she is precisely the patient who most needs to.
Maternal mortality is overwhelmingly concentrated in low-income settings and among the poorest women within every country. The reasons are structural: distance from facilities, cost, staffing, supplies, and delays in seeking, reaching and receiving care. This framework of delays is worth knowing because it locates the nurse's influence precisely — a nurse cannot build a road, but can shorten the third delay by being ready, and can shorten the first by being someone women are willing to come to.
Nurses in many countries care for women affected by female genital cutting, which has consequences for labour, for delivery and for a woman's experience of examination. The obligations are to provide competent care, to understand the anatomy and the complications, to document, and to follow the law and safeguarding duties where the practice concerns a child. The obligation is not to express disgust to the woman in front of you, who is not responsible for what was done to her.
Intimate partner violence frequently begins or worsens during pregnancy, and pregnancy provides one of the few reliable opportunities to detect it because the woman attends repeatedly. Asking requires privacy without the partner present, a direct question, and knowledge of the local referral route. A nurse who asks without knowing what to do with the answer causes harm, so learning the pathway comes first.
Labour records exist to make deterioration visible over time, because no single observation reveals obstructed labour but a series does. The value is entirely in completing them contemporaneously and honestly. A record filled in retrospectively at the end of a shift is a document, not a monitor, and the whole reason for its existence has been discarded.
An effective referral names the problem, states the observations, says what has been done, and says what is being asked for. It also arranges the transport, sends the records, and sends somebody competent with the woman. A referral that consists of telling a family to go to the district hospital is not a referral; it is a delay with paperwork.
Scope of practice in maternity differs enormously between countries, between registered nurses and registered midwives, and between levels of facility. A nurse must know exactly what they are authorised to do where they work, must not exceed it, and must also not fall short of it out of nervousness — a nurse who could have started an infusion and did not has also harmed the patient. Where the situation exceeds your scope and nobody else is available, you act in the patient's best interests, you get help as fast as possible, and you document what you did and why.
Much maternity care in lower-resource settings is delivered under standing orders that authorise specific actions without an individual prescription. These are legal instruments and they work when they are followed exactly and reviewed regularly. A student should read the ones in force where they work on their first day, because they define the difference between competent emergency care and practising outside authority.
Bleeding, infection, high blood pressure, obstructed labour. Those four account for most preventable maternal death, each announces itself before it becomes fatal, and each has a nursing action that is available in every setting. A student who leaves this manual able to recognise all four early and escalate them fast is more useful than one who can recite the mechanism of every obstetric complication described in a larger textbook.
Left tilt after mid-pregnancy, every time. Blood pressure and urine at every antenatal contact, without exception. Empty the bladder when the uterus will not contract. Never examine vaginally in later-pregnancy bleeding. Count the respiratory rate. Believe a mother who says her baby is moving less, and believe a mother who says her newborn is not right. These are small, specific and repeatedly life-saving.
Conducting a delivery, interpreting fetal heart traces, suturing, and newborn resuscitation are practical competencies taught by a mentor and assessed in practice. This manual is written to make that learning faster by ensuring you arrive understanding what each step is for. Anybody who tells you a text can substitute for supervised practice in obstetrics is describing something dangerous.
There are few places in nursing where competence and attention translate so directly into somebody surviving. The woman who lives because a nurse checked a blood pressure that day, or rubbed up a contraction without waiting, or believed a mother's account of reduced movement, will never know it happened. That is the nature of prevention, and it is the reason this subject is worth studying properly rather than passing. It is also worth remembering when the work feels invisible, which it often will: the measure of good maternity nursing is a long run of ordinary days, and every one of those ordinary days was produced by somebody paying attention when nothing appeared to be happening. Nobody thanks you for the emergency that did not occur, and the emergency that did not occur is the entire point of the subject.
Complications of preterm birth are the single largest cause of death in children under five worldwide, and most of those deaths occur in the first days of life. The babies at risk are identifiable before they are born, which is what makes antenatal recognition so valuable: a woman in preterm labour who reaches a facility where the baby can be supported has a very different outcome from one who delivers at home. For a nurse, the practical consequence is that threatened preterm labour is an urgent referral, not a wait-and-see, and that recognising it depends on taking seriously a woman who reports tightening, backache or fluid loss before term.
Small and preterm babies lose heat fast, feed poorly, and tire quickly. The interventions that save most of them are unglamorous and available almost everywhere: warmth, support with feeding including expressed breast milk, prevention of infection through clean hands and clean equipment, and close observation for apnoea, poor feeding and temperature instability. Kangaroo mother care — prolonged skin-to-skin contact with the mother, with support for feeding — has strong evidence behind it and is recommended in most national guidance for stable low-birth-weight infants. It requires no equipment at all, which is precisely why it matters most where equipment is scarce.
A baby too small or too tired to feed at the breast still needs its mother's milk, and supporting a mother to express and to feed by cup, spoon or tube according to what the service uses is core nursing work. It is also work that frequently fails for social rather than technical reasons: a mother who is exhausted, frightened and separated from her baby stops producing milk. Keeping mother and baby together, explaining what is happening, and expressing regularly from the first hours are what preserve the supply.
Anaemia in pregnancy is extremely common in much of the world and it makes every other complication worse. A woman who begins labour anaemic has no reserve when she bleeds, tires sooner, heals more slowly and is more vulnerable to infection, and her baby is more likely to be small. Detection is part of routine antenatal screening and correction follows national policy, which this manual will not reproduce. What a nurse should carry is the reasoning: anaemia is not a minor finding to be noted and moved past, it is the background condition that converts a survivable haemorrhage into a fatal one, and correcting it during pregnancy is one of the cheapest interventions in the whole of maternity care.
Twins and higher-order pregnancies carry raised risk of preterm birth, of growth restriction, of pre-eclampsia, of malpresentation and of postpartum haemorrhage, and they require delivery where help is available rather than at home. The risks compound: a woman carrying twins is more likely to labour early, more likely to need operative delivery, and more likely to bleed afterwards because the over-distended uterus contracts poorly. Identifying a multiple pregnancy antenatally is therefore one of the more consequential findings a nurse contributes to, and where ultrasound is not available it is suspected from a uterus larger than the dates suggest and from more than one fetal heart heard at separate sites.
Parents of a preterm baby are usually told either too little or too much at once. What helps is plain, repeated information about what is happening now and what the next step is, honesty about uncertainty, and being included in the care of their own child rather than watching it. A nurse who involves parents in warmth, feeding and touch is not being kind at the expense of clinical work; involvement improves feeding, weight gain and the parents' ability to care for the baby after discharge.