Maternal and obstetric nursing

In short

Maternal and obstetric nursing is the care of a woman through pregnancy, labour, birth and the six weeks after it, together with the care of the newborn at birth and the management of obstetric emergencies. It matters because India's maternal mortality ratio — about 88 per 100,000 live births in the latest SRS special bulletin (2021-23), down from 93 in 2019-21 and 130 in 2014-16 — is still driven by a handful of preventable causes (haemorrhage, hypertensive disorders, sepsis, unsafe abortion, obstructed labour) that nurses detect and treat first. It is examined in the B.Sc Nursing "Midwifery and Obstetrical Nursing" paper, in the INC-mandated clinical requirement of conducting deliveries, and in NORCET/AIIMS/ESIC/state staff-nurse recruitment, where obstetrics carries one of the largest question shares. On the job it is used in labour rooms, SNCUs, FRUs, PHC/CHC delivery points, private maternity hospitals and in community midwifery under NHM.

Explained

Anatomy, physiology and diagnosis of pregnancy

• Female pelvis types: gynaecoid (round brim, best for birth, ~50%), android (heart-shaped, narrow, risk of arrest), anthropoid (oval, AP diameter long), platypelloid (flat, transverse arrest).
• Key pelvic diameters: true conjugate ~11 cm, diagonal conjugate ~12-12.5 cm (measured per vaginam), obstetric conjugate ~10.5 cm (shortest AP diameter the head must pass); interspinous diameter ~10.5 cm is the narrowest plane.
• Fetal skull: vertex is the area between the fontanelles and parietal eminences; sub-occipito-bregmatic diameter 9.5 cm (full flexion, vertex) is the smallest presenting diameter; mento-vertical 13.5 cm (brow) is the largest and incompatible with vaginal birth at term.
• Maternal physiological changes: blood volume up ~40-50%, plasma more than red cells, hence physiological anaemia of pregnancy; cardiac output up 30-50%; GFR up ~50%; tidal volume up; gastric emptying delayed; a dilutional fall in haemoglobin is normal, but WHO/India define anaemia in pregnancy as Hb below 11 g/dL.
• Signs of pregnancy: presumptive (amenorrhoea, nausea, breast changes), probable (uterine enlargement, Hegar's sign, Goodell's sign, Chadwick's sign, positive urine hCG), positive (fetal heart sounds, fetal movements felt by examiner, ultrasound visualisation).
• Gravida and para: gravida = total pregnancies including the present one; para = births after viability. Viability in India is legally and clinically taken as 28 weeks/1,000 g in most texts; many services now use 24 weeks for neonatal care.

Antenatal care (ANC)

• Schedule: the Government of India/NHM norm is a minimum of four ANC visits — first within 12 weeks of registration, second 14-26 weeks, third 28-34 weeks, fourth 36 weeks to term; WHO's 2016 model recommends eight contacts, and India's PMSMA guarantees quality ANC on the 9th of every month at a public facility.
• Routine investigations: Hb, blood group and Rh, urine for protein and sugar, blood sugar (OGTT with 75 g glucose as per GoI GDM guideline), HIV, VDRL/syphilis, HBsAg, urine culture if indicated, obstetric ultrasound.
• Routine prophylaxis under NHM: iron-folic acid 60 mg elemental iron + 500 mcg folic acid daily for 180 days in pregnancy and 180 days postpartum; folic acid alone for the first trimester/preconception; calcium 500 mg twice daily for 360 days; albendazole 400 mg once after the first trimester; Td (tetanus-diphtheria) — two doses four weeks apart, or one booster if immunised within three years.
• Abdominal examination: inspection, fundal height, fundal grip, lateral (umbilical) grip, first and second pelvic grips (Leopold's manoeuvres) to find presentation, position and engagement; fetal heart with a fetoscope or Doppler (normal 110-160 bpm).
• Danger signs the woman must be taught: bleeding, severe headache or blurred vision, convulsions, reduced fetal movements, leaking fluid, fever, severe abdominal pain, swelling of face and hands, breathlessness.
• Birth preparedness: place of delivery, skilled attendant, transport, blood donor, money, companion — this is the formal "birth preparedness and complication readiness" plan in ANC counselling.

Labour and its management

• Definition: labour is the series of events by which the products of conception are expelled after 28 weeks (term labour: 37 completed weeks to 41 weeks 6 days). True labour = painful regular contractions increasing in frequency, progressive cervical dilatation and effacement, show, descent; false labour = irregular pains, no cervical change.
• First stage — onset of true labour to full dilatation (10 cm). Latent phase up to ~5-6 cm, active phase thereafter; revised norms accept slower progress than the old 1 cm/hour rule, and WHO's 2018 intrapartum guideline states a cervical rate below 1 cm/hour alone is not an indication for intervention.
• Second stage — full dilatation to delivery of the baby: about 2 hours in a primigravida and 1 hour in a multigravida, longer with epidural.
• Third stage — delivery of the baby to delivery of the placenta and membranes; normally under 15 minutes, actively managed; fourth stage = the first 1-2 hours of close observation for haemorrhage.
• Mechanism of labour (vertex, LOA): engagement → descent → flexion → internal rotation → crowning and extension → restitution → external rotation → expulsion of shoulders and body.
• Partograph: a single graphical record of cervical dilatation, descent, contractions, fetal heart, maternal vital signs, drugs and fluids; alert and action lines warn of slow progress. WHO's newer Labour Care Guide replaces the alert/action-line partograph in updated training packages; both are in use in India, so state the version being used.
• AMTSL (active management of the third stage): (1) uterotonic within one minute of birth — oxytocin 10 IU IM is the drug of choice (heat-stable carbetocin is an alternative where available); (2) controlled cord traction with counter-traction on the uterus; (3) uterine massage after placental delivery. Delayed cord clamping (1-3 minutes) is now standard and is not contrary to AMTSL.
• Immediate newborn care: dry and keep warm, skin-to-skin contact, delayed cord clamping, assess breathing — if not breathing, start Helping Babies Breathe/NSSK steps with a bag and mask within the golden minute; initiate breastfeeding within one hour; vitamin K 1 mg IM; weigh and record Apgar at 1 and 5 minutes.
• Episiotomy: a surgical incision of the perineum — mediolateral is standard in India; indications include rigid perineum, instrumental delivery, shoulder dystocia, preterm birth to save the head. Routine episiotomy is no longer recommended.
• Perineal tear degrees: 1st — skin/vaginal mucosa; 2nd — perineal muscles; 3rd — anal sphincter involved (3a <50%, 3b >50% of external sphincter, 3c internal sphincter); 4th — anal/rectal mucosa.

High-risk pregnancy and obstetric emergencies

• Hypertensive disorders: gestational hypertension — BP ≥140/90 after 20 weeks without proteinuria; preeclampsia — with proteinuria (≥300 mg/24 h or 1+ dipstick) or with maternal organ dysfunction; severe features — BP ≥160/110, platelets <1,00,000, raised liver enzymes, creatinine rise, pulmonary oedema, visual or cerebral symptoms; eclampsia — convulsions; HELLP — haemolysis, elevated liver enzymes, low platelets.
• Eclampsia management: left lateral position, airway and suction, oxygen, magnesium sulphate (Pritchard regimen: 4 g IV over 5-10 min plus 10 g IM — 5 g in each buttock — then 5 g IM every 4 hours for 24 h after the last fit or delivery), antihypertensive (labetalol, nifedipine or hydralazine), catheterise, strict intake-output, and delivery as definitive treatment. Monitor before each MgSO4 dose: respiratory rate >16/min, urine output >30 mL/hour, patellar reflex present; antidote is calcium gluconate 1 g (10 mL of 10%) IV slowly.
• Antepartum haemorrhage (APH): bleeding from the genital tract after 28 weeks (some texts 20/24 weeks) before birth. Placenta praevia — painless, causeless, recurrent bleeding, soft uterus, high presenting part; never do a vaginal examination outside an operation theatre. Abruptio placentae — painful bleeding, tense tender "woody" uterus, bleeding out of proportion to shock, risk of DIC and renal failure.
• Postpartum haemorrhage (PPH): blood loss ≥500 mL after vaginal birth or ≥1,000 mL after caesarean, or any loss causing haemodynamic change; primary within 24 hours, secondary from 24 hours to 12 weeks. Causes — the 4 Ts: Tone (atony, ~70%), Trauma, Tissue (retained placenta), Thrombin (coagulopathy).
• PPH management sequence: call for help, uterine massage and bimanual compression, IV access ×2 with wide-bore cannulae, uterotonics (oxytocin; then methylergometrine 0.2 mg IM — contraindicated in hypertension; misoprostol 800 mcg sublingual; carboprost 250 mcg IM — avoid in asthma), tranexamic acid 1 g IV within 3 hours, catheterise, examine for tears, non-pneumatic anti-shock garment, uterine balloon tamponade (condom catheter), then surgical measures — B-Lynch suture, uterine/internal iliac artery ligation, hysterectomy.
• Obstructed labour: no descent despite good contractions; Bandl's ring, oedematous vulva, caput and moulding, dehydration and ketosis, fetal distress; definitive management is caesarean (or destructive operation for a dead fetus by an obstetrician).
• Other emergencies: shoulder dystocia (HELPERR — call for Help, Evaluate for episiotomy, Legs/McRoberts, suprapubic Pressure, Enter manoeuvres, Remove posterior arm, Roll onto all fours), cord prolapse (knee-chest or exaggerated Sims position, relieve pressure, immediate delivery), uterine rupture, amniotic fluid embolism, inversion of uterus.
• Medical disorders in pregnancy: anaemia (Hb <11 g/dL; severe <7; very severe <4 — IV iron sucrose per NHM protocols, blood transfusion in severe anaemia near term), GDM (GoI single-step 75 g OGTT, diagnosed at 2-h plasma glucose ≥140 mg/dL; medical nutrition therapy first, then metformin/insulin), heart disease (NYHA class governs care), hypothyroidism, hepatitis B, HIV (triple ART under NACO's PPTCT), Rh negative mother — anti-D immunoglobulin 300 mcg within 72 hours of delivery or sensitising event.
• Preterm labour, PROM and malpresentations: antenatal corticosteroids (dexamethasone 6 mg IM ×4 doses 12-hourly) between 24 and 34 weeks, MgSO4 for neuroprotection where indicated, tocolysis to buy time for steroids/transfer; breech, transverse lie and brow presentation usually need caesarean (external cephalic version at term by a specialist in selected breech cases).

Puerperium, newborn and family welfare

• Puerperium: the six weeks after delivery when the reproductive organs return to the non-pregnant state. Involution — the fundus falls about 1-1.25 cm per day; the uterus is impalpable abdominally by about 2 weeks and near pre-pregnancy weight by 6 weeks.
• Lochia: rubra (days 1-4, red), serosa (days 5-9, pale brown), alba (days 10-15 onward, whitish); offensive lochia with fever suggests puerperal sepsis.
• Postnatal assessment (BUBBLE-HE): Breast, Uterus, Bladder, Bowel, Lochia, Episiotomy/perineum, Homan's sign/legs, Emotional state.
• Postnatal visits under HBNC/NHM: facility stay of at least 48 hours after normal delivery (under JSSK), and home visits by the ASHA on days 1, 3, 7, 14, 21, 28 and 42 for home deliveries, with a reduced schedule for institutional births; six-week postnatal check-up at the facility.
• Breastfeeding: exclusive for 6 months; correct position and attachment (chin touching breast, mouth wide, lower areola less visible, slow deep sucks); problems — engorgement, cracked nipple, mastitis, breast abscess, inverted nipple. MAA (Mothers' Absolute Affection) is the national breastfeeding promotion programme.
• Puerperal complications: puerperal sepsis (temperature 38 °C on any two of the first ten days excluding the first 24 hours), breast infection, UTI, DVT and pulmonary embolism, secondary PPH, postpartum blues, postpartum depression (EPDS screening), puerperal psychosis.
• Postpartum family planning: lactational amenorrhoea method, PPIUCD within 48 hours or after 6 weeks, progestin-only pills while breastfeeding, Antara (injectable DMPA), condoms, Chhaya (centchroman), minilap/laparoscopic sterilisation and NSV — all under the national Family Planning programme with compensation and Mission Parivar Vikas in high-fertility districts.

Indian law, programmes and standards

• MTP (Amendment) Act, 2021 with the 2021 Rules: abortion up to 20 weeks on the opinion of one registered medical practitioner; 20-24 weeks on the opinion of two RMPs for seven categories of women specified in the Rules (including survivors of rape or incest, minors, change of marital status, disability, fetal malformation); beyond 24 weeks only for substantial fetal abnormality on the approval of a State-level Medical Board. Confidentiality of the woman's identity is mandatory and breach is punishable.
• PCPNDT Act, 1994 (amended 2003): prohibits sex determination and its communication; registration of diagnostic centres, Form F records, mandatory display of the prohibition notice. A nurse must never disclose fetal sex.
• Other statutes: Maternity Benefit (Amendment) Act, 2017 — 26 weeks' paid leave for the first two children; the Code on Social Security, 2020, in force with the four Labour Codes from 21 November 2025, subsumes maternity benefit provisions, so quote the Code for employment-linked benefit questions. Also POCSO, 2012 (pregnancy in a minor is a mandatory report), the Indian Nursing Council Act, 1947 and state council registration for practice, the Clinical Establishments Act, 2010, and the Surrogacy (Regulation) Act, 2021.
• Programmes: JSY (cash assistance for institutional delivery), JSSK (free delivery, caesarean, drugs, diagnostics, blood, diet and transport for mother and sick newborn in public facilities), PMSMA (fixed-day quality ANC on the 9th), SUMAN (assured free, dignified, zero-refusal maternity service), LaQshya (labour room and maternity OT quality improvement with NQAS certification), Dakshata and SBA (skilled birth attendance) training, MusQan and NSSK/HBB for newborn care, Anaemia Mukt Bharat, PMMVY (maternity cash benefit), Village Health and Nutrition Days, and MDSR (maternal death surveillance and response) — every maternal death must be notified and reviewed.
• Facility standards: delivery points are graded as L1 (PHC-level), L2 (CHC/FRU) and L3 (DH/medical college); an FRU must have 24×7 obstetric and newborn care, caesarean capability, blood storage and an anaesthetist. Infection prevention follows NABH/NQAS standards and biomedical waste segregation under the Bio-Medical Waste Management Rules, 2016 (as amended) — placenta and blood-soaked items go in the yellow category.
• Nursing legal duties: informed consent for procedures, accurate contemporaneous records, drug double-checking for high-alert uterotonics and MgSO4, respectful maternity care and the right to a birth companion, no refusal of care, and reporting of adverse events.

Key points

• Obstetric conjugate - shortest AP diameter of the pelvic inlet, about 10.5 cm; the head must pass this.
• Sub-occipito-bregmatic 9.5 cm - smallest diameter of a well-flexed vertex, the reason flexion is promoted.
• Naegele's rule - EDD = LMP + 9 months + 7 days, assuming a regular 28-day cycle.
• ANC minimum - four GoI visits (WHO recommends eight contacts); IFA 180 days antenatal + 180 postnatal, calcium 360 days.
• Anaemia in pregnancy - Hb <11 g/dL; severe <7 g/dL; very severe <4 g/dL needs transfusion and specialist care.
• Three stages of labour - dilatation, expulsion, placental; plus a fourth hour of close observation.
• AMTSL - oxytocin 10 IU IM within one minute, controlled cord traction, uterine massage; prevents most atonic PPH.
• 4 Ts of PPH - Tone, Trauma, Tissue, Thrombin; atony causes about 70%.
• Tranexamic acid 1 g IV - give within 3 hours of PPH onset; no benefit later.
• MgSO4 - the drug of choice for eclampsia; monitor respiration, reflexes and urine output; antidote calcium gluconate.
• Placenta praevia - painless causeless recurrent bleeding; no PV examination except in the OT with everything ready.
• Abruption - painful bleeding, tense tender uterus, shock out of proportion to visible loss.
• Puerperal sepsis - fever 38 °C on any two of the first ten days, excluding the first 24 hours.
• Involution - fundus descends about 1 cm per day; impalpable abdominally by roughly 2 weeks.
• Lochia sequence - rubra → serosa → alba; offensive lochia means infection.
• MTP Act as amended in 2021 - 20 weeks (one RMP), 20-24 weeks (two RMPs, specified categories), beyond 24 weeks only via a State Medical Board for substantial fetal abnormality.
• PCPNDT Act - sex determination and its disclosure are criminal offences.
• India's MMR - about 88 per 100,000 live births (SRS 2021-23; 93 in 2019-21); the SDG target is below 70 by 2030.

Formulas and examples

Example 1 — EDD and gestational age. LMP = 12 March 2026.

• Naegele's rule: 12 March − 3 months = 12 December 2025, + 7 days = 19 December 2025, + 1 year = 19 December 2026.
• Gestational age on 4 November 2026: 12 March to 4 November = 19 (March) + 30 + 31 + 30 + 31 + 31 + 30 + 31 + 4 = 237 days → 237 ÷ 7 = 33 weeks 6 days.

Example 2 — Johnson's formula and fundal height. A woman has a fundal height of 36 cm and the vertex is engaged.

• Fetal weight = (36 − 12) × 155 = 24 × 155 = 3,720 g (3.72 kg).
• If the vertex were not engaged: (36 − 13) × 155 = 23 × 155 = 3,565 g. By McDonald's rule 36 cm suggests about 36 weeks, though the rule is unreliable after 34 weeks and with obesity, polyhydramnios or multiple pregnancy.

Example 3 — Oxytocin infusion rate. 5 IU oxytocin in 500 mL Ringer lactate, to run at 10 milliunits/min with a 20 drops/mL set.

• Concentration = 5 IU ÷ 500 mL = 0.01 IU/mL = 10 milliunits/mL.
• Required 10 mU/min ÷ 10 mU/mL = 1 mL/min = 60 mL/hour.
• Drops per minute = 1 mL × 20 drops/mL = 20 drops/min. (Always prefer an infusion pump; titrate to contractions, not to a fixed rate.)

Example 4 — Blood loss and MMR. A 55 kg woman loses 1,200 mL after vaginal birth.

• Term blood volume ≈ 55 × 100 = 5,500 mL; loss = 1,200 ÷ 5,500 = 21.8% — class II-III shock territory: this is severe PPH needing resuscitation, uterotonics, tranexamic acid and blood.
• A district with 18 maternal deaths and 24,000 live births: MMR = 18 ÷ 24,000 × 1,00,000 = 75 per 1,00,000.

Example 5 — Bishop score for induction. Dilatation 3 cm (2), effacement 60% (2), station −1 (2), consistency soft (2), position mid (1).

• Total = 2 + 2 + 2 + 2 + 1 = 9 → favourable cervix, induction with oxytocin or ARM is likely to succeed without prior ripening.

Where it is used

• Public labour rooms and FRUs: staff nurses and ANMs conducting normal deliveries, running partographs/Labour Care Guide, AMTSL and newborn resuscitation under LaQshya and SUMAN — district hospitals, CHCs and PHC delivery points across every state NHM.
• Private and corporate maternity services: Apollo Cradle, Fortis La Femme, Cloudnine, Rainbow Children's Hospital, Motherhood — labour-room nurses, OT nurses for LSCS, lactation consultants and childbirth educators.
• Community midwifery and outreach: ANM/LHV roles at sub-centres and Health and Wellness Centres, HBNC visits with ASHAs, PMSMA camps, VHND sessions, Anaemia Mukt Bharat screening.
• Specialist and teaching posts: Nurse Practitioner in Midwifery (NPM) programme, midwifery educator at colleges of nursing, labour-room quality assessor for NQAS, maternal death reviewer in MDSR.
• Recruitment and licensure: NORCET (AIIMS), ESIC, RRB staff nurse, state PSC staff nurse, military nursing service, and screening tests for Gulf/UK/NHS posts — obstetrics is a high-weight section in all of them.
• Research and programme roles: NGO and donor maternal-health programmes (Jhpiego, PSI, state Nursing Cells), audit of PPH and preeclampsia care, simulation training on obstetric drills.

Interview questions

• Q: What are the three steps of active management of the third stage of labour? A: A uterotonic — oxytocin 10 IU IM — within one minute of birth, controlled cord traction with counter-traction on the uterus, and uterine massage after the placenta delivers.
• Q: Why must a vaginal examination not be done in suspected placenta praevia? A: It can dislodge the placenta from the lower segment and cause torrential haemorrhage; it is done only in theatre with blood, anaesthesia and a double set-up ready.
• Q: How is PPH defined and what are its causes? A: Blood loss of 500 mL or more after vaginal birth, 1,000 mL after caesarean, or any loss causing haemodynamic instability; the causes are the 4 Ts — Tone, Trauma, Tissue, Thrombin — with atony accounting for about 70%.
• Q: What do you check before each repeat dose of magnesium sulphate? A: Respiratory rate above 16 per minute, urine output above 30 mL per hour and a present patellar reflex; withhold the dose and give calcium gluconate if toxicity is suspected.
• Q: Which uterotonic is contraindicated in a preeclamptic woman and why? A: Methylergometrine, because it causes vasoconstriction and can precipitate a dangerous rise in blood pressure; use oxytocin instead.
• Q: How do you differentiate true from false labour? A: True labour has regular progressively stronger contractions with progressive cervical dilatation and effacement, show and descent; false labour has irregular pains with no cervical change.
• Q: What is a partograph used for? A: To record cervical dilatation, descent, contractions, fetal heart and maternal condition on one chart so that slow progress or fetal compromise is detected early; WHO's Labour Care Guide is the updated form in current training.
• Q: Up to how many weeks is MTP permitted in India and under whose opinion? A: Up to 20 weeks on one registered medical practitioner's opinion, 20-24 weeks on two RMPs' opinion for categories specified in the 2021 Rules, and beyond 24 weeks only with a State Medical Board's approval for substantial fetal abnormality.
• Q: What does JSSK entitle a pregnant woman to? A: Free delivery including caesarean, drugs, consumables, diagnostics, blood, diet and transport in public health facilities, with the same entitlements for sick newborns up to one year.
• Q: A baby is not breathing at birth — what do you do in the first minute? A: Clamp and cut the cord, move to the resuscitation area, position and clear the airway, stimulate, and if still not breathing start bag-and-mask ventilation with room air/oxygen within the golden minute as per NSSK/HBB.
• Q: How do you manage shoulder dystocia? A: Call for help and follow HELPERR — consider episiotomy, McRoberts position, suprapubic pressure, internal rotational manoeuvres, delivery of the posterior arm, and all-fours position; never apply fundal pressure.
• Q: What is the significance of Hb 6.5 g/dL at 34 weeks? A: It is severe anaemia; it needs urgent evaluation, parenteral iron or blood transfusion as per protocol, referral to an FRU, and planning for delivery where blood and intensive care are available, as anaemia multiplies the risk of death from PPH.

Common mistakes

• Applying fundal pressure in shoulder dystocia or for a slow second stage — it worsens impaction and risks uterine rupture.
• Confusing placenta praevia with abruption, and doing a vaginal examination on a bleeding woman outside theatre.
• Pulling on the cord without counter-traction on the uterus, which can cause uterine inversion or a torn cord.
• Giving methylergometrine in hypertension or carboprost in asthma because "PPH needs the strongest drug".
• Mis-stating MgSO4 monitoring (quoting pulse and BP instead of respiration, reflexes and urine output) or forgetting calcium gluconate as the antidote.
• Counting fundal height as a reliable gestational age after 34 weeks, or using Naegele's rule on an irregular cycle without adjustment.
• Quoting obsolete law and norms — pre-2021 MTP limits, or a rigid 1 cm/hour cervical rule as an automatic indication for caesarean.

Related topics

Child health nursing · Medical-surgical nursing · Nursing pharmacology · Community health nursing · Reproductive and child health programmes · Nursing ethics and legal aspects of practice