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79 Cards in this Set

  • Front
  • Back
A. Facilitates maternal relaxation and provides comfort measure throughout
labor by administering/ encouraging:
1. massage--conveys a sense of caring, reassurance, understanding and non-verbal support. Woman's comfort with this varies, caregiver must be tactful and observe and change according to the woman's desires. Specifically massage can induce relaxation and relieve pain
2. hydrotherapy- reduces muscle tension, pain and anxiety dramatically for many women. Immersion can provide bouyancy and warmth, which can bring immediate pain relief, relaxation, lowering of catacholamines, increase of oxytocin and more rapid active labor progress.(compresses, baths,
3. warmth for physical and emotional comfort- increases local skin temp, circulation and tissue metabolism, it reduces muscle spasms and increases pain tolerance. It can also reduce the fight-or-flight response. (e.g., compresses, moist warm
towels, heating pads, hot water bottles, friction heat)
4. communication in a calming tone of voice, using kind and encouraging words
5. the use of music or sound
6. silence
7. continued mobility throughout labor (positions changes, rocking, walking, birth ball, etc.)
- eating and drinking freely as the mother desires is important to kep her energy levels NML
A. Facilitates maternal relaxation and provides comfort measure throughout
labor by administering/ encouraging:
8. pain management:
a) differentiation between normal and abnormal pain (sharp, acute, horrific, stinging etc. is abnl)
b) validation of the woman’s
experience/fears (sometimes just asking if she is ready to give birth will help these issues to surface so that they can be discussed)
c) counter-pressure on back (counter-pressure on "dimples" or sacro-illiac joints on either side of the sacrum can relieve back pain, knee-press, and hip squeeze also help to release and relieve pain)
d) relaxation/breathing techniques (talking her through UC's(ie. reminding her to relax certain body parts and breathe), massage, heat/cold, hydrotherapy etc)
e) non-allopathic treatments (hydrotherapy, acupressure, acupuncture, herbs-- valerian to induce sleep/relaxation, St. John's Wort for muscle/back pain,-- homeopathic hypericum and arniflora(gel). (Davis 48)
f) position changes
B. Evaluates/responds to during first stage:
1. assess maternal/infant status based upon :
a) vital signs
Measured every 2-4 hrs, unless it is abnml then it should be increased. Hypotension may be caused by a supine position, shock, or as a result of epidural analgesia. Hypertension may occur from from preeclampsia, GD.

If the rate increases to >100 bpm it may indicate anxiety, pain, infection, ketosis, or hemorrhage. Record ever 1-2 hrs in early labor and every 30 min when labor is more advanced.

Should be recorded at least every 4 hours. Abnl is >20 in severe anxiety or other pathologies. In late labor and 2nd stage RR will vary due to physical effort and breathing techniques.

Should remain within it's NML range (Axillary 96.6-98.6, Oral- 97.6-99.6). Fever (or pyrexia) is indicative of infection or ketosis, may be associated with epidural. In NML labor it should be recorded ever 4 hrs.
(Myles 486)
B. Evaluates/responds to during first stage:
b) food and fluid intake/output
- mother should stay well-hydrated (drinking hourly) with water, fruit juice, electrolyte drinks etc. and to ensure elctrolyte balance
- Food to the mothers desire (she may not want food as labor progresses, but a spoonful of honey or fruit juices may help to prevent clinical exhaustion).

- record should be kept of all urine(or bm) passed to ensure bladder(or colon) is being emptied. She should be urinating hourly and make SURE she urinates before 2nd stage, a full bladder can hinder descent and lead to PP hemorrhage.
(Davis, 119, 113)(Myles 487)
B. Evaluates/responds to during first stage:
c) status of membranes
- Upon vaginal examination you can determine if the membranes are intact or not
- The mothers report of her water breaking, water leaking etc. can help determine status of membranes also.
- Monitor FHT as soon as ROM occurs and try to minimize vaginal exams from that point on to decrease infection.

COLOR of amniotic fluid:
- Green- meconium that may cause (or already has) fetal hypoxia
- green-muddy/slightly green- previous meconium from which fetus has recovered
- frank thick meconium- indicates a breech position
- golden-yellow- (rare) fetus severely affected by Rh isoimmunization (excess bilirubin in urine)
- bleeding(upon ROM)- may be caused from ruptured vasa previa and is an acute emergency
(Myles 488)
B. Evaluates/responds to during first stage:
d) uterine contractions for frequency, duration and intensity with a basic intrapartum examination
- The frequency, length and intensity of UC's should be noted as a part of the initial labor exam to help assess which stage of labor she is in and throughout labor to assess labor progress.
- UC's which are unduly long or very strong and in quick succession give cause for concern of the development of fetal hypoxia.
- Keeping in mind that labor plateau's may occur (commonly at around 4, 7, and 9 cms) periodically so that the mother can integrate and move at her own pace through each phase of labor. Paying attention as the midwife at this time to the maternal and fetal well-being while remaining in the background and allowing the mother to labor naturally is important. However, do not become too complacent, if the mother is languishing in ineffeectual positions or struggling futilely with labor sensations, step in and help out. Try to find the balance between the mother's need to find her own pace in labor and the midwife's need to make responsible assessments and keep things on track.
(Davis 114) (Myles 487)
B. Evaluates/responds to during first stage:
1. assess maternal/infant status based upon :
e) fetal heart tones (when to listen, ass risks with brady and tachy, define baseline, varibility, decels and diff types of decels).
- FHT should be taken (in uncomplicated preg/labor) every hour in early labor, every 30 min in active labor, and every 15 min (or every few UC's) in 2nd stage. After establishment of baseline and regular rhythm, listen for 30 s minimum after UC.

- FHT should also be taken when: ROM occurs, maternal position change, immersion into water, recognition of abnl UC pattern or strengthened UC's, vaginal exam

- Tachycardia is high FHR, above 160 bpm (marked tachy at or >180 bpm) and transient periods of acceleration can be NML. Sustained tachy is associated with: (maternal) dehydration, overheating(hot baths/exercise), oxygen deprivation, hemorrhage, fever, infection or hyperthyroidism; (fetal factors) anemia, blood loss, side effects of drugs

- Bradycardia is low FHR, below 120 (marked brady at or <100) sustained bradycardia is associated with: oxygen deprivation, umbilical cord compression/tanglement, fetal hypoxia, maternal drug intake, maternal hypothermia
(Frye, 987-88)

- Baseline FHR: is the approx mean FHR rounded to increments of 5 bpm, during a 10 min segment (in any 10 min window the minimum baseline duration must be at least 2 min)

- Baseline Variability: fluctuations in the baseline FHR. The baseline rate should vary by at least 5 beats over a period of 1 min. Loss of this variability may indicate fetal comprimise (May be caused by 'fetal sleep' cycles—no more than 80 min in duration--, drugs, anemia, hypoxia and acidosis, prematurity, congenital neurologic or cardiac abnmlties)

- Acceleration: a brief/transient rise in FHR above baseline of at least 15 beats for at least 15 s. They are associated with fetal movement, normal pH, it is a good indicator of fetal well-being, and can be induced by external stimulation, fetal scalp or acoustic stimulation.

- Deceleration: a drop from baseline of 15 beats for >15s but < 3min (>3 min is referred to bradycardia)

- Early Decel: thought to be caused by head compression. Can occur at 4-7cm dilation from pressure of cervix on post. Fontanelle (in NML presentation) or from pressure on head from perineal floor during UC's just before birth. They are NOT considered to be a pattern requiring intervention or treatment as long as they are carefully differentiated from late decels.

- Variable decels: are the most common FHR pattern change in labor and are not usually associated with abnl outcomes. They are thought to be caused by umbilical cord compression from the positioning of the cord around fetal neck or body, true knots in cord, frank and occult cord prolapse, and compression due to decreased AFV. The seriousness of variable decels depends on their frequency, depth, rate of return, effect on baseline FHR, and variability. They are considered to be nonreassuring when they become progressively repetitive and deeper (drop to <70 bpm for >60s w/a slow return to baseline), last longer, and are associated with, tachycardia, and/or diminished variability.

- Late Decels: is thought to be due to uteroplacental insufficiency and subsequent decrease of oxygen to fetus. They are caused by decreased placental perfusion caused by UC's. The decel shows a drop in FHR beginning near or after the peak of the UC and resolution of the deceleration occurring after the contraction has subsided. When the decels are persistent, occurring with a majority of the UC's, prolonged hypoxic events occur, metabolic acidosis develops and myocardial depression begins to occur, they are considered NONreassuring. Uncorrected uteroplacental insufficiency is a life-threatening condition always requiring intervention or expeditious delivery must ensue. FHR in a late decel will usually be WNL and can be as shallow as 10 bpm below baseline. Severity of fetal hypoxia cannot be measured by the depth of the decel.
CAUSES of late decels include: IUGR (associated with chronic hypertension, lupus, poorly controlled diabetes, hyperthyroidism, and intrauterine infection), hypertensive disorders, hypotension (ass with supine position, anesthesia, severe dehydration or septic shock), hypertonic UC's (usually from drugs-oxytocin), placental abnlties, fetal anemia (ass w/RH, hydrops, fetal-maternal hemorrhage).

- Prolonged Decels: decels lasting longer than 60-90 s and usually occuring as isolated events. Management of prolonged decels depends on the cause, length of deceleration, and recovery of the fetus following the pattern. If the precipitating cause is alleviated, the fetus will usually recover spontaneously. Occasionally the decels become protracted and may precede to fetal death.
CAUSES/associated risks of prolonged decels: Umbilical cord compression, profound uteroplacental insufficiency, hypotension(supine position and anesthesia), hypertonic or tetanic UC's, drugs, maternal hypoxia (ass w/ seizures or acute resp depression), pelvic exam, maternal valsalva, rapid descent of fetal head.

- Sinusoidal Pattern: An undulating, repetitive, uniform, FHR equally distributed 5-15 bpm above and below baseline for at least 10 min. It is I extremely rare and identified by an absence of short-term variability and no FHR accels following its occurrence. It is associated with chronic fetal anemia (issoimmunization or placental abruption, hypoxia with acidosis). It is always an ominous FHR pattern requiring immediate intervention.

- Wandering baseline: appears to be a very late development in the progression of fetal deterioration. An extremely rare finding, diagnosed when baseline FHR is unable to be found or established. It is usually WNL of 120-160, but is identifiable by its total absence of short-term variability. This is also an ominous indicator of fetal distress.

NOTE: If any of these decels occur (particularly late decels and below) and/or persist immediate transport to the hospital is necessary.
(Varneys 798-810) (Davis 113-120) (Myles 482-83)
B. Evaluates/responds to during first stage:
f) fetal lie, presentation, position and descent with:
(1) visual observation
(2) abdominal palpation
(3) vaginal examination
(1) visual observation:
- Observing the mothers position that she chooses and any reports from her of back or other pains may clue you into the position of the baby
- externally you can monitor the descent of the fetal shoulder (by where your hear FHTs)
- check for descent at the abdomen by looking for a change in the contour of the abdomen just above the pubic bone. Prior to about +1 station, there is a slight bulge in this area, which smooths out as the baby descends further (be sure the slight buldge is not due to an overfull bladder.)
- Development of a crease above the pubic bone (parallel to the symphysis) will appear as dilation advances. The crease develops and becomes wider from side to side as labor progresses.

(2) abdominal palpation:
Abdominal palpation for lie, presentation, position and descent (leopolds and other maneuvers discussed in previous section) should be
done upon arrival and between UC's as to not disturb the mother.
- externally you can use your hand placed just above the PB to assess how much of the fetal head is still above the PB, attempting to assess station of head and descent.

(3) vaginal examination
fetal lie, presentation(by checking fontanelles or whatever may be presenting), position (partially), and descent (by checking station) can all be assessed during the vaginal exam. Vaginal exams should be kept to a minimum to reduce infection and because of there effect on the mothers emotional and physical ability to release down and out. When they are done, they should be performed between UC's for the mothers comfort. As a beginning midwife more frequent checks may be helpful until you learn to read the signs of progress in the mother's appearance or behavior. Check whenever in doubt as a rule of thumb and remember that the goal is to be as gentle and undisruptive as possible, while quickly obtaining as much information as you can.
(Davis 109)(Frye Vol 2, 374-77)

NOTE: if labor is prolonged or there is a lull in progress consider the baby's position. If posterior and the head poorly applied and deflexed(UC's short and irregular with slow progress), consider manually repositioning head. The position may self-correct in time, meanwhile encourage rest followed by upright positions to encourage descent. (Manual repositioning--with rebozo and other techniques-- can also be considered for asynclitism and other positions effecting descent)
B. Evaluates/responds to during first stage:
g) effacement, dilation of cervix and station of the presenting part
Start the exam the moment a UC ends with the mother's consent

- estimate the percentage of the cervix that has been drawn up into the lower uterine segment (how thin is it?)

- take care not to stretch the cervix as you assess
- record your assessment in cm (1-10)
- Visually dilation can be assessed by observing a dark red/purplish line between the cheeks of the buttocks that will rise in cms (1-10) from the anus to the sacrococcygeal joint.

- by seeing how much of the head or presenting part fills the pelvis (and how evenly it fills it)
- find the presenting part and the ischial spine, the stationg refers to the relationship between these to and is considered to be at 0 station when the presenting part is at the level of the ischial spines. It is measured in cm from -4 to +3 with a negative station the head will be above the ischial spines and with a positive it will be below.

- to assess the position of the presenting part the cervix should be at least 6 cm dilated or effaced enough to feel through the landmarks of the baby's head (sutures and fontanelles). Find the sagital suture and feel for a fontanelle at one end or the other. (if baby is term onyl one fontanelle will be felt) If you feel the triangular-shaped posterior fontanelle then the head is flexed, if you feel the diamond-shaped anterior fontanelle then the head is deflexed.
(Davis 115-16)

NOTE: also check for the consistency of the cervix (soft, medium, or hard/tight-rimmed and non-stretchy) and for the position of the cervix (anterior, midline or posterior)
NOTE: Vaginal exams should be kept to a minimum to reduce infection and because of there effect on the mothers emotional and physical ability to release down and out. When they are done, they should be performed between UC's for the mothers comfort. As a beginning midwife more frequent checks may be helpful until you learn to read the signs of progress in the mother's appearance or behavior. Check whenever in doubt as a rule of thumb and remember that the goal is to be as gentle and undisruptive as possible, while quickly obtaining as much information as you can.
(Davis 109)
B. Evaluates/responds to during first stage:
h) maternal dehydration and/or vomiting by administering: (how to admin IV)
- assess maternal hydration by making sure she drinks and voids hourly. A uring dipsitck can also be done to evaluate ketones and specific gravity.

(1) fluids by mouth--some sort of electrolyte drink, water, or a fruit juice(not if she has recently vomitted--too acidic--) can help. (do not give fluids by mouth if the mother is in shock)

(2) ice chips

(3) oral herbal/homeopathic
Homeopathic china, carbo veg or ustilago can help dehydration, as for nausea/vomitting, pulsitilla, sepia, nux vomica, antimonium tart and more can help. Ginger can help with nausea also.

(4) IV fluids (administer or refer for)
- administration of IV fluids and medicine depends upon your state laws/what is allowed in your scope of practice and the condition of the woman you are caring for.
- - Usual IV solution for a woman in labor, as said in Varney's (762), consists of 1000aa given at 125cc/hr. This may vary if the woman is mildly dehydrated, in which case approx 300cc may be run in and then the IV slowed to 125cc per hour. IV's for women in labor should always be adminstered with an IV catheter (as opposed to butterfly needle).
STEPS for inserting IV Catheter:
1. Hang IV and clear tubing of air (fill with water) in prep for connecting IV cath.
2. Apply tourniquet with the arm at or below the level of the heart
3. Select a vein, find a vein site that will not cross a joint if possible.Veins in the forearm are 1st choice as to veins on the back of the hand.
4. Place a chux under the limb you will be inserting the IV and put on gloves
5. Clean the insertion site with alcohol wipe (rubbing from center outward and allow to dry)
6. Insert the needle and catheter into the vein making sure the tips of both are in by advancing approx 1/4 in once your are getting a "flash" (blood into unit)
7. Connect the IV infusion tubing to the catheter, release the tourniquet, and start infusion flow at desired rate.
8. Tape the cath and IV tubing securly to limb
9. Wipe off any blood from puncture site and woman and clean up/throw away the rest of the equipment in appropriate place (ie. sharps container if needed)
10. After procedure have the woman wiggle her fingers and arm to realize that she still can have motion.
(Varneys 1121-24)

B. Evaluates/responds to during first stage:
2. anterior/swollen lip by administering/
a) position change
b) light pressure or massage to cervical lip
c) warm bath
d) pushing the lip over the baby’s head
while the mother pushes
e) deep breathing and relaxation between contractions
f) non-allopathic treatments (sepia, arnica and then sepia--200C every 10-15 mins-- by mouth or gel directly onto cervix)
(Davis 127)
B. Evaluates/responds to during first stage:
3. posterior, asynclitic position by encouraging and/or supporting:
a) the mother’s choice of position

b) physical activities (pelvic rocking, stair climbing, walking, etc.)

c) non-allopathic treatments:
counterpressure (back press, knee press, hip squeeze) and cold packs can help with back pain, hot compresses, injection of sterile water papules. Essential oils for muscle and back pain and homeopathic arnica may help.
d) rest or relaxation (lying on the side that you want to baby to be in, valerian may help or skullcap for relaxation)

e) manual internal rotation (“dialing the phone”)
repositioning a posterior baby( Upon vaginal exam you should feel the anterior fontanelle near the pubic bone. 1. slightly disengage--dislodge ant. font. from the plane in the pelvis where it is lodged, by spreading your fingers to either side of the sagittal suture and push upward on the parietal bones--flexion and rotation may occur with this alone. 2. Exert steady even pressure on the bony edge of ant. font. and rotate it to transverse position. 3. Now flex the head by pushing the font. toward the side of the vaginal wall, quickly reach for the posterior fontanelle, secure an edge and complete the rotation to anterior. (an assistant can help externally by grasping the baby's shoulder and backside and pushing it to the anterior position. The mother can slowly roll over in the direction you are turning the baby at the same time--immediately check FHT's)
Rebozo can also be used for rotation.
(Davis 150-52)
B. Evaluates/responds to during first stage:
4. pendulous belly inhibiting descent by:
a) assisting the positioning of the uterus over the pelvis:
- a belly-binder or lifting the abdomen can counteract the effects of a pendulous abdomen and allows the mother to assume forward-leaning positions that keep the brim open.
- belly lifting can be used when the woman prefers to stand or walk (and can be done in the latter part of pregnancy to encourage optimal positioning of baby), lift at the level of the navel (not bellow). It can also be used when the cervix is ripe just below the navel with some of her toning UC's, it may help to stimulate stronger UC's. (Frye Vol2, 974, 1001)
- belly binding (with a rebozo, light weight cloth/strip of bed sheet or maternal girdle) can help to move a baby into an optimal position in the case of lose abdominal tone (from oblique), or to keep a baby from reverting to a transverse position after he has been turned. The binder should be applied between UC's to as it will fit better (two towel can be rolled and placed vertically on either side of the belly and then wrapped around the belly with the binder to ensure optimal positioning)

b) positioning semi-reclining on back( lifts the baby into a more vertical position and therefore brings the presenting part more directly over the pelvic inlet)
c) lithotomy position, (belly-down positions like kneeling, hands-and-knees, and knee-chest are generally contraindicated for pendulous abdomen because of the downward pull of gravity that can result in the baby "descending" uphill and can make pushing harder)

NOTE: To help prevent cord prolapse the belly can be binded (it may also eliminate the need for AROM). You should start at the lower uterine segment, wrapping tightly and wrap upwards gradually loosening as you move up the abdomen.
NOTE: Belly binding and lifting to help the baby into a position ofver the pelvic inlet can also help to prevent uterine rupture. It is usually associated with grand multiparity, when the uterus hangs far forward, stretching the posterior vaginal wall. Labor progress is obstructed because of fetal malpositioning and stretches and thins the cervix and lower uterine segment to the point of lesion in the posterior fornix and lowermost uterine segment. The lesion is referred to as a colporrhexis and unless the forces of the UC's can lift the baby into a correct position over the pelvic brim, the weakest point will give way and become the site of rupture.
(Frye Vol2, 422-23, 1014, 1082, 1135)
B. Evaluates/responds to during first stage:
5. labor progress by providing:
a) psychological support:
- ask her questions (if timing is right) about her feelings surrounding birth, if she feels ready to give birth. Listen carefully to the answers and try to be encouraging, understanding and supportive at every point along the way while also reminding her of the importance of surrending--which can often be the most difficult thing to do with psychological issues--.
- Explain that as labor progresses, her body will release endorphins that will make the pain easier to bear, and as long as she continues to surrender, she will find resources for coping that she does not even know that she has (physically, emotionally and spiritually). Once she lets go and makes this shift, frantic agitation gives way to peaceful resignation as endorphins are released.
(Davis 107, 111)

b) position change can aid and may have beneficial effects on the following:
- alignment of pelvic bones and resulting shape and capacity of pelvis
- frequency, length and efficiency of UC's
- 'drive angle' that is, the angle formed by the axis of the fetus' spine and the axis of the birth canal (helping fetus to get into optimal position relating to the pelvis--eg. aligning fetus up with pelvic inlet as with pendulous abdomen--)
- effects of gravity (eg. rotating a posterior baby with knee-chest or other position changes, releasing weight of baby with help of gravity)
- oxygen supply to fetus
- side-lying or semi-sitting positions can help women relax who have exhaustion
- upright positions help with gravity to apply pressure onto cervix, make UC's more effective, enhance fetal descent
- forward leaning help rotate baby and reduce back pain
- asymmetric positions with one leg elevated, changes shaoe of pelvis, helps rotation, reduces back pain
- exaggerated lithotomy helps facilitate passage of a "stuck" baby beneath PS (shoulder dystocia),
- Dorsal positions tend to cause hypotension, increase back pain and are less likely to improve labor progress.
(Simkin 22, 197-8)

c) nutritional support:
- see that the mother is well hydrated and urinates. She should be encouraged to eat as long as possible, drink fruit juices, or take an occasional tablespoon of honey to help prevent exhaustion
- if labor is prolonged (3 hrs or so without any apparent progress) do a urinalysis to check for ketones. A trace reading is acceptable, anything above that indicates a disrupted electrolyte balance and the need for more fluid and calories. (IV lactated ringers solution would be given at the hospital and can be considered for home, if she can drink and eat anything at all it will help immensely.)
(Davis 113)

d) rest:
- If labor starts in the afternoon or at night, the priority should be rest and whatever measures help to induce rest until active labor occurs. Massage, warm bath or shower or any relaxation techniques the mother has learned or used that she knows to help induce relaxation (ie. Visualization, muscle relaxing techniques, counting/self-hypnosis) can help.

e) physical activity:
- walking or moving to elicit stronger UC's or optimal fetal positioning for progress, or for fresh air in the case of stale, dull, lag or nausea in labor.
- walking up and down stairs, “baby boogy” dancing (rocking/swaying pelvis), rhythmic motions (swaying on birth ball or in standing, squatting or kneeling positions) or putting one foot up on a stool in a lunge position can help relieve back pain, in the positioning, rotation and descent of the baby in the pelvis, and can help involve the partner to provide support(increasing oxytocin).
- pelvic lifting can help reduce back pain, provide gravity advantage (as with pendulous abdomen)
- pelvic press (hip squeeze), back pressure on sacroilliac joints (dimples), and the knee press all help to relax and provide pain relief in the pelvic and back regions.

f) non-allopathic treatments:
- Hops tincture, valerian tincture, skullcap tincture, and homeopathic aconite can help induce sleep and relaxation if exhaustion is of concern
- Cramp bark, cotton-root bark, blue cohosh(dropperful q 2-3hrs), homeopathic caulophylum 200C, and acupuncture and acupressure techniques(4 fingers up on inside of ankles and inbetween thumb and index finger) all help to bring about UC's. Aconite helps to release fears and anxiety in labor.
(Davis 49, 127, 86)

g) nipple stimulation, kissing, intimacy, massaging (rubbing legs) holding hands, stroking, touch even wearing one of her partner's shirts (saturated in his scent) can help raise oxytocin levels and therefore aid in bringing about UC's
(Simkin 258-9)
C. Demonstrates the ability to evaluate/
support during second stage:
1. wait for the natural urge to push:
- Avoid internal exams whenever possible
- the woman still has some dilating to do when: the pushing urge occurs only at the peak of the UC, pushing urges vary in intensity and don't occur with every UC, if there is still bloody show(bllody show only occurs when the cervix is dilating still)
- when the urge begins at the beginning of the UC, comes for every UC and there is no bloody show, the dilation is then complete and she is ready to push on her own

2. encourage aggressive pushing in emergency situations:
- When there is fetal distress or other complications present that necessitate a quick delivery and birth is imminent
- when all other attempts at bringing on an urge to push are futile, the baby is at least at +1 station, and the mother cannot rest and regroup and psychological issues have been discussed.
- THEN directed pushing can be instigated by the following: have the mother touch the presenting part inside of the vagina herself, help her assume an upright position, ask her to push as though she were expelling a tampon (NOT to push as though she were having a BM, this sends energy to rectum instead of vagina and can worsen hemorrhoids), have her cough between UC's and focus on what type of muscles are released when coughing so that she can do that during a UC.
- If the above does not work, put the mother on a birthstool, don gloves and place 2 fingers of each hand inside the vag at 4 and 8 o'clock. As the UC builds use the length of first 2 fingers to apply deep bilateral pressure to help stimulate the proprioceptors in vag, and stimulate pressure of presenting part, which prompts an irge to push. As the mother pushes, gradually draw your fingers outward while maintaining pressure. (Repeat if nec.)
(Frye Vol2, 444-49)

3. allow the mother to choose the birthing position

4. recommend position change as needed:
- side-lying or semi-sitting positions can help women relax who have exhaustion, can also reduce strain on perineum
- upright positions help with gravity to apply pressure onto cervix, make UC's more effective, enhance fetal descent
- forward leaning (knee-chest, leaning over something on knees or feet etc) help rotate baby(as in shoulder dystocia), good for big babies, and for moms who have pushed a long time with the head low and reduce back pain
- asymmetric positions with one leg elevated, changes shaoe of pelvis, helps rotation, reduces back pain
- exaggerated lithotomy helps facilitate passage of a "stuck" baby beneath PS (shoulder dystocia),
- Dorsal positions tend to cause hypotension, increase back pain and are less likely to improve labor progress.
(Simkin 22, 197-8)

5. perineal support:
- if desired, hot compresses and lubricant (olive oil) can be used while doing peri-support and can help prevent tears (NOT CURRENT RESEARCH)

6. encourage the mother to touch the newborn during crowning

7. provide an appropriate atmosphere for the moment of emergence
- the room should be warm, with all the necessary equipment close by, at hand including warms towels and receiving blankets.
- "No matter how many births a midwife has attended, there can be nothing matter-of-fact about this sacred moment, especially if she lets her participation be guided by love. Every birthing is unique! There are skills for making it run smoothly, but the midwife's main responsibilty is to open fully and respond with devotion. Not only is she an assistant to the mother and her supporters, but handmaiden to the forces of creation" (Davis122)
E. Demonstrates the ability to recognize and respond to labor and birth complications
such as:
1. abnormal fetal heart tones and patterns by:
a) administer oxygen to mother:
- mild brady.(109-100bpm) may be acceptable in 2nd stage, but moderate bradycardia in labor(below 100) necessitates quick delivery or transport and for either bradycardia or severe earyl decels, oxygen should be administered at 6 liters per minute.

b) change maternal position, and listen, sometime FHT's may be abnml from maternal malpositioning alone that is causing cord compression.

c) facilitate quick delivery if birth is imminent: get mother into an upright position and use directed pushing if needed

d) encourage deep breathing

NOTE: keep the mother well hydrated and give her vit. C if the baby is slightly tachy

e) evaluate for consultation and referral: consult for any abnml FHT's that do not resolve with corrective measures.

f) evaluate for transport: for marked bradycardia or tachycardia that does not resolve, or for abnml FHR patterns such as late decels, prolonged decels, sinusoidal pattern or wondering/abscent baseline FHR
E. Demonstrates the ability to recognize and respond to labor and birth complications
such as:
2. cord prolapse by:

The obstetrical emergency that occurs in about 0.6% of pregnancies, when the umbilical cord descends beside, beneath or below the presenting part. There are two types of cord prolapse, frank and occult.

Frank prolapse: (or Overt) occurs when the cord slips through the cervix and is not life threatening if it is a transverse lie or footling breech when cesarean delivery is available.

Occult prolapse: when the cord slips down beside the presenting part, but does not protrude through the cervix. The danger in either type is fetal hypoxia from cord compression between presenting part and the maternal pelvis.

- Ruptured membranes (or non-ruptured) of a breech or compound presentation, transverse lie, small fetus (<2000gm/4lbs 6.5oz), or a second born twin.
- Multiple Gestation
- Preterm labor
- Contracted pelvis (poor fit between baby and pelvis) or -- CPD
- Lower-uterine segment placental implantation (puts cord near cervical os)
- Polyhydramnios
- An excessively long umbilical cord
- Interventions precipitating causes of cord prolapse: (Varney, H. pp.870)
---Administration of enema if membranes are already ruptured in a compound presentation, unengaged head, shoulder presentation, unengaged breech or footling breech
--- An AROM, accidental rupture of membranes during vaginal exam or spontaneous rupture of membranes if one of the following is present: a noncephalic presentation, compound presentation, an unengaged head, with presence of tense bulging membranes, and/or a small fetus whose presenting part (either cephalic or breech) does not fill the pelvis.
--- Displacement of vertex position during fetal assessment/palpation or attempted fetal movement/obstetric manipulation (e.g. manual rotation of head, external version)

- Significant change in FHT's immediately after rupture of membranes
- Feeling cord or cord pulsation upon vaginal examination (details under diagnostics)
- Seeing the cord or mother reporting seeing or feeling something like unto a cord

a) change maternal position to kneechest

b) activate emergency medical
services/medical backup plan

c) monitor FHT and cord for pulsation

NOTE: Insert your hand into the vagina and lift the presenting part up off the cord at the pelvis inlet, to reduce cord compression.

d) keep the presenting cord warm, moist and protected

e) administer oxygen to mother

f) place cord back into vagina

g) facilitate immediate delivery, if birth is imminent

h) prepare to resuscitate the newborn
E. Demonstrates the ability to recognize and respond to labor and birth complications
such as:
a) breech:
Identifying/recognizing breech discussed in previous section (IV.D.5.a).)

RESPONDS (fully discussed in (IV.D.5.c).)
(1) understands mechanism
of descent and rotation for
complete, frank, or footling
breech presentation
- more irregular shaped complete breech does not fill the birth canal as fully and is more compressible (than the frank), making it a somewhat inefficient dilator

FRANK: breech engages(bitrochanter of fetus in through pelvic brim) pelvis anteriorly usually or maybe slightly to one side (or post) with all 3 positions, frank fills the pelvis most evenly of all 3 and dilates the cervix most efficiently of the breech positions.

- feet or knees are extended toward the os, there is really nothing sizeable to dilate cervix except for intact membranes (this position has higher risk of premature urge to push, prompt ROM, and cord prolapse)

- the sacrum rotates to the transverse portion of the pelvis and is born one leg/hip at a time, usually the anterior hip comes out first, the sacrum then rotates (internally restituting) back to the anterior position when it is outside of the mother
- and internal rotation of thh upper body then occurs so that the anterior arm/shoulder can be born (first usually) then the posterior
- the occiput then usually rotates to the OA position and is born just as NML birth

(2) hand maneuvers for assisting delivery(9):

- Bracht Maneuver: pelvis and splinted legs are grasped together with both hands, fingers of the sacrum and thumbs over thighs, anterior rotation of fetal sacrum is encouraged and suprapubic pressure. When rotation is near complete slowly lift and hold up body (as would naturally happen in diff position, not supine). This technique risks extension of the head and injury to the spine, it is used to deliver a baby that would be born on its own in an upright position and therefore not recommended.
- Burns-Marshall: Baby is gently supported while internal rotation of the head occurs, then baby is allowed to hang by his own weight. Do not interfere as long as steady progress is noted and baby is well. Specific tech differ at this time depending on maternal position. If she is in an upright position , once the head is born to the biparietal diameter, gently ease it out as the mother breathes, allowing the head to birth slowly. In a supine position some sort of assistance is needed to facilitate pivoting of the occiput under the PB as it does not do this by itself. You must wait until you can see the nape of the neck and jawline or else it could cause never damage, break the neck ot produce severe suboccipital trauma. Once this is seen, and no before, grasp the baby's feet, bringing the ankles together--suprapubic pressure can now be applied-- and stretch the baby's body straight out (lifting feet up towards moms belly), away from the perineum.
- Kristeller: can be used when baby is in a reclining, belly-up position and baby is sacrum anterior. Place hand on mothers abdomen over the baby's and apply pressure to encourage flexion. Irving Potter (breech expert) warns never to apply pressure prior to the birth of the arms, as this encourages the arms and head to extend.
- Lovset: Anatomically sound and relatively safe maneuverwhen performed correctly. It facilitates the delivery of otherwise inaccesible arms. Essentially (once the umbilicus-nipple is born) you grab the baby's hips, thumbs on back fingers in front and rotate the baby half of a circle in one direction (eg. RST to LST) to encourage birth of anterior arm and then rotate back to the other direction for the other arm.
- Mauriceau-Cronk: Place the baby belly on your nondominant forearm with her legs straddling your arm. Gently slide your index and middle fingers up begind the pubic arch and push the baby's occiput down to encourage flexion. At the same time slide 2 finger of your other hand in, past the perineum onto the baby's maxillary ridge(bones just below eyes) and apply gentle downward pressure, (the mother can then and only then, after flexion has occurred, move down into knees chest). Follow rotation of head as it pivots around PB.
- Mauriceau-Banks: Same as above with the mother in a standing or supine position. All Mauriceau maneuvers use pressure on the occipital and parietal eminences respectively and eliminate shoulder traction and neck damage.
- Mauriceau-Smellie-Veit: Placing finger in baby's jaw with downward pressure to encourage flexion. Not recommended.
- Pinard: bringing down extended legs when descent is completely arrested in frank position and for soem reason transport is ill-advised/not possible? Always try flexing the anterior leg 1st, if descent resumes, stop there. Do not flex posterior leg by itself. Ideal to wait until baby is born the the back of the knee. Then, place 2 finger along the length of the back of baby's thigh, with your fingertips at the back of the knee. Confirm that there is no cord entaglement. Apply gentl pressure behind the knee or use all 4 fingers to apply well-distributed pressure along the length of the femur to flex the thigh away from the midline. As you do so the lower leg will sweep down across the abdomen , this will automatically bring the foot lower, foot may be born at this point. Once the knees are flexed, the torso should be free to flex and birth should proceed spontaneously.
- Rosshirt: bringing down posterior shoulder in a larger baby when you can't reach the elbow. insert hand along baby's back, hook 2 fingers over the tip of the posterior shoulder and pull it further down toward introitus. If you meet strong resistance stop, as you may damage the brachial plexus. This is easiest accomplished with mother in hands and knees position. Once posterior shoulder is well below promontory, try to reach the humerus and sweep the arm down, otherwise proceed to Lovset.
(Frye Vol2, 944-69)

(3) techniques for release of nuchal arm with breech
- following the baby's back up to the shoulder and then to the elbow, try to bend the elbow and sweep it across the baby's body to bring it down and out.
- if post. arm is out wrap one hand around the posterior shoulder/arm and the other around the chest and give slight downward pressure to release anterior arm.
(Frye Vol2, 950)
E. Demonstrates the ability to recognize and respond to labor and birth complications
such as:
3. variations in presentation:
b) nuchal hand/arm:
- Usually not discovered until head is birthing--if it is, you can try gently pinching the baby's finders well before the head crowns, which may cause it to retract its hand--

(1) apply counter pressure to hand/or arm and the perineum
(2) sweep arm out: grasp the hand and manually restitute the head while bringing the arm across the chest and outward (or go up to the arm/shoulder and roll it forward)
(Davis 157-58)
E. Demonstrates the ability to recognize and respond to labor and birth complications
such as:
3. variations in presentation
c) nuchal cord:(list 4 tech and 1 what to prepare for?)
(1) loop finger under the cord, and sliding it over head
(2) loop finger under the cord, and (making a loop large enough for shoulders)sliding it over the shoulder
(3) clamp cord in two places, cutting
the cord between the two clamps
(4) press baby’s head into perineum/mothers thigh and somersault the baby out
(5) prepare to resuscitate the baby
E. Demonstrates the ability to recognize and respond to labor and birth complications
such as:
3. variations in presentation
d) face and brow:
RECOGNIZE: by palpation the occiput will be the cephalic prominence and is on the same side as the baby's back
- upon vaginal exam you may feel the anterior fontanelle (or be unable to locate fontanels), or you will be able to feel the brow and anterior font in a brow position, or the eyes, ears, mouth and chin will be felt on a face presentation (soft and lumpy, similar to breech presentation, rather than hard and smooth).

(1) prepare for imminent birth
(2) determine position of chin, upon vaginal exam (if the presentation presents itself as mentum posterior(chin directly posterior), then, unless it rotates to mentum anterior, vaginal birth is NOT possible.
(Varneys 892)
(3) prepare resuscitation equipment: baby is face up and may get a nose full of fluids as the head births as head births
NOTE: also watch for breathing difficulties due to tracheal edema
(4) prepare treatment for newborn bruising/swelling: this is a clear indication for arnica and vitamin K.
(5) administer arnica
(6) position the mother in a squat
(7) prepare for potential eye injury or intracranial bleeding (transport and give vit K)
E. Demonstrates the ability to recognize and respond to labor and birth complications
such as:
3. variations in presentation
e) multiple birth and delivery:
(1) identifies multiple gestation
Risk Factors:
- previous multiple gestation
- family hx of multiple gestation

- FH greater than GA
- abundance of fetal parts upon palpation
- twins are not usually detected with auscultation until 28-32 weeks of two different FHT's. (If you note a 10-15 pt. difference in rhythms with distinct patterns of variablility, you have almostcertainly identical twins.
- confirmed with U/S

Associated Risks:
- Anemia
- polyhydramnios
- cord prolapse
- hypoxia
- placental abruption
- PP hemorrhage
- overdistended uterus
- heightened pressure can cause varicose veins, edema, and backache
- NML pregnancy discomforts can all be heightened from extra enlargened uterus and hormones, amniotic fluid can also double the NML pregnancy.
(Myles 433-39)(Davis 78-79)

(2) consults or transports according to plan
* both babies vertex is most favorable/safe
* when first twin is vertex and 2nd breech fetal outcomes are not better with surgical delivery
Transport for the following
* when first twin is not vertex medical opinion favors surgical birth and complications may increase, parents need to be aware of breech complications and informed consent signed would be prudent (possibilty of rare but disastrous locked twin with this situation, this is why many advise transport)
*If first baby is oblique or transverse, transport is safest option
- Obstruction of descent due to fetal positioning (Collision, impaction, compaction, and interlocking)
- Monoamniotic gestation (occurs 1 in every 100 monozygotic twins, cord entaglement or pertially or total unseparation of cords may occur, anastomoses leading to possible DIC, greater incedence of interlocking)
- Extremely delayed interdelivery periods (linked to preterm delivery or very rare superfetation--two babies conceived at different times, infection is a problem and placenta problems)
- Fetal defects and anomalies
- death of one baby
- plus any other labor complications that could occur in single labor (ie. cord prolapse, abnl FHT etc.)

(3) prepares for attention to more than one
(strategies for multiple gest birth on card section IV.D.6.b).
E. Demonstrates the ability to recognize and respond to labor and birth complications
such as:
3. variations in presentatf) shoulder dystocia:ion
RECOGNIZE: (occurs when the anterior shoulder is impacted behind the PB, shest compression impairs venous return from head and can lead to intercranial bleeding, brain damage and death unless the problem is swiftly remedied)
- An unusually large head passes over perineum (usually slower than NML) and pulls back or retracts on the neck--known as turtle sign--
- restitution does not occur
- baby's color rapidly deepens to dark purple
- despite mothers pushing efforts nothing changes and diagnosis is made

(1) apply gentle traction while
encouraging pushing

(2) reposition the mother to:

(a) hands and knees (Gaskin

(b) exaggerated lithotomy
(McRobert’s position)

(c) end of bed: so that the mothers bottom hangs off of the bed

(d) squat

(3) reposition shoulders to oblique diameter:
- reach inside the perineum for the posterior shoulder, place 2 fingers in front of the shoulder and push backward to the oblique diameter.

(4) extract the posterior arm:
- splint the arm with 2 fingers, sweep it across the chest, grasp the hand and extract the arm

(5) flex shoulders of newborn, then corkscrew:
- Rotate the baby 180 degrees (with hands in the same position as with turning it to oblique) thereby substituting the posterior shoulder for the anterior shoulder. Always rotate the body so that the back is rotated anteriorly (back up)

(6) apply supra-pubic pressure(in almost all of the positions and maneuvers this can help)

(7) sweep arm across newborn’s face to extract arm and make more space

(8) fracture baby’s clavicle:
the danger in this is punctureing the inderlying lung or injuring the subclavian vessels. The anterior clavicle is broken first by placing 2 finger (index and middle) on the front of the baby's clavicle and the thumb on the back side and breaking it towards the front and away from the lungs between your fingers.

(Transport immediately if there is a even minimally prolonged shoulder dystocia)
(Varneys 888) (Davis 159-61)
E. Demonstrates the ability to recognize and respond to labor and birth complications
such as:
3. variations in presentation
4. vaginal birth after cesarean (vbac)
all contained on card IV.D.8.
E. Demonstrates the ability to recognize and respond to labor and birth complications
such as:
5. management of meconium stained fluids:
a) assess degree of meconium:
- yellow-tinge= old mec, brief episode of hypoxia much earlier in labor (baby has recovered)
- green/brown/pea soup= fresh mec, recent or current fetal distress--listen immediately to FHT's for several UC's tracking even slightlest deviation from NML. Unless the baby sounds absolutely perfect, with healthy acceleration response to each and every UC, consider transport, particularly for a 1st baby.
- fresh dark thick mec (not watered down) usually indicates breech position

b) prepare to resuscitate the baby

c) instruct the mother to stop pushing after delivery of head

d) clear the airway with suction of mouth and nose: this is done on the perineum as standard of care. Check to see if the lid of Delee is screwed on tightly. Insert tubing about 4 1/2 in intobaby's mouth, withdraw slowly while sucking. If you are still bringing up mec as you suck, then repeat the procedure.

NOTE: Randomized study (with 2K infants) showed that infants with mec staining showed no significant differences in outcome between the 2 groups, suggesting that mec aspiration (MAS) is probably caused by an earlier incident of severe depression in utero.
(From Davis)
(Davis 118, 124-25)
E. Demonstrates the ability to recognize and respond to labor and birth complications
such as:
6. management of maternal exhaustion by:
RECOGNIZE: by steps e) thorough h) below

a) adequate hydration (drinking plenty of fluidsincluding water, electrolyte drinks and juices if desired--drinking and voiding hourly--)
b) nutritional support (keep up electrolytes, drinks, smoothies, crackers/toast, the mother should eat as long as she can)
c) increase rest (induce relaxation with hydrotherapy, massage, aromatherapy, music, comfortable/peaceful/darker environment, bed to rest in)
d) non-allopathic treatments (herbs/homeopathics for relaxation--skullcap, valerian, hops, aconite--, for exhaustion try-- china, carbo veg, ustilago, honey, royal jelly(for short term revival of system)--
e) evaluate the mother’s psychological condition: discuss any of her hears or concerns surrounding birth, try to gently encourage her to find her own answers instead of telling her what to do
f) monitor vital signs(signs of clinical exhaustion):
- elevated temp
- elevated pulse
- ketonuria
- NOTE: Unless this (above) is reversed fetal distress will occur and transport will become necessary. If these signs are present then immediate remedial measures of nutrition and hydration should be implemented)

g) monitor fetal well-being:
- if s/s of labor appear the FHT's should be closely monitored for distress (tachy usually), unless labored has tapored off and mother is resting.
- NOTE: CARDINAL rule for handling prolonged labor is, "If labor begins to slow down, do not try to stimulate it!" Diminishing UC's is a sign that uterus is fatigued and mother should be encouraged to eat and rest in order for it to rebound. (Risks of stimulating labor with the uterus is this kind of condition can result in fetal distress and PP hemorrhage)

h) evaluate urine for ketones:
- do a urinalysis to check for ketones. A trace reading is acceptable, anything above that indicates a disrupted electrolyte balance and the need for more fluid and calories.

i) evaluate effect of support team or visitors:
- if there is a room full of tired or drowsy assistants or supportive fam/friends, this is not conducive to labor progress, everyone should be cleared out for a time, open windows, fresh air etc.
- help aid womans partner and support group to most effectively help progress(partner to help with comfort measures, make sure he gets rest also if labor is prolonged-- help supportive group to be effective, send them on errands, give them tasks, help them feel supportive, make sure everyone gets rest when labor is prolonged)

j) evaluate for consultation and/or referral
- if clinical exhaustion occurs with even the slightest hint of fetal distress transport
--Also do vaginal exam to check for descent, asynclitism, cervical lip or other signs that may be hindering progress.
(Davis 113, 140-43)
F.recognize/consult/transport for signs of:
1. uterine rupture
- abdominal pain in lower abdomen(over previous scar site)
- abnlties of FHR
- vaginal bleeding (might not be seen until later)
- maternal tachy
- maternal drop in BP
- maternal rapid RR
- poor labor progress
(Myles 635)(Frye Vol 2, 1135-39)

NOTE: differential diagnosis may include: abruption, previa, amniotic fluid embolism(no bleeding), hematoma of broad ligament, abdominal pregnancy.

- iniciate EMS and transport immediately at first sign of uterine rupture
F.recognize/consult/transport for signs of:
2. uterine inversion
Define: rare, but potentioally life-threatening complication of 3rd stage of labor (approx 1 in 20,000) Classified as:
- 1st degree- fundus reashes internal os
- 2nd- body or corpus of uterus is inverted to the internal is
- 3rd- the uterus, cervix and vagina are interted and visible
- Also can be classified according to timing of event and can be acute (occurs within 24 hrs), subacute (after 24hrs, before 4 weeks), or chronic (after 4 weeks, rare)

- major sign is profound shock
- usually hemorrhage
- severe abdominal pain (thought to be caused by peritoneal nerves and ovaries being pulled and stretched)
- on palpation the fundus will feel deeply or partially inverted (hollow, empty), or it may not be felt at all in severe inversion and may be seen at the vulva
- diagnosis may be difficult/missed if inversion is incomplete

CAUSES include:
- mismanagement of 3rd stage--excessive cord traction to actively manage placental delivery-- may be with combination of fundal pressure
- uuse of fundal pressure with atonic uterus to deliver placenta
- pathologically adgerent placenta
- spontaneous occurrance/unknown cause
- primip
- fetal macrosomia
- short umb. cord
- sudden emptying of distending uterus
NOTE: careful management of 3rd stage is needed to prevent inversion.

- immediately activate EMS, give the mother oxygen and transport immediately
- while waiting for transport the midwife should immediately attempt to replace uterus, if replacement is delayed the uterus may become edemateous and replacement will become increasingly difficult. Replace by pushing the fundus with the palm of the hand, along the direction of the vagina, towards the posterior fornix. the uterus is then lifted toward the umbilicus and returned to position with a steady pressure. (Make sure to be very cautious of sterile technique, long/elbow length sterile gloves). Once uterus is in place, hold it there until firm UC is palpated/ until transport occurs. If replacement cannot be acheived immediately, the mother should be out into an elevated position with hips up to take pressure off uterine ligaments and ovaries.
NOTE: if placenta is still attached it should be LEFT ALONE/in situ--attempts to remove it could cause uncontrollable hemorrhage.
(Myles 637-39)
F. recognize/consult/transport for signs of:
3. amniotic fluid embolism
(define, causes, s/s, transfer)
Define: (AFE) rare, unpredictable, and unpreventable, when amniotic fluid enters the maternal circulation via uterus or placental site; maternal collapse can be rapidly progressive.

CAUSES/Predisposing factors: difficult to predict and prevent
- raised intra-amniotic pressure (such as in termination of pregnancy or placental abruption)
- procedures-- ARM or insertion of intrauterine catheter, intrauterine manipulation, amniocentesis
--- Should be suspected in cases of sudden colapse or uncontrollable bleeding

- fetal compromise
- Respiratory: cyanosis, dyspnea, resp arrest
- Cardiovascular: tachy, hypotension(low BP), pale clammy skin/shivering, cardiac arrest
- hematological: hemorrhage from placental site, coagulation disorders (DIC)
- Neurological: restlessness, panic, convulsions, pain is less likely
----- Clinical picture: Suddenly woman begins to gasp for air and rapidly develops seizures and cardiorespiratory arrest assompanied by DIC, massive hemorrhage and death. There may be extremely severe pinpoint, knife-like cheast pain(indicating where embolus is stopping blood-flow).---

Differential Diagnosis includes: heart attack, septic shock, uterine rupture, placental abruption (esp when coagulopathy is primary symptom), aspiration pneumonia, anaphylactoid reaction and a ruptured cerebral aneurism.
Ass. Risks: DIC (likely to occur in 30 mins of initial collapse), hemorrhage (all of s/s are potential risks), acute renal failure, uterine atony

- Immediate/prompt transport to intensive care unit improves outcome of AFE

NOTE: Delay in time from initial maternal collapse to delivery needs to be minimal if fetal compromise and death is to be avoided. However, maternal resus may, at the time, be a priority.
(Myles 635-37)

NOTE: Transport as quicly as possible by ambulance. Give CPR with high oxygen, as indicated. Provide volume expansion via an IV to optimize ventricular preload (left ventricular heart failure is likely to occur). Consider both mother and baby's well-being, esp when birth has not yet occurred, if a choice must be made the mother's survival takes precendence over baby's. Listen to FHT's as often as possible when transporting. (The baby cannot survive long after cardiorespiratory arrest, consider baby anoxic at all times, fetal outcomes are very poor. If the mother has given birth transport in supin position and do bimanual compression, a massive uncontrollabe hemorrhage may occur.
(Frye Vol2, 1191)
F. recognize/consult/transport for signs of:
Define: Loss of the pregnancy due to natural causes after the 20th week of preg. It is traumatic for mother and family and can cause grief and lead to heightened risk for PPD in mother.

severe deformity/chrom. Abnltie
placental abnlties (ie. placental abruption)
SGA/IUGR fetuses
infection in mother or fetus
medical condition of mother, diabetes, epilepsy, hypertension
umbilical cord problems
sudden severe hemorrhage
often cause is unknown

Decrease in fetal movement
vaginal bleeding
persistent or even stabbing pain in pelvis, back, or lower abdomen (labor s/s)

Discuss options with parents well beforehand. Consult with physician and pediatrician (if fetus has defects that may permit it to live for a time) and set specific care plan. Referral to the hospital can be made if it is the parents desire to birth there. Transport may become necessary if complications arise during labor birth or PP. If the parents choose to stay home, discuss option of autopsy and that the coroner must be notified of any stillborn infant weighing more than 500 grams (1.1 Lbs), the physician signs death certificate in the hospital, but out of the hospital this is the coroner's task.
If at home (baby should be caught/received into a towel or blanket and depending on when the fetus died it's skin may be loose and should be handled with care) the parents should be encouraged to stay emotionally present and connected, to look and caress their baby if they wish. The midwife should be knowledgeable about the phases of grieving—shock, denial, anger, and resolution-- andbe ready to share this info with the mother. She is at higher risk for PPD and should be given careful P and prolonged PP care to ensure her safety, well-being and healing through this transition and process of letting go and eventually moving forward. Make sure a strong and steady support system is set up for her and her family.
(Davis 181) (Myles 730) (Frye Vol2)
G. assesses the condition of, and provides care for the newborn:
1.keep baby warm
4. keep baby and mother together (How and why?):
1. Keep baby warm by placing baby on mother (skin-to-skin) and placing a receiving or other warm blanket on top of them. If they are in the water then keep the baby body in the warm water and cover its head with a blanket or hat.
(NOTE: If the mother is not kept warm, adrenaline will remain high, which can disrupt placental separation by opposing oxytocin.)
keep labor room warm, dry baby at birth (Myles), encourage skin-to-skin, wrap baby and encourage breastfeeding, switching off fans, closing curtains etc
provision of optimal thermal environment is paramount in facilitating a successful transition to extrauterine life
(Myles 756)
The mother and baby should stay together for the baby's and mothers optimal outcome (helps normalize baby's vitals and helps mother to facilitate the rest of the birth with less complications and is essential for bonding and has great effects on hormonal levels to make all of the above things to occur at the right timing and intensity)
G. assesses the condition of, and provides care for the newborn:
2. make initial newborn assessment
3. determine APGAR score at:
Define: APGAR, A-appearance (color—blue/pale, body pink/extrem blue, or completely pink); P- Pulse (HR- absent, <100bpm/slow/irregular, or >100bpm good/crying); G-Grimace (reflex-- none, minimal grimace, or cough/sneeze); A- Active (Muscle Tone-- limp, some flexion of limbs, or active); R-Resp effort (RR- absent, slow/irregular, or good/crying). Each is scored from 0-2, 10/10 being highest possible score.

APGAR should always be done at 1 and 5 minutes and only needs to be done at 10 mins if the 5 minute score was below 7/10
a) 1 minute
b) 5 minutes
c) 10 minutes (as appropriate)
(Varney's 974)(Myles 755-56)
G. assesses the condition of, and provides care for the newborn:
5.monitor respiratory and cardiac function by assessing: (What are NML/ABNML for each)
a) symmetry of the chest-- should be symmetrical and diaphragmatic, chest and abdomen rising and falling synchronously, asymmetrical could indicate retractions and is abnml

b) sound and rate of heart tones and
- HR: 110-160 bpm, and fluctuates in accordance with the baby's respiratory function and activity or sleep state.

- RR: 40-60 breaths/min, respirations are shallow and irregular, being interspersed with brief 10-15s periods of apnea.

c) nasal flaring- abnml to see flaring after brief initial resp efforts at birth

d) grunting- abnml to see grunting after brief initial resp efforts at birth

e) chest retractions- abnml to see retractions after brief initial resp efforts at birth

f) circumoral cyanosis- peripheral circulation is sluggish resulting in mild cyanosis in feet, hands, and cirumoral areas and is transient up to 24-hrs, after which time is can be an indicator of infection

g) central cyanosis- is serious, if the tongue and mucous membranes appear blue this indicates low oxygen saturation levels in the blood, usually of respiratory or cardiac origin. Could lead to convulsion
(Myles 836, 756, 765-66)
G. assesses the condition of, and provides care for the newborn:
6. stimulate newborn respiration:
a) rub up the baby’s spine

b) encourage parental touch, and call newborn’s name-- “ Neonatal intensive care nurses report that babies' oxygen levels surge upon hearing the sounds of their mothers voice.” (Davis 177)

c) flick or rub the soles of the baby’s feet

d) keep baby warm

e) rub skin with blanket

f) apply percussion massage for wet lungs
G. assesses the condition of, and provides care for the newborn:
7. responding to the need for newborn resuscitation:
Determine primary cause of neonatal depression:
- most common cause of last-minute distress is secere head compression (which seldom presents a problem if the baby is born promptly--depending on mother's health status and length/intensity of labor)
- cerecral hypoxia during labor or traumatic delivery
- preterm/immature baby (underdeveloped lungs, low surfactant and a soft pliable thoracic cage)
- severe anemia (caused by Rh incompatibility which diminishes oxygen carrying capacity of blood)
- major congenital abnlties ( of the CNS or resp tract, choanal or tracheal atresia--choanal atresia should be suspected when a baby is pink when crying out, but becomes cyanosed at rest)
(Myles 750)

Aims of Resus:
- establish and maintain clear airway
- ensure effective circulation
- correct acidosis
- prevent hypothermia, hypoglycemia and hemorrhage

RESPOND(in 2ndary apnea--Apgar <2, white and limp):
- Have assistant call 911, wrap the baby in warm blankets and cover the head
- clear the airway (suction mouth with bulb or delee)
NOTE: NOT apart of NARM 1st line, postural drainage can always be used first just before starting NRP.
- move baby to a flat surface, with chin up but no overextended--to open airway--
a) administer mouth-to-mouth breaths or bag-mask resus with oxygen (5 slow long inflation breaths allowing an exhale between to start with--you should see chest wall movement--1-1k, 2-1k, 3 release)

b) positive pressure ventilation for 15-30 seconds (pattern is--breathe...2, 3,-- if the HR is <100 and >60, then continue, if it is >60 move to chest compressions, have assistant check HR ever 30 sec)

c) administer oxygen

d) leave cord unclamped until placenta delivers

e) consult and transport if needed (911 should be called if baby is born limp, floopy and white--while you are doing NRP)
(Davis 178-79)
G. assesses the condition of, and provides care for the newborn:
8. recognize and consult or transport for apparent birth defects
- Most anomalies require no immediate treatment, except for heart defects (indicated by cyanosis or resp distress) or spina bifida (nueral tube defects involving membrane-covered or exposed defects.
- In both cases pediatrician should be contacted and baby immediately transported.
- For membrane-covered or exposed defects, the primary aim should be to provide gentle support for defects enclosed in a membrane to distribute weight and minimize pressure and trauma. It should be kept moist continually while being transported, with a sterile gauze wrapped in warm saline water.
- With hear defects keep the baby warm and give blow-by oxygen while transporting
- Although not urgent, a baby with other anomalies should be seen as soon as possible, as there may be internal defects not detected by exam.
(Davis 180)
- Most common sign of nuerologic comprimise in NB period is seizure activity (most frequent reason for seizure is hypoxic-ischemic encephalopathy)
- Abdominal wall defects are subdivided into gastroschisis (the eviscerated abdominal organs are not covered by a sac) and oomphalocele (abd. organs are external but are covered in sac), in both potential is great for dehydration and hypothermia and infection. (care is same as spina bifida)

- tracheo-esophageal fistula and esophageal atresia are not visible but have s/s of excess salivation, resp distress, swallowing problems, and abdominal distention. (Position baby in prone position with head elevated, no oral feeding--transport)
- Diaphragmatic hernia s/s include: decreased left-side breath sounds, heart sounds on right, severe resp distress at birth, secondary to persistent pulmonary hypertension. (Transport, use of bag-mask ventilation will only worsen situation)
- Cong. defects that can lead to intestinal obstruction (malrotation, mid-gut volvulus, meconium plugs, meconium ileus, Hirschsprung's disease, and imperforate anus), with all these defects, the major diagnostic signs are bile-stained emesis and failure to pass stool. (No oral feeding should be given, transport.)
(Varneys 1034-36)
G. assesses the condition of, and provides care for the newborn:
9. recognizes signs and symptoms of Meconium Aspiration Syndrome and consults or refers as needed
Define: Fetal asphyxia causes the passage of mec, this mec is unproblematic unless the baby gasps or breathes in amniotic fluid, potentially inhaling mec. This puts the baby at risk for serious resp problems.

- rapid breathing
- nasal flaring
- grunting with exhale
- retractions of chest and abdomen
- cyanosis

- give blow-by oxygen and immediately contact pediatrician for transport.

NOTE: If beby seems congested, but not otherwise comprimised, help by providing it steam (turn on shower full-force and take baby into bathroom) also can apply percussion to release meconium from lungs, by putting baby belly down (with head lower) on your lap, with back exposed and tap sharply with 2-3 fingertips in each quadrant of the lungs, particularly in any are you know to be obstructed... If baby resumes NML breathing for several hours and parents understand warning signs of futher trouble, check back next day, if not, transport.
(Davis 201) (Myles 849-50)
G. assesses the condition of, and provides care for the newborn:
11. immediate cord care:
a) clamping the cord after pulsing stops

b) cutting the cord after clamping
(Use of sterile technique is imprtant with a-b, the mother or partner/support person can assist in cutting the cord with the midwife's direction if desired)

c) evaluating the cord stump: AVA- there should be 3 vessels, 2 arteries and 1 vein, if there are only 2 vessels baby may have anomalies not immediately apparent and pediat. should be notified.
- Wharton's Jelly should be present at juncture of cord and placenta

d) collecting a cord blood sample, if needed. It may be needed for following:
- when mother is Rh- or as precaution if blood type is unknown
- when atypical antibodies have been found during an antenatal screening
- where hemoglobinopathy is suspected (ie. sickle cell)

How to take it:
- the sample should be taken as soon as possible from fetal surface of the placenta where blood vessels are congested and easily visible. Make sure the correct tube is used for desired testing.
G. assesses the condition of, and provides care for the newborn:
12.administer eye prophylaxis
Eye prophylaxis should be given in the immediate PP period for the baby of the mother with Gonorrhea or Chlamydia, or who otherwise chooses to have the prophylaxis administered.
- It is standard of care to give to all babies, but if the mother would like to get tested she may
- Education surrounding this topic is important, knowledge that the newborn can only get this infection from gonorrhea or chlamydia can be helpful.
G. assesses the condition of, and provides care for the newborn:
13. assess gestational age
- Combination of observing/assessing nueromuscular and physical maturity using the NBS (New Ballard Scale, accurate within a range of 2 weeks)

- Neuromuscular Evaluation
1. Posture: with infant supine and quiet (should crease at elbows, knees and feet--good tone)
2. Square Window: Flex hand at wrist; exert pressure to get as much flexion as possible (should flex good amount)
3. Arm Recoil: Fully flex forearm for 5 sec, then fully extend by pulling the hands, and release (elbow should flex at roughly 90* angle)
4. Popliteal angle: With infant supine and pelvis flat on exam surface, the leg is flexed on the thigh and the thigh fully flexed using one hand; with the other hand the leg is then extended (roughly around 90*)
5. Scarf Sign: take infant's hand and draw it across the neck and as far across the opposite shoulder as possible; assist the elbow by lifting it across body. (hand/elbow should not overly cross opposite side)
6. Heel-to-ear maneuver: put infant's heel as close to ear as possible without forcing it, keep pelvis flat on exam surface (should not go up to ear or mush past navel)

Physical Evaluation:
- Skin: cracking pale areas, rare veins
- Lanugo: bald areas/mostly gone
- Plantar surface: creases anterior over 2/3ds
- Breast: raised areaola 1-2/3-4mm bud
- Eye/Ear: Pinna formed and firm, instant recoil
- Genitals (Male): Testes down, good ruggae
- Genitals (Female): Labia majora large and minora small

Categories include:
1. Preterm (GA ,38wks scor of 30 or below)
2. Term (GA 38-42 weeks, score of 35-45)
3. Postterm (GA or >42 wks, score >45)

- It is important to note that birth weights vary in accord with altitude, race, country of origin, and socioeconomic class. Thus there is no international standard of birth weight. The midwife should use a table that contains anthropomorphic data appropriate to his or her region.

Categories include:
1. SGA
2. AGA
3. LGA

(9 possibilities)
- Preterm (1-3 SGA, AGA, or LGA)
- Term (4-6 SGA, AGA, or LGA)
- Postterm (7-9 SGA, AGA, or LGA)
(Varney's 1002-04)
G. assesses the condition of, and provides care for the newborn:
14. ***** for central nervous system disorder
- The neurologic exam (reflexes) will assess the newborn's senses, sight, hearing, and smell and is an indicator of the integrity of th CNS.
- Poor/diminished(hypo) or absent response to stimulation may indicate: damage to the nerve itslef, secondary depression from medications, sensory pathway damage, reflecting spinal or CNS lesion and sometimes it can be from temporary motor nerve damage that prevents muscles in affected areas to respond (ie. weak palmar grasp after breech or facial nerve pralysis after forceps delivery). Sometimes damage is permanent as with brachial plexus injuries or spinal cord defects.
- Accentuated (hyper) responses of also of concern and can relfect a central neurological deficit.

Elicitation of Reflexes:
1. Eyes: pupillary reflex, red reflex, doll's eyes reflex(turn infant head to one direction and eyes will glance the opposite direction), blink reflex(responds to bright light)
2. Upper extremeties: Palmar grasp (moro reflex, should disappear within 2-4 mo's)
3. Lower extremeties: Patellar reflex(or knee jerk), plantar reflex, babinski reflex
4. Torso: Anal wink, tonic neck reflex
(Varneys 1006-08)
H. Assist in placental delivery and responds to blood loss:
1.remind mother of the onset of third stage of labor
- The mother may look st you a bit anxiously, reporting that she feels something. She may squint her eyebrows together, feel "crampy" or show other signs of placental separation and preparation for expulsion. As the midwife, be aware of these and explain and remind the mother of the onset of 3rd stage and that she is still in labor until complete expulsion of the placenta has occured.
(Davis 130)
H. Assist in placental delivery and responds to blood loss:
2. determine signs of placental separation such as(list 5):
- 9 out of 10 times the placenta separates all at once
a) separation gush
b) contractions
c) lengthening of cord
d) urge to push
e) rise in fundus
H. Assist in placental delivery and responds to blood loss:
3. facilitate the delivery of the placenta by:
a) breast feeding/nipple stimulation, bonding and breastfeeding helps to release oxytocin and bring about UC's

b) change the mother’s position (have the mother get in a squat or upright position)

c) perform guarded cord traction: Guard the uterus and use controlled cord traction ONLY if you have followed the cord up to the cervical os and the placenta is immediately behind it. (Beware, if the placenta is not separated you run the risk of inverting the uterus which could cause death)

d) emptying the bladder: if the mother is struggling with this you can try running the sink water, putting peppermint oil in the toilet bowl, have her put her hands or feet in warm water, or arnica 200C to help relieve swelling of urethra. If these do not work a catheter will need to be placed to remove urine.

e) administer non-allopathic treatment:
- Angelica tincture can be used to help bring and attached or partially attached placenta

f) encourage release verbally

g) manual removal of placenta:
If it is still attached, have the assistant call the ambulance and notify hospital as midwife removes it--it is painful for the mother and can lead to PP infection)
- Don a fresh elbow length sterile glove and our antiseptic over gloved hand
- insert golved hand through os while using your other hand at fundus to prevent uterus from being forced upward. (you can also form outside hand around area where clot is attached inside to help clamp the area)
- Slip your internal hand between the separated portion of the placenta (which should be hanging free) and uterine wall , then carefully pry the rest off--using edge of your hand like spatula.
- Once you have removed it, quickly skim the rest of the uterine wall for any fragments, then grasp the placenta and bring it out
- Assistant should give methergine and/or pitocin at this point along with vigorous unterine massage.

h) transport for removal of placenta:
- if the placenta can't be removed
- if after the placenta is removed, the vitals remain abnl (BP-low, pale, cold or clammy, pulse erratic)
- give O2 and transport
(Davis 127,166)

NOTE: - As soon as the placenta is out immediately check the uterus to make sure it is well contracted and give it a few quicl squeezes to expel any clots that may have formed behind the placenta (unecessary if mother is in squat).
H. Assist in placental delivery and responds to blood loss:
4. after delivery, assess the condition of the placenta
FETAL side:
- Cord insertion site:
--central insertion (at center)
-- marginal insertion (at edge)
-- battledore (cord is attached at very edge in manner of tennis bat)
-- velamentous (cord is inserted into the membranes some distance from the edge of placenta. If placenta is normally positioned and active management of 3rd stage is avoided, there is no risk. If the placenta is low-lying it could cause vasa previa (vessels over the os) and there is great danger upon ROM--esp AROM, avoid this-- vessels could be torn causing rapid exsanguination of fetus.)
-- succenteriate lobe (vessels running from edge of placenta into the membranes leading to a separate piece of placenta. Danger if the small lobe is retained in utero after placenta delivery and if it is not removed may lead to infection and hemorrhage.)
- Circumvallate placenta (opaque ring on fetal surface formed by a doubling back of the chorion and amnion and may result in the membranes leaving the placenta nearer the center instead of the edge as usual. It is associated with prematurity, prenatal bleeding, abruption, multiparity, and early fluid loss)

- roughly 20 cotyledons, separated by sulci (furrows), into which decidua dips down to form septa(walls).
- exam for any missing cotyledons, by pulling away any clots and cup the placenta together in your hands to see if all the pieces match together, also check edges to see if any fragments were torn away. If there is missing fragments a manual removal must be performed in order to control bleeding.
(Davis 130-33)
H. Assist in placental delivery and responds to blood loss:
5. estimate blood loss
- PP Hemorrhage is considered to be a loss of 500cc/mL of blood or more (this does not mean that one should wait until 500mL of bleeding has occurred before taking action to correct hemorrhage. Early action in presence of excessive bleeding may prevent actual hemorrhage.)
(Varneys 925)
- 250ml/cc = 1 cup
H. Assist in placental delivery and responds to blood loss:
6. respond to a trickle bleed by:
a) assess origin:
- Atonic uterus, uterine inertia, overdistention of uterus
- Full bladder
- Uterine rupture
- Placenta abruption
- Precipitous labor
- Blood coagulation disorders
- Lacerations or tears: vaginal, perineal or cervical
- Retained fragments of placenta, membranes or clots

b) assess fundal height and uterine size:
- ABNML: boggy, above umbilicus, and lacking in tone

c) fundal massage: if sequestered clots is the problem the best way to deal is by preventing them which can be done firmly after the placenta is delievered, or deliver in an upright position. If uterine atony is the cause firm fundal massage is essential

d) assess vital signs
if vitals remain abnl (BP-low, pale, cold or clammy, pulse erratic) after corrective measures (possibly even before) give O2 and transport

e) empty bladder: if the mother is struggling with this you can try running the sink water, putting peppermint oil in the toilet bowl, have her put her hands or feet in warm water, or arnica 200C to help relieve swelling of urethra. If these do not work a catheter will need to be placed to remove urine.

f) breastfeeding or nipple stimulation

g) express clots: by massage or by manual removal (on card H.8.d.)

h) non-allopathic treatments:
- shepherds purse (only after the placenta is out as it causes clots)
- hemhault (blue cohosh ½ dropperful in combo with, witch hazel full dropperful under tongue)
(Davis 128) (Varneys 926)
H. Assist in placental delivery and responds to blood loss
7. respond to a vaginal tear and bleeding with::
- Quickly but thoroughly check the vaginal floor for lacerations.
a) assessment of blood color and volume; tends to bleed in gushes similar to a partial separation bleed

b) direct pressure on tear; clamp an artery forceps wherever blood-flow is most (with gauze?)

c) suturing: use tie-off suturing to control bleeding (if bleeding from partial separation is simultaneously occuring take care of this first before suturing as it is more life-threatening)

d) clamp with forceps
(Davis 164-5)

NOTE: A dropperful of Trillium or Birthroot helps to constrict small blood vessels. (Davis 128)
H. Assist in placental delivery and responds to blood loss:
8. respond to postpartum hemorrhage with:
- Determine the cause of the bleeding before initiating treating (ie. lacerations, placenta partially attached, full bladder etc)

a) fundal massage: if sequestered clots is the problem the best way to deal is by preventing them which can be done firmly after the placenta is delievered, or deliver in an upright position. If uterine atony is the cause firm fundal massage is essential

b) external bimanual compression:
- grasp and lift the uterus firmly with both hands, then pressing them together as hard as possible

c) internal bimanual compression:
- One hand is inserted into the vagina and is doubled up into a fist and pressure is exerted towards the anterior fornid (palmar side up).
- At the same time the other hand presses deeply into the abdomen behind the uterus aapply pressure and massage firmly to the uterus between the two hands
(Varneys 1273-74)(Davis 169)

d) manual removal of clots:- Don a fresh elbow length sterile glove and our antiseptic over gloved hand
- insert golved hand through os while using your other hand at fundus to prevent uterus from being forced upward. (you can also form outside hand around area where clot is attached inside to help clamp the area)
- Insert your gloved hand and quickly, but efficently skim uterus wall for any fragments or clots and sweep them off and down toward os, then grasp the any clots and bring them out.

e) administer medication:
Draw up and administer either oxytocin(contracts uterus, lowers BP), methergine(closes the cervix, heightens BP), or cytotec(contracts uterus, only if oxytocin is not working), whichever is best for the mother and situation. Follow specific state guidelines— doses/amount, time lapse, types of medication etc.-- in administering any drugs.

f) non-allopathic treatments:
- shepherds purse (only after the placenta is out as it causes clots)
- hemhault (blue cohosh ½ dropperful in combo with, witch hazel full dropperful under tongue)

g) maternal focus on
stopping the bleeding/ tightening the uterus: Help her keep her attention focused in the here and now, command her to stay present to look into you are her partners eye. Firmly and passionately you must call upon her to rally her vital force, particularly if she is drifting or fading out.

h) administer oxygen

i) treat for shock : in card II.E.3.

j) consult and/or transfer

k) activate medical emergency backup plan

l) prepare to increase postpartum care: If the mother was not transported to the hospital from the hemorrhage then she will especially need PP watch in the first few days from experienced assistants or information given to the support group on watching for s/s of furthered problems.

m) administer or refer for IV fluids: insert a 16 gauge needle and 5% dextrose in lactated Ringer's solution
(Varneys 928)(Davis 164-70)
I. Assess general condition of mother:
1. assess for bladder distension
a) encourage urination for bladder distension:
if the mother is struggling with this you can try running the sink water, putting peppermint oil in the toilet bowl, have her put her hands or feet in warm water, or arnica 200C to help relieve swelling of urethra. If these do not work a catheter will need to be placed to remove urine.

b) perform catheterization for bladder distension:
- indicated for 2 reasons, to remove any obstacle that is preventing involution and to provide relief to bladder.
(Myles 668)
I. Assess general condition of mother:
2. assess lochia
- NML blood flow in the immediate PP period is dark, sporadic and should not exceed that of a heavy mestrual period and is often much lighter. NML blood loss may contain clots that rounded would fit in a tablespoon and may be as large as a lemon.
- It is considered excessive for the woman to soak 1.5 pads (maternity size) during the 1st hour with a maximum of 3 pads in first 2 hours (shouldn't soak more than a pad in 1 hour)
(Frye Vol2, 766)
I. Assess general condition of mother:
3. assess the condition of vagina, cervix and perineum for:
a) cystocele: Insert fingers into vagina and press down posteriorly, ask the woman to bear down and assess for evidence of a cystocele by feeling for a bulge of the anterior vaginal wall. 1st degre=bulging of anterior vag wall; 2nd degree= bulging reaches vaginal orifice or introitus; 3rd degree=bulging extends betond the introitus

b) rectocele: (Doing the same thing as for cystocele) Spread your finger and ask woman to bear down again. ***** for evidence of rectocele by feeling foe bulging upward into vagina and outward toward the introitus. Rectoceles are graded in same degrees as cystoceles.

c) hematoma: (tissue swelling containing blood)
- characterized by extreme pain and/or pressure in pelvic floor region
- tense, fluctuant swelling
- bluish or blue-black discoloration of tissue

d) tears, lacerations:
- With sterile gloves, a sterile field and several sterile gauze pads, begin to examine for lacerations. Place gauze pads in the vagina to aid exposure and sop up the oozing that can obscure landmarks (make sure to remove it when finished as it will be practically invisible). If the mother is too uncomfortable it may be helpful to give local anesthesia and then continue exam. Take time, find landmarks, examine any lacerations and make sure you see the full extent of the tear and not assume it's size or depth.
(Davis 172)

e) hemorrhoids:
- examined externally or one finger can be inserted into the anus as the mother bears down, to feel for hemorrhoid, they are difficult to feel, because they are soft.

f) bruising: observe externally for any bruising, it may lead to hematoma. Give arnica

g) prolapsed cervix:
If the cervix is prolapsed (coming down towards or out of introitus), then gentle (with gloved hand) push cervix back up to its usual position. Instruct woman to stay in bede as much as possible and begin exercising pelvic muscles. Sepia 200C can help.
(Davis 199)
I. Assess general condition of mother:
4. repair the perineum:
a) administer a local anesthetic:
Always rule out allergy to lidocaine first.
Injected by sterile technique with 22-gauge, 11/2-inch attached to 10mL syringe. 1% lidocaine, 10mg/mL is to be injected around the edges of the wound, waiting a few minutes for the medication to take effect.
(Varney's 1235-40) (Davis 73-76)

b) perform basic suturing of:
Strict use of sterile technic with the help of an assistant is necessary to set up a sterile field and prevent any possibility of infection.

(1) 1st degree tears: Usually heal nicely by themselves (without suturing) as long as the mother takes good care of them (hygeine and little to no movement or friction of any kind of the torn area)

(2) 2nd degree tears: (even some 2nd degrees heal on there own, such as when there is a minor internal split of the bulbocavernosus muscle, and the perineum intact. As long as the split is no more than 1/2 way through the muscle and bleeding can be controlled with a bit of pressure these can heal on there own)
- Close lacerations in layers--muscle, fascia, then skin, trying to eliminate tension in any one spot.
- Eliminate dead spaces between layers, these space are weak and prone to infection, hematoma/sweeling and oozing.
- Don't suture to tightly as it can impair circulation. Also do not use too many stitches, as each interferes with circulation to some extent and exposes a new area to possible infection
- Check your landmarks very carefully and repeatedly throughout procedure.
- Sutures should be placed so that depth is greater than width
- Never clamp the suture with the needle holder as it may break at this site
- An assistant can be very helpful by cutting sutures as they are place or holding an extra light in place for a better visual.

(3) labial tears: Many of these should or cannot be sutured because the sutures will not be imbedded in enough flesh to hold. Rarely you may need to attach piece together, try to get some substantial tissue in it to hold.

c) provide alternate repair methods (non-suturing): apply comfrey leaves, use tape, honey, stay down flat for up to 2 weeks, tie legs together at knees (don't use stairs or movements that separate legs)
I. Assess general condition of mother:
5. provide instruction for care and treatment of the perineum
- If there is swelling after repair (even if there is not this might still be a good idea) give arnica and have her apple alternating cold and warm packs onto perineum to stimulate circulation (ice packs should only be used if swelling is extreme)
- instruct the mother to rinse the area each time she uses the toilet, using warm water with a squirt of betadine
- Helpful to expose the perineum to sunlight, a light bulb, or a hairdryer to keep it dry
- She should avoid applying Vit E or other oils to the wound as this retards the healing
- She should be instructed to stay down or close to her bed for a week or two to encourage healing, any movement of the area (by opening and closing or crossing or lifting her legs) retards healing also.
(Davis 176)
I. Assess general condition of mother:
6. facilitate breastfeeding by assisting and teaching about:
a) colostrum:
- high in protein immunoglobins/antibodies and low in fat
- looks white and thick
- 1st hour after birth most important for B.F. highes amount of immunoglobin in colostrum and best for baby reflexes and helps give baby immunities

b) positions for mother and baby
- Whatever position you feed your baby in your baby needs to be nose to nipple and tummy to mummy.
- a few positions are: the common cradle hold, football hold, laying down, or baby laying on tummy feet towards mothers feet are some common ones.

c) skin-to-skin contact: is essential to initiate bonding and breastfeeding. The care-provider should do all in her power to see to it that the mother and baby are put skin-to-skin as soon after the birth as is safe (which is almost immediately in nearly all cases) help initiate breastfeeding and bonding.

d) latching on: more of the bottom of the areola should be in the baby's mouth (not too much) to help the nipple to the top of the baby's mouth. The baby's tongue should be almost visible on the bottom of its mouth (not sucked inside) when sucking.

e) maternal hydration: the mother needs always to stay hydrated when breastfeeding. Remind her that she should always have a cup or bottle of water/fluid by her so that everytime she feeds she is replacing what she loses with more fluid, to keep up her milk production.

f) maternal nutrition: Her nutritional needs may be ignored after birth, but in reality, her caloric intake needs to be increased slightly from her pregnant diet. Remind her that she is still eating for two, but that now her baby is growing and breasfeeding can be a big toll/exercise on the body and that she needs to be "refilling" everytime she "empties" (nurses). However this should be a natural and not forced action. " As milk production would appear to 'drive' apetite, rather than the reverse, hunger will effectively regulate the calorie intake of a breastfeeding woman, and the practice of encouraging breastfeeding mothers to eat excessively should be abandoned." (Myles 788)

g) maternal rest: with the increased demand upon the mothers body to breasfeed, she must get adequate and increased rest. When the baby is still breastfeeding during the night the mother should be taking naps (with the baby if she desires) during the day.

h) feeding patterns:
Breastfeed- on-demand and at least every 2-3 or 4 hrs, wake if not occuring this often, burp after each feeding.
- Don't try too hard to get the baby on a feeding pattern, that will come with time, at first just breastfeed when the baby desires/on-demand

i) maternal comfort
measures for engorgement:
- cool compresses, cabbage leaves, comfrey leaves, express milk, coat breasts with aloe vera (to help reduce infection risk)

j) letdown reflex: It is only when oxytocin is released, and the myoepithelial cellls contract, that milk is made available to the suckling infant. Milk release is under meuroendocrine control. Tactile stimulation of the breast also stimulates the oxytocin, causing let-down. This occurs in descrete pulses throuhgout the feed and may well trigger the bursts of active feeding. In the early days of lactation, this reflex is unconditioned. Later, as it becomes a conditioned reflex, the mother may find her breasts responding to the baby's cry (or other circumstances related to the baby or feeding). In one small study, psychological stress, was found to reduce the frequency of oxytocin pulses. (Myles 788)

k) milk expression:
- many women find it easier to oil the entire breast 1st, and then using long strokes toward the nipple, work down from the collar bone with one hand and up from the base of breast with the other. If specific lumps are noted have the mother work from behind these areas. This may hurt at first, but have mother continue and with enough pressure to make sure that milkis being expressed (up to 10 sweeps may be necessary before milk appears at the nipple, to get flow started graps the edges of the areola, pressing inward, squeezing together, and then pulling toward nipple.)
(Davis 194-5)

l) normal newborn urine and stool output:
Bowel Movements- Meconium is passed w/in 1st 24hrs and up to 72 hrs. Then 3-5 days transitional stool occurs, after the milk comes in stool is bright yellow and occurs 1-4 or more times per day.
Voiding- first should occur before 24 hrs after that at least 4-6 or more wet diapers per day and clear or pale yellow
J. Perform a Newborn Exam by assessing:
1. the head for:
a) size/circumference:
- should be larger then the abdominal circumference (shouldn't be more than a few cm difference-- a larger chest than head, particularly in a larger baby could indicate glucose intolerance and baby should be checked for hypoglycemia) (Davis 136)

- the occiupitofrontal circumference is on average 34-37cm
- molding or sweeling/caput may change this measurement, some wait until 3rd day for head to resume its normal contours to estimate size.
(Myles 771)

b) molding: determine degree of molding by the amount of overriding of bones at sutures and fontanels. The shape of the baby's head can be a result of molding and parents should be reassured that molding usually resolves within a few days after birth.

c) hematoma
- is an effusion of blood under the peristeum that covers the skull bones (it will never cross suture lines, confined to one bone, however, more than one bone may be affected--bilateral) A cephalhematoma is not present until 12hrs PP and grows larger over next few days, can persist for weeks. The swelling is firm, does not pit upon pressure, is fixed and located on one bone. No treatment is necessary, swelling subsides and is reabsorbed.
- parents should be reassured that it usually resolves within a few weeks
d) caput: may be noted overlying the presenting part as a result of pressure from the cervical os. It is moveable not fixed and can cross suture lines
- will disappear spontaneously within 24 hrs.

e) sutures: bones should feel hard in a term baby and sutures should not be splayed/wide may indicate hyrdocephalus of immaturity.

f) fontanels: a wide anterior fontanel is abnl and could also indicate hydrocephalus or immaturity
(Myles 770)

NOTE: Cephalhematoma, bruising, or excessive molding are signs of significant trauma, necessitating administration of Vit. K and baby should be seen by pediatrician.
(Davis 134)
J. Perform a Newborn Exam by assessing:
2. the eyes for:
a) jaundice:
- depress baby's skin in chest and extremeties and check for yellow undertone.
- Jaundice is unusual on day one and could indicate pathological jaundice (from liver disease, an obstructed bile duct, infection, or RH hemolytic disease), however it could also be jaundice from an ABO compatibility--which usually corrects itself-- to be safe refer any 1st day jaundice to a pediatrician.
- A bit of yellow tinge (physiological, ABO or breastmilk jaundice) can be normal in the face and down the nipple line on day 3, but unusual in extremeties.
- yellow in the eyes could also indicate jaundice
- If baby is very yellow, have have mother place him in a sunny window for 30 min twice daily, helps liver conjugate and eliminate bilirubin
- make sure mother is nursing long and frequently and check upon her the next day

b) pupil condition:
- check to see if they are equal in size and in reactivity to light

c) tracking: Check for tracking by moving your finger back and forth close to the baby's face

d) spacing: Check for shape and spacing of the eyes, noting any irregularities, NML space between yese is up to 3cm

e) clarity: each eye should be visualized to confirm that it is present and that the lense is clear.

f) hemorrhage: check for any red spots or hemorrhages of the sclera caused by pressure in the birth canal. It requires no treatment and will fade and reabsorb over time.

g) discharge:
check for any signs of discharge, may be insignificant , but could indicate infection.

NOTE: It is standard of care to provide erythromycin eye ointment to all babies for the possible risk of exposure to gonorrhea or chlamydia, however the mother may still decline and sign a waiver (for state laws) (Davis134)
J. Perform a Newborn Exam by assessing:
3. the ears for:
a) positioning: the top of the ear should be level with the corner of the baby's eye. Low-set ears are associated with kidney problems or other anomalies--baby should be seen at once if this is discovered

b) response to sound: there should be NML response to sound (a snap by the ear and the baby should react)

c) patency: should be open

d) cartilage: should be firm and errect from head in a term baby (soft in preterm)
(Davis 134)
J. Perform a Newborn Exam by assessing:
4. the mouth for:
a) appearance and feel of palate: feel with gloved finger to make sure that the palate is intact and will have a high arch, this will stimulate the sucking reflex, note its strength at this time.

b) lip and mouth color: should be pink, circumoral cyanosis could indicate
a problem with baby's ability to regulate temperature

c) tongue: check the frenulum under the tongue, for NML length, if it is short it may be of no significance, but it could possibly effect breastfeeding.

d) lip cleft: the midwife uses her little finger to feel for any submucus cleft, a normal baby will respond by sucking.
(Myles 770)

e) signs of dehydration:dried lips and lack of adequate salivation
J. Perform a Newborn Exam by assessing:
5. the nose for:
a) patency:
- close baby's mouth and occlude one nostril (one at a time) and baby should breathe normally out of each, which indicates an open patency.
- Not patent could indicate an obstruction or choanal atresia

b) flaring nostrils/grunting heard upon expiration: could indicate respiratory comprimise

- Position should be midline (off midline, flattened nasal bridge, breaked or enlarged could indicate congenital malformation or syndrome)
-(Varneys 1301, 1031)
J. Perform a Newborn Exam by assessing:
6. the neck for:
a) enlarged glands; thyroid and lymph: could indicate thyroid problems, goiter(rare), or congenital infection

b) trachea placement: should not be abnmly placed or occluded

c) soft tissue swelling:
- the short thick neck of the baby must be examined to exclude the presence of swellings and to ensure that rotationg and flexion of the head are possible
(Myles 770)
- short neck could indicate downs
- if lymph mass is present it is most commonly a cystic hygroma, caused by sequestered lymph channels, which dilate into large cysts, it can me small(few cm) or massive and may cause severe nursing difficulties or airway comprimise. Very small ones may regress, but usually surgical resection is necessary.
- redundant or webbed neck skin can indicate Turner, Noonan, or Downs syndromes.

d) unusual range of motion:most likely due to in utero fetal positioning
(Varneys 1303-04)
J. Perform a Newborn Exam by assessing:
7. the clavicle for:
a) integrity: there should be no lumps along bones, the newborn bones are much more gentle than adults

b) symmetry:
should be even and symmetrical. Asymmetry, uneven, fracture or lump may indicate a birth injury.
(Varneys 1304)
J. Perform a Newborn Exam by assessing:
8. the chest for:
a) symmetry:
- rounded, contoured and symmetrical is NML
- ABNML is scaphoid(boat-shaped) and could indicate a diaphragmatic hernia or malnourishment
- asssymetrical ribs could indicate a birth inury or congenital injury

b) nipples:
- NML: nipple spacing on line without extra nipples
- ABNML: nipple spacing not on line, wide spaced nipples or extra nipples could indicate congenital syndrome

c) breast enlargement
including discharge:
- NML: areola should be raised (approx .75-1cm) and without discharge
- ABNML: flat areola, and discharge, (or overly enlarged) could indicate prematurity or from hormonal influence

d) measurement (chest circumference)
- average circ. is 30-36cm
- <30cm (11.8 in) SGA or prematurity

e) count heart rate & f) monitor heartbeat for irregularities:
- 100-160 bpm, regular sounds, without murmurs
- ABNML: >160 tachy or <100 bom brady, murmur, may be secondary to resp difficulty, increased workload on heat, prematurity, sepsis, congenitak heart defect with or w/out cyanosis

g) auscultate the lungs, front and back for:
(1) breath sounds:
- RR should be 40-60 and resp effort should be easy, unlabored rhythm, may be irregular, abdominal breathing
-ABNML: apnea lasting >15s and accompanied by duskiness, cyanosis, or RR >60. Accessory muscle retraction, flared nostrils, stridor or grunting-- could indicate RDS or difficulty--ABNL RR, could indicate: prematurity, resp difficulty, sepsis, tachypnea in c-section or full-term infants may be transient (from retention of lung fluid)
(Varneys 1297)

(2) equal bilateral expansion:
- Clear breath sounds, equal bilaterally, anteriorly and posteriorly indicates clear lung fields
- ABNL: Unequal breath sound, expiratory grunting, rales after the first day, ronchi or wheezing--could indicate lung congestion, RDS, pulmonary edema, pneumonia,-- unequal breath sounds could indicate pneumothorax or diaphragmatic hernia.
J. Perform a Newborn Exam by assessing:
9. the abdomen for:
a) enlarged organs:
- enlarged organs could indicate infection, disease or malformation of that particular organ. Liver or spleen abnlties could indicate heart problems--congestive or congenital. A distended bladder could indicate a urinary tract obstruction

b) masses & e) rigidity:
- tense, rigid, tender or masses could indicate inestinal deformity or obstruction, renal or urinary tract deformity

c) hernias:
- NML: no hernias or groin masses
- ABNL: groin masses could indicate inguinal hernia

d) bowel sounds:
- NML: present
- ABNL: absent indicates obstruction; hyperactive (unless just after feeding) could indicate hypermotility.
J. Perform a Newborn Exam by assessing:
10. the groin for:
a) femoral pulses:
- femoral pulse rate strong and regular bilaterally
- ABNL: pulse rate weak or absent belaterally could indicate coarction of the aorta

b) swollen glands:
- is ABNL and could indicate and inguinal hernia or undescended testes
(Varneys 1306)
J. Perform a Newborn Exam by assessing:
11. the genitalia for:
a) appearance:
- should be clearly distinguishable as male or female
- ABNL: sex not clearly distinguishable, may have both organs, could indicate ambiguous genitalia or endocrine problems

b) position of urethral opening
- In female should be present in front of the vaginal orifice, if it is displaced could indicate urinary malformation
- In male the urinary stream should void straight from the penis (not straight could indicate an obstruction or malformation or fitula)

c) testicles for:
(1) descent:
- testes descended on at least one side indicates full-term
- testes not palpable indicates prematurity or undescended testes

(2) rugae:
- full and numerous rugae indicates full-term
- flaccid smooth or few rugae indicates prematurity

(3) herniation:
- any masses may indicate hernia

d) labia for:
(1) patency: vagina should be patent with or w/out white discharge. Not patent w/ or w.out bleeding is ABNL and could be caused from a hormonal influence

(2) maturity of clitoris and labia:
- both labia should be present and well-formed and
the labia majora should be larger than the minora (if not then could be premature)
- the clitoris should be present and may be enlarged (in full or preterm)
(Varneys 1306-08)
J. Perform a Newborn Exam by assessing:
12. the rectum for:
a) patency:
- should be positioned midline and be patent. If not could indicate imperforate anus or anal defect
- anal wink should also be present as a sign of NML sphincter strength

b) meconium:
- the presence of mec in the anal orifice indicates patency, not just seeinf an orifice.

- presence of mec in vaginal or urethral orifice suggests a rectovaginal or rectourethral fistula
(Varneys 1307)
J. Perform a Newborn Exam by assessing:
13. abduct hips for dislocation
Palpation of hips:
- NML: hips without clicks and with full range of motion
- ABNL: limited renge of motion, or positive result of Ortolani's or Barlow's manueuvers

- Ortolani's: flex NB's hips and knees, then abduct and adduct hip to detect a slipping of the hip out of the acetabulum,"", or an uneven motion unilaterally
- Barlow's: flex NB's hips and knee's, then place finger on the femur and trochanter, put hip through full range of joint motion and listen for audible click.
(Varneys 1311)
J. Perform a Newborn Exam by assessing:
14. the legs for:
a) symmetry of creases in the back of the legs:
- asymmetry of hip creases may suggest hip dislocation and congenital hip dysplasia should be ruled out

b) equal length:
- NML: length in proportion to body and equal bilaterally, limbs straight
- ABNL: length not in proportion to body, short or unequal, limbs not straight, leg internally rotated or bowed--could indicate congenital syndrome, diabetic mother

c) foot/ankle abnormality:
- Feet NML: straight, ten toes w/out webbing and equal spacing, if not could indicate congenital syndrome
- ABNL Feet: turned valgus or varus could indicate absent fibula or from fetal position.
- Ankle dorsiflexion (foot is flexed up to ankle) 0-degree angle is NML, >0 angle could indicate prematurity
J. Perform a Newborn Exam by assessing:
15. the feet for:
a) digits, number, webbing:
-NML: straight, ten toes w/out webbing and equal spacing, if not could indicate congenital syndrome

b) creases:
- cover the sole of the foot indicates maturity
- few or only anterior 3rd of sole of foot indicates prematurity

c) abnormalities:
- limited range of joint motion or flexion could indicate birth injury/trauma or prematurity
- tarsal or metatarsal absent, fractures or unequal bilaterally/deformed may be associated with congenital syndromes
(Varneys 1310)
J. Perform a Newborn Exam by assessing:
16. the arms for symmetry in:
a) structure:
- length in proportion to each other and lower extremities and body symmetry should be NML. Shortened, absent or assymetric extrem. could indicate diabetic mother, congenital syndrome or maternal drug use.

b) movement:
- Full range of joint motion should be noted in shoulder, clavicle, elbow and wrist, if not, could indicate injury to that particular bone/joint/nerve, birth injury or trauma, prematurity, fetal positioning.
(Varneys 1308-09)
J. Perform a Newborn Exam by assessing:
17. the hands for:
a) number of digits, webbing:
- NML: 10 fingers, no webbing, and equal spacing
- ABNL: >10 digits (polydactyly) could be part of a syndrome; webbed, digital tags (syndactyly), or unequal spacing could indicate congenital syndrome

b) finger taper:
- fingers that are pointed or narrow in shape, they could indicate syndrome

c) palm crease:
- a simian crease (crease extending across the entire palm) indicates Down syndrome

d) length of nails:
- NML: extend beyond nail-bed in full-term NB.
- ABNL: short or spoon-shaped could indicate congenital syndromes or fetal alcohol syndrome; absent nails may also have absent radius; mec-stained nails could indicate fetal distress.
(Varneys 1308-09)
J. Perform a Newborn Exam by assessing:
18. the backside of baby for:
a) symmetry of hips, range of motion:
- should be symmetrical creases and NML range of motion w/no hip clicks, if not, then could indicate congenital hip dysplasia

b) condition of the spine:
(1) dimpling:
- any soft masses, dimpling or bulge could indicate spina bifida

(2) holes:
- open spinal defect or may be covered with tissue, involving meninges and spinal cord or just spinal cord, could indicate meningomyelocele

NOTE: sinus tracts present could indicate Pilonidal cysts

(3) straightness:
- curved could indicate congenital scoliosis which can be associated with genitourinary tract anomalies and other syndromes
(Varneys 1311)
J. Perform a Newborn Exam by assessing:
19. temperature
- skin should be warm to the touch and axillary temp should be 35.5-35.6* C (approx 96-98* F)
- Cool or below that temp could indicate poor peripheral perfusion/hypothermia or prematurity
- Warm or above average could indicate hyperthermia or fever
(Varneys 1298)
J. Perform a Newborn Exam by assessing:
20. flexion of extremities and muscle tone
- Strength and tone strong, palmar grasp strong indicates good overall strength and full-term baby
- strength and tone weak, hypotinia, or flaccid, or weak palmar grasp could indicate birth asphyxia or prematurity.
(Varneys 1296)
J. Perform a Newborn Exam by assessing:
21. reflexes:
Reflexes and proper responses indicate good neurological condition of newborn, if a poor or absent response is found in any of the following, it could indicate damaged sensory pathway reflecting a spinal or CNS lesion, temporary nerve damage affecting muscles, prematurity, it can be permanent damage (ie. spinal cord defects or brachial plexus injuries)
- - Accentuated (hyper) responses of also of concern and can relfect a central neurological deficit

a) sucking:
- feel with gloved finger to make sure that the palate is intact and will have a high arch, this will stimulate the sucking reflex, note its strength at this time.

b) moro:
- evalutaion of neurologic status of infant, in NML infants the response (by putting the baby's wrists together, in supin position, then letting go) should be symmetrical and usually disappears in 2-4 months.

c) babinski:
- stroke the babys foot from top to bottom and the toes should spread/splay outward

d) plantar/palmar:
- plantar: press your thumb into the ball of the baby's foot and its toes will flex down towards your thumb
- palmar: press your thumb into the center of the baby's palm and the baby will grasp your hand

e) stepping:
- lift the baby up, perpendicular to the floor and the baby should stretch its feet out towards the floor in s stepping motion

f) grasping:
- see plantar/palmar, letter d)

g) rooting:
- baby turns head towards nipple and makes a sucking motion with mouth, tyring to find breast and feed

h) blinking:
- responds to bright light by blinking
(Varneys 1006-08)
J. Perform a Newborn Exam by assessing:
22. skin condition for:
a) color:
- NML: pink (in dark skinned infants mucus membranes should be pink)
- ABNL: duskiness or cyanosis (other than acrocyanosis) could indicate poor circulation or RDS or difficulty
- Acrynosis of hands/feet in 1st 24 hours of life is not abnl. if it lasts more than 24 hrs it could indicate poor peripheral perfusion and possibly cardiac compromise
- Reddish hue immediately after birth isn't nec abnl and indicates an adjustment in oxygen levels in extrauterine life. If it persists/plethora would indicate elevated hemat or hemog, polycythemia or hyperviscosity of blood
- Pale color is abnl and could indicate cardiopulmonary compromise or failure

b) lesions:
- Erythema toxicum: benign rash found in up to 70% NB's, consisting of white or yellow papules or vesicles with an erythematous base, can be on any part of body, most commonly seen on face, trunk or extremeties. It can last anywhere from a few hours to several days, most commonly occurring 24-48 hrs of life but can be happen up to 3 months.
- herpes is one of the most serious viral infections of NB, rash appears as vesicles or pustules on an erythematous base, clusters of lesions are common. 60% mortality rate.

c) birthmarks:
- Port Wine Nevus: flat pink or reddish purple lesion consisting of dilated congested capillaries directly beneat the epidermis

d) milia:
- Milia are multiple yellow or pearly white papules about 1mm in size, usually seen on face in up to 40% of NB's, when found inside mout they are called Epstein's pearls. They are of no harm and resolve within the 1st few weeks of life

e) vernix:
- thick white cheesy material increases with gestational age
- no vernix=premature

f) lanugo(fine hair all over body):
- scant lanugo=full-term
- abundant lanugo=premature

g) peeling:
- dry, peeling, cracked indicates postmature infant
- NOTE: wrinkled skin indicates IUGR and gelatinous with visible veins indicates premature

h) rashes:
- Eryth. toxicum (seen above under lesions)
- Thrush: common infection of NB's caused by candida, appears in patches of white material scattered over tongue and mucus membrane it is adherent and cannot be scraped off (unlike milk residue which can be)

i) bruising:
- could be NML on presenting part from pressure of birth canal, could indicate birth injury, or vit k deficiency disorder.

j) Mongolian spots:
- most common pigmented skin lesion in NB, seen in up to 90% of african american, asian and hispanic infants and 10% caucasion. most commonly seen over buttocks, gray or blue-green in color, they usually fade within first 3 yrs of life butcan persist into adulthood
J. Perform a Newborn Exam by assessing:
23. length of baby
- Average:
35.6–50.8 cm (14–20 inches)
- smaller indicates SGA, premature, IUGR
- larger could indicate LGA (glucose intolerance issues), postmature etc
J. Perform a Newborn Exam by assessing:
24. weight of baby
- avergae is 3.5 kg or 7.7lbs