OB test 2

Molding

biparietal diameter

vertex

diamond

fetal attitude

• head flexed
• chin on chest
• arms crossed over chest 
• legs flexed w/thighs on abdomen

fetal lie

longitudinal

• fetal spine at right angle to mother's spine
• Can't deliver vaginaly

LOA

• fetus spine on mom's left side
• (Left Occipital Anterior)

presentation

fetal position

• head partly extended
• Largest AP diameter is presented to pelvis
• CANT DELIVER

• head is hyperextended
• CANT DELIVER

c section

• knees are straight
• butt presents
• NEED TO KNOW

• knees and hips are flexed
• feet present to pelvis

• both legs extended and present to pelvis
• NEED TO KNOW

engagement

engaged

• bollatoble
• "floating"

effacement

fetal station

• F -3: Floating High
• I -2: In the right direction 
• S -1: Settling in 
• H 0: Halfway There
• I +1: Inching out
• N +2: Nearly there
• G +3: Get the crown

• uterine muscle contraction 
• (complete effacement and dilation of cervix)

use of abdominal muscles to push during 2nd stage of labor

rhythmic tightening and shortinings of uterine muscles

frequency

the beginning of a contraction to completion of it

contraction strength

Can only be measured with IUPC

10-12 mm Hg

• 25-40 mmHG (early labor)
• 50-70 mmHG (late labor)

80-100 mmHG

>100 mmHg

• Lightening
• Braxton-Hicks Contractions
• Ripening- softening
• Bloody show- loss of mucus plug
• Rupture of membranes
• Sudden burst of energy "nesting"
• Wt loss
• Increased backache
• Diarrhea, Indigestion, N/V

• Onset of regular contractions
• 5-7 hrs
• Contractions increased in duration, frequency and intensity
• Cervix: 0-3 cm
• Contractions every 3-30 min
• Duration: 20-40 sec
• Intensity: mild-moderate
• Mom happy, excited

• 2-5 hrs
• Cervix: 4-7 cm
• Contraction every 2-5 min
• Duration: 40-60 sec
• Intensity: moderate to strong
• Mom is anxious, fear, doesn't want to be left alone
• *Use focal point, back rub, tries to find comfortable position

• approximately 3.5 hours
• cervix: 8-10 cm
• contractions every 1.5-3 min
• duration: 60-90 sec
• intensity: strong
• Uncontrollable urge to bare down- distract her until she gets to 10 cm (use breathing)
• Restless, tired, difficulty coping, yelling, irritable foul language, anger

• usually 2 hrs after cervix completely dilated
• urge to push
• contractions every 1.5-2 min
• duration 60-90 sec
• intensity strong
• increased pain/fear
• once able to push may feel sense of control

mechanism of labor, in which fetus changes positions in order to come through the birth canal

• Descent
• Flexion of head
• Internal rotation
• Extension of head
• Restitution
• External rotation (so posterior shoulder is free first)
• Expulsion (anterior shoulder is free, rest of body follows quickly)

head emerges from canal, untwists and turns to side to align with position of back

• placental separation
• membranes separate
• placental delivery
• If >30 min elapses, placenta is retained

• uterus can't clamp down in order to prevent hemorrhage 
• "retained" if placenta is not delivered within 30 minutes of baby

• 1-4 hrs after birth
• uterine changes
• hemodynamic changes

• blood loss of 250-500 mL
• Redistribution into venous beds
• Moderate decrease in BP
• Moderate tachycardia

• remains contracted and midline
• fundus 1/2 way b/w umbilicus and symphysis pubis
• cervix widely spread
• N/V
• Thirsty, hungry
• Shaking, chills: shaking may be due to over extention of muscles
• bladder hypotonic (can't pee)

• Contractions @ reg intervals
• Intervals b/w contractions shorten
• Contractions increase in duration/intensity
• Discomfort starts in back and radiates to abdomen
• intensity increase with walking
• cervical dilation and effacement progressive
• contractions dont decrease with rest or warm tub bath

• contractions irregular
• no change in interval b/w contractions
• no change in duration
• discomfort in abdomen
• walking has no effect on/or lessens contractions
• no change in dilation or effacement
• rest and warm tub bath lessen contractions

• Copy of prenatal records sent to hospital @ 36 weeks
• May be limited
• Protect privacy
• Note history of depression (elevates risk of postpartum depression)
• Assess for intimate partner violence
• honor cultural beliefs

• VS
• Contraction-frequency/intensity
• Dilation
• Effacement
• Station
• Membrane status
• Fetal presentation/position
• FHT
• Fetal movement
• Labs- RPR, Rubella, syphilis, Rh

baby not in adequate station which results in a risk of cord prolapse

• sleep and active states
• decreased fetal movement, breathing movements and variability during sleep (usually 40 minutes)

• 28 weeks
• begins 23-24 weeks

touch

light

• 1. Palpate upper abdomen with both hands
• 2. Determine location of back, palpate abdomen deep
• 3. Determine what fetal part is above inlet. Grasp lower portion of abdomen just above symphasis pubis
• 4. Stand at head, move fingers slowly down sides of uterus toward pubis

just as effective as toco if nurse pt ratio is 1:1, pt low risk and nurse stays with patient

• count for 30-60 seconds
• Listen before, during, and after contractions
• Can't ID variability

• place fingers of 1 hand at the top of uterus
• Apply gentle pressure
• During peak estimate firmness:
•    Mild: tip of nose
•    Moderate: chin
•    Strong: forhead

• noninvasive
• readily accessible
• hands on 
• allows mother freedom

• cant measure pressure
• no record
• doesnt work on obese

• presentation
• position
• station
• flexion of fetal head
• swelling of scalp
• dilation

slice of banana

ritz cracker

soda can

bagel

• External
• Measures frequency and duration
• Noninvasive
• can be removed
• continous
• must palpate intensity
• uncomfortable and needs constant adjustment
• DOES NOT MEASURE INTESNITY

• measures intrauterine pressure
• measures intensity 
• measures resting tone
• 2 lumens- fluid filled
• membranes must be ruptured 
• invasive
• increased infection risk

fetal monitoring

110-160

• idiopathic
• Maternal related: fever, dehydration, anxiety, anti-tocolytics (medicines that decrease contractions)
• Fetal factors: early fetal hypoxia, fetal anemia, infection, prematurity, arrhythmias

• <110 for 10 min
• can be sign of significant fetal compromise
• stimulation of vagus nerve can cause it
• fetal heart block= caused by systemic lupus
• accidental monitoring of maternal HR

• smooth, wavelike
• can be benign or serious
• usually always nonreassuring (not sure if baby is ok)
• causes could be : fetal anemia, twin to twin transfusion, umbilical cord occultion, CNS malformation
• IMMEDIATE INTERVENTION

• smooth, meandering pattern
• fluctuates in normal baseline without variability
• indicates congenital defect or metabolic acidosis
• IMMEDIATE INTERVENTION 
• imminent delivery

• mostly benign 
• if occasional its ok
• if consistent then concerned

measure of fetal cardiac and neurological well-being to the push and pull of sympathetic and parasympathetic nervous system

baby has good response

difference between successive heart beats

large rhythmic fluctuations

amplitude undetectable

detectable but 5 BPM or less

amplitude range of 6-25 bpm

amplitude range > 25 bpm

• abrupt increase in baseline
• has a peak and returns to baseline
• episodic accels are REASSURING
• associated with fetal movement or any kind of stimulation
• indicates fetal well being
• associated with stimulation of SNS

Reassuring

lowest point

• uniform 
• mirrors contraction pattern
• due to head compression
• normal, no nursing action needed

• Nadir after peak of contraciton
• Ominous

placental insufficiency

• turn mom from side to side
• oxygen to mother
• stop oxytocin
• may give fluid bolus
• notify provider
• prep for C section

2-10 minutes

• onset, depth duration varies with contractions
• severe if below 60 for >60 seconds
• Due to cord compression
• turn mom
• o2
• fluid bolus

• 1. Normal "Reasurring"
• 2. Indeterminate- iffy (not predictive of acid-base status of fetus)
• 3. Abnormal- nonreassuring (Predictive abormal acid-bae balance at time of delivery)
• requires prompt eval

• V: variables     C: cord compression
• E: earlies         H: head compression
• A: accels         O: okay
• L: late decels   P: placental insufficency

press fetal scalp with fingers during vag exam to elicit accel

• place sound device on maternal abdomen to elicit accel
• If accel: reactive
• Absence: nonpredictive, further evaluate

• significant abnormal FHR
• Meconium staining amniotic fluid
• Depression at birth 
• only if APGAR >7 @ 5 minutes
• Can determine if fetal academia due to cord compression or placental insufficiency
• 8-10 inch sample

• Rupture of membranes
• decreased fetal movement
• regular, frequent contractions (q 5 min for first time moms, every 6-8 min for multi)
• any vaginal bleeding

coach, advocate, continuous support

• BP, HR, RR q1hr
• temp q 4 hr
• Palpate contractions  q 1hr
• vag exam only when management changes
• FHT q30 min if normal (no decels)
• talk and teach
• encourage ambulation (if no bleeding, normal FHT, ROM if head is engaged)
• Clear liquid/ice chips
• Oral care if vomiting

• palpate contractions q15-30 min
• watch for bloody show
• encourage frequent voiding
• FHT q30 min (15 if high risk)
• VS q1hr
• IVF
• Note ROM
• If FHT drop- do immediate vag exam

• may see heavy bloody show
• palpate contractions q15 min
• sterile vag exam
• VS q30 min (15 if high risk)
• FHT q30 min
• At end of contractions, deep breath, blow out, relax
• Quite environment
• Mom has body diffusion
• Less aware of environment
• May not want to be touched
• May be unable  to speak in sentences
• Feels increased rectal pressure and perineal burning
• HELP HER NOT TO PUSH

• passage of gas/stool
• voice deepen
• moan-guttural
• change in vocalization
• discomfort-pain, sweaty, hot, tired
• reaction of pain: BP, HR up, pupils DILATE, muscle tension builds
• Avoid holding breath
• Frequent position changes q1hr
• Encourage ambulation
• Rocking, leaning, pillow under mid-back
• Avoid pressure behind knees and calves (DVT)

• Change pads frequently 
• wash perineum w/warm soap and water
• Fresh, smooth, dry linens
• Clean fresh gown
• Cool washcloths
• Empty bladder q1-2 hr
• vaseline for lips
• socks
• effleurage, back/neck rbs
• breath through nose and out mouth 
• birthing ball

widens pelvis, helps fetal decent

helps fetus go from OP to OA

• express confidence in her abilities
• assit with breathing
• demonstrate genuine concern
• praise efforts

• keep informed
• assure them of normal sounds/behaviors
• explain equipment and procedures
• praise efforts

• assess every woman
• be alert for unexplained anxiety, unrelenting pain, intense fear during vag exam

• 1-1000, 2-1000, 3-1000...
• until contraction over

• 1&2, 2&2, 3&2...
• Exhale on number, in on &

• in & out through mouth "hee-hoo"
• begin with 3:1, progresses to hee hoo

• deep and rhythmic
• slow
• quick: pant-pant-blow
• Count aloud to encourage slow breaths
• ID beginning, peak, and descent of contraction

• vag exam to determine onset
• assess fetal descent
• HR, BP q5 min
• FHT q5 min
• Utterances indicate change in coping
• DO NOT PUSH UNTIL dilated 10 cm and feels urge to push

• padded
• puts legs up at same time
• adjust for mothers legs
• avoid pressure points

• most popular 
• convienent
• easy to maintain sterile field
• easy for episiotomy
• decreased BP
• increased aspiration risk and perineum pressure
• interferes with contractions

• use of gravity
• increased pelvic outlet size
• difficult balancing

• deceases frequency of contractions
• increases intesnsity
• more comfortable for mom
• less aspiration risk
• less risk for shoulder dystocia
• easier to deliver baby if OP

• vanished due o childbed fever
• becoming more popular
• stronger, more efficient contractions
• may diminish or eliminate sever back pain
• mom able to see birth

too rapid of a descent

down gently to release the anterior shoulder

below the level of the vagina

GU abnormalities

about 24 hrs if the cord is drying

after cord is clamped but before placenta is expelled

• mostly done by pro-profit agencies
• cost often prohibitive
• annual fee for storage

• head
• wet blankets/towels form bed

• 7-10: Desirable
• 4-6: moderately depressed
• 0-3: severe depressed
• Only 5 minute is associated with long-term neuro outcome
• If less than 5 at 5 min, continue every 5 min till above 5
• DOES NOT GUIDE RESUSCITATION
• MOST IMPORTANT IS HR

• Female of childbearing age
• often overweight
• Usually compulsive
• relies on manipulation lying & deception
• Frequently indicates she has lost a baby or is incapable of having one
• Often married or cohabitating
• Lives in the community where the abduction takes place
• Visits nursery & maternity units, asks detailed questions about procedures & floor layout
• Plans the abductions but seizes any opportunity present
• Frequently impersonates a nurse or other health professional
• Becomes familiar with staff cares, work routines, victim’s parents
• Demonstrates a capability to provide “good” care to the baby

• size and shape of head
• posture and movement
• skin
• resp effort
• abdomen
• heart 
• cord genitals and anus
• extremities

• talk in high pitched voice
• place on moms abdomen
• first hour, infant is awake and alert-gazes at parents
• encourage breast feeding
• dim lights
• delay interventions, delay visitors
• avoid loud noises 
• consult with mother about how much contact she wants

• uterus rises upward as the placenta settles downward
• umbilical cord lenthens
• sudden trickle or spurt of blood
• uterus changes from discoid
• check for Ballooning which may indicate uterine relaxation and bleeding

• have mom bear down
• controlled cord traction (danges of uterine inversion, snapping of cord, hemorrhage)
• fundal pressure (uncomfortable for mother)

• pitocin IV or IM
• methergine IM (dont give preclamptics)
• hemabate: IM
• Cytotec: off label use

• check lochia q15min
• continuous observation if soaked in 15 min or blood pools
• should not exceed 1 pad/hr
• BP q5-15min
• VS q5-15min

uteroplacental shunt

vag or cervical tear

• Tachycardia
• Hypotension
• Uterine atony
• Excessive bleeding
• fever >100

• Cervical changes
• distention of lower uterine
• uterine ischemia
• Impulses transmitted via T11 & T12 spinal nerve segment & accessory lower thoracic & upper lumbar Sympathetic nerves

• intense, sharp, burning
• well localized
• results form stretching and distention of perineal tissues and pelvic floor as fetus moves through
• transmited via pudendal nerve through S2 and S4 spinal nerves and PNS

pressure of palm on lower back

practiced before birth

bradley

• sensory memory
• stanislavky relaxation

the placenta

• Mother wants it
• Mother has stable VS
• FHR 120-160
• NST reactive
• Short/long term variability present
• No late decels
• no meconium staining
• established contractions
• cervix dilated to 4 cm (G1) or 3cm (G2)
• presenting part engaged
• progressive descent of presenting part

oral

• Stadol/Nubain
• Rapid onset, peak 30-60 min
• SE: resp/cv depression, drowsiness, dizziness, blurred vision, N/V, diaphoresis, urinary urgency
• Antidote: Narcan
• ****3 hr lifespan, if given to and effects wear off while drug is still in system, baby will stop breathing, give another dose of Narcan

• MATERNAL HYPOTENSION (prevented with dextrose fluid bolus)
• Can take up to 30 min to work
• Lengthens 1st and 2nd stage of labor which increases stress to fetus
• increased c section risk
• puritus
• hyperthermia

total spinal HA


HA related to CSF leak: do blood patch

• for 2nd stage of labor, birth, episiotomy repair
• Works for delivery pain, not labor pain
• Injected below pudenal plexus transvaginal
• Disadvantes: doesnt relieve uterine pain, decrease urge to push, can cause ligament hematoma, perforated rectum
• Advantage: simple, safe, doesnt lower bp, more direct

37-38 wks

<2500g

labor at 20-37 wks

preterm labor

2x more common in black women

• BV
• roughtine treatment is not indicated, but surveillance is!!!

• 20-30% women colonized
• no assocation between preterm birth and vag colonization
• preterm women should be screened and treated if possible

• risk of 50% preterm birth if not treated
• Asymptomatic bacteriuria also increases risk

• Vag washing or AF
• pos test can indicate SROM
• presence is abnormal after 20 weeks but returns near term
• neg results are highly predictive
• if neg, chance of delivery within 7 days is about 1%

• fetal demize
• severe PIH
• chorionamnioitis
• fetal lung maturity
• <24 weeks
• nonreactive NST
• Absent end-diastolic umbilical blood flow
• repetitive decels
• lethal fetal anomaly
• abruption
• severe IUGR
• nonreasurring GHT
• oligo
• pos CST

• pain
• menstrual like cramps
• vag bleeding
• bloody show
• pelvic pressure
• diarrhea

• uterine contractions every 5 min 
• OR
• 8 contractions in 60 min
• AND
• Documented cervical change or cervical effacement of 80% or more
• OR
• cervical dilation greater than 1 cm

• Prevent recurrent preterm delivery due to SROM or SPTL
• begun 16-20 weeks, IM in hip every week until 37 weeks

• delay birth by 24-48 hrs
• allows betamethasone to be given

• IV, IM, subq, or PO
• SE: decreased BP, increased HR, pulmonary edema

• Do not use with CA channel blockers
• Bolus 4-6g IV over 20 min
• Main 1-4 g/hr
• Titrate to Mg levels (5.5-7.5) and DTRs
• Maternal SE: flushing, HA, dizzy, nystagmus, nausea, dry mouth
• Fetal S: hypotonia, Resp. depression, decreased BG, decreased Ca

• indomethcin
• give with antacid or meals
• do not give if coagulation disorder or kidney disfunction
• can cause premature DA closure

• empty bladder
• lie on side
• drink 3-4 cups of fluid
• soak in warm bath tub with uterus submerged
• rest for 30 minutes after symptoms have subsided
• call health care provider if symtpoms persist

2-3 quarts of juice

rupture of water after 37 weeks but before labor onset( if labor has not occured within 12 hrs condisdered PROM)

greater than 24 hrs

• infection
• amnio
• previa/abruption
• hydraminos
• LEEP
• 2+ babies
• maternal genitalia anomalies
• fetal anomalies
• connective tissue disease (lupus)

• AF more alkaline than normal vag secretion
• Normal ph: 2.5-5.4
• AF pH: 7-7.5
• False positives: BV, semen, urine, blood, antiseptic soaps

• sterile vag exame
• if labor- digital exam, bear down (gush of fluid) slide shows ferning

• blood infiltrates uterus
• Blue

DO NOT PERFORM VAG EXAM

• multiparity
• placenta accrete
• abnormal blood vessels
• prior C-section
• cocain use
• smoking 
• recent abortion
• large placenta

decreases fetal urine output

pulmonary hypoplasia (life threatening)

37 weeks

3, 40-60 sec contractions in ten minutes with good relaxation between contractions

terbutaline

< 1 cm dilation/ hour

no change in dilation for 2 hrs

<3hr of labor before delivery

• 1st preg
• >35 years
• <4 ' 11
• >41 wks
• Epidural
• Dystocia
• Large fetal head

AF embolism

• SOB
• hypoxia
• cyanosis
• respiratory failure
• CV collapse
• Emergency-Code-CPR-C section w/cpr

previous c section

• nonreassuring FHT
• bradycardia