Ob - Exam 2

Front 1

Fetal Position

Back 1

1st letter- location of the presenting part in the [R]ight or [L]eft side of pelvis.
2nd letter - the specific presenting part of the fetus; [O]cciput, [S]acrum, [M]entum (chin), [Sc]apula (shoulder)
3rd letter - location in relation to anterior. [A]nterior, [P]osterior, [T]ransverse
Ex. LOA, ROA, LOP, ROP, RMT

Front 2

Factors affecting labor

Back 2

Five P's
Passenger - (fetus and placenta)
Passageway - birth canal
Powers - (contractions)
Position of the mother
Physiologic response

Front 3

Presentation

Back 3

Part of the fetus that enters the pelvis inlet first and leads thru the birth canal during labor at term.

Front 4

3 main presentations are

Back 4

cephalic - head first (occiput=vertex)
breech - butt or feet first
shoulder

Front 5

attitude

Back 5

the relation of fetal body parts to one another
General flexion - chin flexed on chest; thighs are flexed on abdomen; legs are flexed at knees

Front 6

Types of pelvis

Back 6

gynecoid - classic female type (50% of women have this type)
android - resembling the male pelvis (23%)
anthropoid - resemble the pelvis of anthropoid apes (24%)
platypelloid - flat pelvis (3%)

Front 7

Fetal position - Station

Back 7

Measures the degree of descent of the presenting part of the fetus through the birth canal in relation to the ischial spines.
0 - is at ischial spines
+4-+5 birth is eminent

Front 8

engagement

Back 8

Largest transverse diameter of the presenting part has passed through the maternal pelvic brim or inlet into the true pelvis.

Remember it is the widest diameter of the fetal presenting part to at least a zero station---ischial spines

Front 9

The way the fetus moves through the birth canal is determined by

Back 9

Size of the fetal head
Fetal presentation
Fetal lie
Fetal attitude
Fetal position

Front 10

fetal lie

Back 10

the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother.
The two primary lies are longitudinal (vertical) and transverse (horizontal or oblique).

Front 11

dilation

Back 11

• Opening of the cervix
• Contractions and pressure exerted by the presenting part
• Increases from Long/Thick/Closed to 10 cm
• When the cervix is 10 cm, it can no longer be palpated
• Scarring of the cervix from surgery or infection can slow or inhibit cervical dilation

Front 12

Effacement

Back 12

Shortening and thinning of the cervix
• Generally speaking a primigravida’s effacement advances before dilation
• Subsequent pregnancies—effacement and dilation occur together although I have seen
multigravidas dilate first before effacement.

Front 13

lightening

Back 13

when the fetus's presenting part descends into the true pelvis. Primigravidas the uterus sinks downward and forward about 2 weeks before term

Front 14

bloody show

Back 14

brownish or blood tinged cervical mucous

Front 15

braxton hicks contractions

Back 15

strong, frequent, but irregular uterine contractions
-may be a sign preceding labor

Front 16

back labor

Back 16

a result of an occiput posterior or transverse position.
-the "all fours" position may be used to relieve the backache and may assist in the anterior rotation of the fetus.

Front 17

true labor contractions

Back 17

-occur regularly, becoming stringer, lasting longer and occurring closer together.
-become more intense with walking
-usually felt in lower back, radiating to lower portion of abdomen
-continue despite comfort measures

Front 18

preterm labor contractions

Back 18

uterine contractions more frequent than every 10 minutes, persisting for 1 hour or more.
-can either be painful or painless.
-occur between 20-37 weeks gestation

Front 19

The 3 Stages of labor

Back 19

First stage- Latent phase (1cm-3cm); Active phase (4cm-7cm); Transition phase (8-10cm)
Second stage - pushing phase (10cm to birth of baby)
Third stage- birth of placenta

Front 20

Stage One
Latent Phase

Back 20

• Onset of regular contractions
–Frequency 5-15 minutes apart
–Duration 30-40 seconds long
–Intensity mild to moderate
• Mom’s Behavior
–Excited anticipation
–Mild fear/anxiety
–Relief-It is almost over

Front 21

Stage One
Active Phase

Back 21

• Cervix: 4-7 CM (Descent of baby can be rapid)
• Contractions
–Frequency 2-5 minutes apart
–Duration 60 seconds long
–Intensity Moderate to Strong
• Mom’s Behavior
–Increasing apprehension/tension
–Fear of being alone

Front 22

First Stage
Transition Phase

Back 22

• Cervix: 8-10 CMs (Stretching Pelvic Sensation)
• Contractions:
–Frequency 2-3 minutes apart
–Duration 60-90 seconds
–Intensity --Strong to Very Strong
• Mom’s Behavior
–Little desire for interaction
–May vomit/shake/shiver/perspire
–Difficulty controlling behavior

Front 23

Second Stage

Back 23

• Lasts from the time the cervix is fully dilated to birth of the baby.
• Lasts an average of 1-2 hours for primigravidas
• Lasts an average of 10-60 minutes in multiparous
• If she has an epidural and the mom-baby unit is stable may last 4-5 hours
• Laboring down is GREAT!!!!

Front 24

mechanisms of labor

Back 24

cardinal movements that occur in a vertex presentation are:
engagement
descent - the degree is measured by station
flexion
internal rotation
extension
restitution and external rotation
expulsion of the infant

Front 25

Mechanism of Labor -
1. engagement

Back 25

–Presenting part is reaches the level of the ischial spines and is encircled by the bony pelvic inlet

Front 26

Mechanism of Labor -
2. Descent

Back 26

–Progress of the presenting part through the pelvis
• Measured by station

Front 27

Mechanism of Labor -
3. Flexion

Back 27

–Chin is brought into closer contact with the chest

Front 28

Mechanism of Labor -
4. Internal rotation

Back 28

–Turns to fit through the ischialspines

Front 29

Mechanism of Labor -
5. Extension

Back 29

–Head and neck ease under the pubic bone and emerge

Front 30

Mechanism of Labor -
6. Restitution/External Rotation

Back 30

–Once outside the introitusthe head will rotate to realign to his/her original position

Front 31

Mechanism of Labor -
7. Birth/Expulsion

Back 31

–The rest of the body is birthed
–Birth is complete
–Time of birth is recorded
–Second stage ends

Front 32

Nursing care during First stage of labor

Back 32

• Monitor maternal vital signs
• Monitor uterine activity
• Monitor fetal heart rate
• Vaginal show
• Monitor behavior, mood and energy level of mother and partner
• Vaginal examinations to assess labor progression if per hospital protocol

Front 33

Nursing care during Second stage of labor

Back 33

• Monitor BP more frequently
• Promote comfort level of mom
• Position changes
• Monitor fetal well-being
• Prepare for birth—delivery set up
• Update/Call Midwife/Physician
• Update Staff for Baby Nurse and/or NICU

Front 34

Positions used in Labor -
Back Labor

Back 34

-Hands and knees position
-All fours; allows for pelvic rocking.
-relieves backache
-facilitates internal rotation of the fetus by increase mobility of the coccyx, increasing the pelvic diameters and using gravity to turn the fetal back and rotate the head.
-can also use the trendelenburg position or squatting position to help rotate head

Front 35

Positions used in Labor -
Cord prolapsed

Back 35

place woman in extreme trendelendburg position or knee-chest position (Sim's)
-to take pressure off the cord and get more oxygen to the fetus

Front 36

positions used in Labor -
speed up labor

Back 36

Upright position (walking, sitting, kneeling, or squatting) is useful. Gravity can promote the descent of the fetus and the uterine contractions are generally stronger and more efficient in effacing and dilating the cervix resulting in shorter labor.

Front 37

positions used in Labor -
Cord prolapse

Back 37

Modified Sim's, trendelenburg or knee-chest position, in which gravity keeps the persenting part off the cord.

Front 38

positions used in Labor -
epidural

Back 38

for placement- sitting or in a modified Sim's position
after placement - woman is preferably positioned onher side that the uterus does not compress the ascending vena cava and descending aorta, which can impair venous return, reduce cardiac output and decrease placental perfusion.
during 2nd stage- usually lithotomy

Front 39

positions used in Labor -
late deceleration

Back 39

change to a lateral position to allow for placental perfusion.

Front 40

PROM

Back 40

-premature rupture of membranes
• Rupture of the amniotic sac and/or leakage of amniotic fluid at
least 1 hours before the onset of labor at any gestational age

Front 41

PROM treatments

Back 41

– Goal is to prevent infection
– Hospitalization
– Bedrest
– Hospitalization
– Bedrest (depends on many factors)
– Frequent FHR and UC monitoring
– Maternal vital signs every 4 hrs.
– Track Amniotic Fluid via a pad count
– Prophylactic antibiotics

Front 42

PROM assessments

Back 42

• Nitrazine
– pH strip turn blue (6.0-6.5)
– False positives if woman has infection or has had sex in the
last 12 hours
• Fern Test
– Must have a microscope
– Must use a slide without the cover
– Must be dry, looks like a fern (salt H2O)

Front 43

PROM complications

Back 43

Infection is most serious side effect; Can precipitate cord prolapse

Front 44

Preterm Labor

Back 44

-Uterine contractions 5 or more per hour
-Lower abdominal cramping
-Dull intermittent lower back pain
-Bloody show or leaking of fluid

Front 45

Preterm Labor Risk Factors

Back 45

-Regular uterine contractions causing cervical changes between 20 & 37 weeks
-Infections
-Age < 17 or > 35 years
-History of previous preterm labor or birth
-Cervical incompetence
-Multifetal pregnancy
-Hydramnios
-PIH
-Poor nutrition
-substance abuse
-PPROM

Front 46

Preterm Labor Prevention

Back 46

- Bedrest
- No sexual activity
- Tocolytic medications

Front 47

Preterm Management (drug therapy)

Back 47

- Procardia
- Magnesium sulfate
- Terbutaline
- Prostaglandin Inhibitors
Betamethasone: Given when preterm birth is threatened; stimulates fetal lung maturity
24 to 34 weeks: Monitor maternal hyperglycemia and Pulmonary Edema.

Front 48

Epidural

Back 48

Nerve block that can be a single injection or continuous pump
Advantages:
• Excellent pain relief
• Partial but not full leg paralysis
• Flexibility in dosing

Front 49

Epidural complications

Back 49

• Marked hypotension
• Impaired placenta perfusion
• Ineffective breathing pattern
• Bladder Atony
• Uterine Atony

Front 50

Epidural Interventions

Back 50

• Bolus of IV Fluids
• Lateral positioning
• Frequent vital signs, including monitoring labor
• Continuation of fetal monitoring
• O2 available
• IV Vasopressor available (Ephedrine)
• O2 available
• IV Vasopressor available (Ephedrine)
• Mom must void in bedpan or with indwelling Foley or straight
catheter (red robin)
• Bedrest until sensation returns.

Front 51

pudendal block

Back 51

“Saddle Block”; Relieves pain in lower vagina, vulva and perineum
- Must be administered 5 - 10 minutes prior to be effective
-does not change maternal hemodynamic or resp functions, VS or FHR; but the bearing down reflex is lessened or lost completely

Front 52

Cesarean - Indications

Back 52

-consistent abnormal FHR and pattern
-CPD
-malpresentations (breech, shoulder)
-placental abnormalities (previa, abruptio)
-umbilical cord prolapse
-dysfunctional labor pattern
-multiple gestation
-medical factors -HTN disorders, active genital herpes, positive HIV status, diabetes

Front 53

Cesarean complications - maternal

Back 53

aspiration, pulmonary embolism, wound infection, wound dehiscence, thrombophlebitis, hemorrhage; UTI, injuries to bladder, ureters or bowel and complications to anesthesia

Front 54

Cesarean complications - infant

Back 54

Fetus may be born prematurely if gestational age has not been accurately determined

Front 55

Placenta Previa

Back 55

Bright Red Blood
Painless
Uterine tone WNL
No clotting defects
Fetus often stable
High risk of PPH

Front 56

Placenta Abruptio

Back 56

Dark Red Blood
Uterus/Abdomen very painful, tender
Signs of shock
Fetal Distress
Clotting defect possible
PIH associated
Substance Abuse

Front 57

Episiotomy

Back 57

-1st degree - through the skin only
-2nd degree - through the muscles (need to repair)
-3rd degree - through the anal sphincter
-4th degree - through the rectal mucosa into lumen of the rectum

Front 58

Purpose of episiotomy

Back 58

made to enlarge the vaginal outlet.
-good nutrition, and appropriate hygienic measures help to maintain the integrity and suppleness of the perinal tissue, enhance healing and prevent infection.

Front 59

Fetal monitoring - normal HR for fetus

Back 59

110 - 160 bpm

Front 60

baseline FHR

Back 60

-the average rate during a 10 minute segment that excludes accelerations, decelerations and periods of marked variability.
-there must be at least 2 minutes of baseline segments in a 10 min segment.

Front 61

Variability

Back 61

– Absent—undetectable
– Minimal—>undetectable to <5 beats/minute
– Moderate—6 to 25 beats/minute
– Marked-->25 beats/minute

Front 62

Early decelerations

Back 62

a visually apparent gradual decrease and return to baseline FHR associated with UCs.
-Head compressions caused by UCs, vag exam, fundal pressure, placement if IUPC
-sometimes referred to as the "mirror image" of a contractions.

Front 63

Early decel interventions

Back 63

benign so therefore interventions are not necessary.

Front 64

Variable decelerations

Back 64

• Variable
– Visual abrupt decrease in FHR
– Umbilical cord compression
– Looks like “V’s”, “U’s” or “W’s”.
-repetitive variable decels indicate a recurrent disruption in the O2 supply of the fetus.
-occasional var. decels have little clinical significance.

Front 65

Variable deceleration interventions

Back 65

-change positions (side to side, knee chest)
-d/c pitocin
-administer O2
-assess for cord prolapse

Front 66

Late decelerations

Back 66

-gradual decrease in and return to baseline FHR.
-caused Uteroplacental insufficiency caused by:
maternal supine hypotension
epidural or spinal
placenta previa or abruptio
HTN disorders
postmaturity
IUGR
Diabetes
Intraamniotic infection

Front 67

Late decel interventions

Back 67

-change position (lateral)
-correct maternal hypotension by elevating legs
-increase IV fluids
-d/c pit
-assess for tachysystole
-consider internal monitoring
-prepare for deliver (svd or c/s)

Front 68

periodic

Back 68

occurs with a contraction

Front 69

episodic

Back 69

occurs independent of a contraction

Front 70

pitocin and FHR pattern

Back 70

if pit produces tachysystole it may reduce the blood flow thru the placenta and result in FHR changes such as bradycardia, tachycardia, decreased or absent baseline variability, late decelerations.

Front 71

accelerations

Back 71

can be caused by occiput posterior and breech positions

Front 72

PPH risk and causes

Back 72

uterine atony
laceration in birth canal
retained placental fragments
ruptured uterus
inversion of uterus
placenta previa or abruptio
mag sulfate during labor or PP

Front 73

uterine atony causes

Back 73

overdistended uterus
anestheisa and analgesia
previous Hx
high parity
prolonged labor, oxytocin induced labor
trauma during labor and birth - forceps, vac, c/s

Front 74

meds used for PPH

Back 74

oxytocin
Methergine
prostaglandin
cytotec
-all used for contraction of uterus
-monitor bleeding and uterine tone

Front 75

Nursing care for PPH

Back 75

-massage fundus
-empty bladder and monitor output
-IV access
-admin meds
-notify primary
-fluid/blood replacement
-provide discharge instructions
-observe for delayed/insufficient lactation and PPD

Front 76

Emotional responses to PPH

Back 76

- promote maternal/infant bonding
- promote breastfeeding
- monitor return of sensory perception (from epidural)
- monitor for thrombophlebitis
- provide food and fluids