OB Exam III

List common suspicions for what causes labor to begin.

1. Stretching of the uterus

2. Amniotic fluid level

3. Shift from progesterone to estrogen dominance

4. Increased oxytocin sensitivity (oxytocin receptors increase = increases the sensitivity to oxytocin = uterus is more receptive to contractions)

5. Increased release of prostaglandins

List the signs that indicate labor is near.

1. Cervical changes “Ripening”

2. Lightening

3. Increased energy level (nesting)

4. Bloody show

5. Braxton Hicks “False Labor”

6. SROM

What is “Ripening”?

• Ripening = cervical changes that indicate labor is near

• Cervix must soften and stretch to allow dilation

—>Can occur over weeks or within hours

—>Prostaglandins and Relaxin starts releasing to relax the pelvis and soften the cervix

What is lightening?

• A sign that labor is near

Lightening: Fetal presenting part engages into the pelvis

• Before the presenting part was ballotable (floated around)

• Once engaged, its in there

• Resulting from lightening:

—>Improvement in breathing b/c the fetus is not pressing on the diaphragm as much

—>May have more frequent voiding because of more pressure on the bladder

—>More pelvic pressure, leg cramps, dependent edema, back discomfort, vaginal discharge

—>May happen a few weeks before or during labor

What is nesting?

• A sign that labor is near

Nesting: Sudden increase in energy before labor begins

• Prep for baby; setting up the nursery then rearranging it 5 times, folding and refolding baby clothes, packing bags for hospital, scrubbing the floor on hands & knees (not a bad thing), etc.

• Usually occurs 24-48 hours before the onset of labor

• Assumed to be caused by an increase in epinephrine release caused by a decrease in progesterone

What is bloody show?

• A sign that labor is near

Bloody show: Mucus plug expels as the cervix softens, effaces, and dilates

• Cervix has small capillaries that bleed as the cervix ripens and it mixes with mucus, aka “bloody show”

• May happen as labor begins, and may happen later in labor

• Mucus plug means NOTHING!

What are Braxton-Hicks contractions, what is are important nursing considerations of them, and what is their function, and describe what they feel like vs real contractions?

• A sign that labor is near

Braxton-Hicks: “false labor” warm up contractions that encourage cervical ripening but aren’t true labor contractions’

Nursing Considerations of Braxton-Hicks:

1. A woman can be in early stages of labor for days, which is called prodromal labor

2. Women have true anxiety of going into the hospital thinking they’re in labor, but being sent home

—>Reassuring them that we are always here when she needs to be evaluated and educating on signs of true vs false labor may be helpful

—>Also reassure her that things are “warming up” for the birthday party and every annoying contraction, whether real or false is doing a job

Functions of Braxton-Hicks:

1. Moves the cervix from posterior to anterior in prep for labor

Description of Braxton Hicks vs Real Contractions

1. Tightening or pulling sensation at the top of the uterus and spread through low abdomen and groin

2. Braxton Hicks are short, irregular, annoying more than painful

3. Real contractions may be felt in the front or the back

What is SROM?

• A sign that labor is near

SROM: Water breaks

What is PROM and PPROM, and what do these pose an increased risk of?

PROM: water breaking before labor begins

—>If this happens, labor usually begins within 24 hours

PPROM: preterm water breaking

—>Treatment may buy enough time to get betamethasone in but not always

Why can these be dangerous?

• Amniotic fluid has some of mom's antibodies

• Keeps baby cushioned

• Amniotic sac protects against infection

• Increased risk of cord prolapse if ROM before Lightening occurs

What maternal physiologic responses occur during labor?

1. HR increases by 10-20 bpm

2. Cardiac output increases 40-50%

3. BP increases during contractions

4. WBC’s increase to 25,000-30,000

5. RR increases and more oxygen is consumed due to increase in metabolism

6. Gastric motility and food absorption decrease, leading to N/V

7. Joints loosen due to Relaxin to allow for baby to pass through the pelvis

8. Blood glucose levels decrease due to stress of labor

What fetal physiologic responses occur during labor?

1. Periodic FHR accels and decels related to fetal movement, fundal pressure, and uterine contractions

2. Decrease in circulation and perfusion to the fetus due to uterine contractions

3. Decrease in fetal breathing movements

What could maternal hypotension during labor indicate? What does this lead to?

• Hypotension of mom can be normal or a side effect of the epidural, but can indicate intrauterine hemorrhage

• This leads to late and prolonged fetal heart rate decelerations

What could maternal tachycardia during labor indicate?

Maternal tachycardia can indicate hemorrhage

What might a maternal feeling of increased apprehension (“impending doom”) indicate?

Increased apprehension “impending doom” can be anxiety or signs of oxygen deprivation, hemorrhage, or other emergent situations

What could meconium fluid present in the amniotic fluid indicate?

Meconium fluid may indicate recent or prolonged fetal distress

What could fetal hyperactivity indicate during labor? What can this complication lead too?

• Fetal hyperactivity may indicate signs of hypoxia and present as marked variability on fetal monitoring

• Low oxygen perfusion leads to acidosis and may cause permanent neurological damage

What are the 4 P’s of labor?

1. Passage: Birth canal and pelvis

2. Passenger: Fetus and placenta

3. Powers: Contraction

4. Psyche

For the “passage” part of labor, what is involved?

Passage:

• Fetal head is wider circumference than the rest of the body

• The passage is soft tissue (ligaments, tendons, muscle, fascia) and the pelvis

• Relaxin and estrogen relax connective tissues and allow the joints to become more flexible

Describe the gynecoid pelvis shape.

Gynecoid: Is most favorable for vaginal births because the inlet is round and has room for the baby to maneuver

Describe the android pelvis shape.

Android: Is funneled & heart-shaped

• Vaginal birth is not very successful with this shape because baby cannot rotate effectively

Describe the anthropoid pelvis shape.

Anthropoid: Is common in men and most common in non-white women

• Oval pelvic inlet and long sacrum

• Vaginal birth is typically successful with this shape

Describe the platypelloid pelvis shape.

Platypelloid: Flat pelvis

• Least common shape

• Oblong pelvic inlet and prominent sacrum

• Vaginal birth is not very successful with this shape

For the “passenger” part of labor, what is involved?

• Passenger: The fetus and placenta

Fetal Attitude

Fetal Lie

Fetal Presentation

Fetal Position

Fetal Station

What should you know about the fetal head during the passenger part of labor.

Fetal Head

• Suture lines/fontanelles of the fetal head allow the head to mold to fit through the pelvis and birth canal

• Molding “cone head”: The bones overlap, which is important in helping the infant navigate through the pelvis. It resolves within a few days.

• Engagement: Is the fetal head dropping and “locking” into the pelvis. This is prevented with malposition of the fetal presentation (so abnormal fetal station)

What should you know about the fetal attitude during the passenger part of labor.

Preferred: Chin to chest with back rounded so smallest diameter of head fits into the pelvis

What should you know about the fetal lie during the passenger part of labor.

Fetal Lie: Long axis of fetus and how it correlates to the long axis of the mother

• Longitudinal: up & down in line with maternal spine

• Transverse: laying side-ways

What is fetal presentation during the passenger part of labor? List the types of fetal presentation.

Fetal presentation: Body part that can be felt in/near the pelvis

Types

1. Cephalic

2. Frank breech

3. Complete breech

4. Single footling

5. Double footling

What is fetal position during the passenger part of labor? What is the most preferred position?

Fetal position: Which position of the maternal pelvis is the fetal occiput facing

• LOA most preferable presenting position for labor, followed by ROA

What is fetal station during the passenger part of labor?

Fetal Station: How high or low baby is in the pelvis

Engagement:

• The fetus is engaged in the pelvis when the presenting part is at 0 station

• Negative is high, which means it’s harder to reach baby through the birth canal

• Positive is low, which means it’s much easier to reach baby; +3 & +4 is visible at the opening of the vagina, also called crowning

Describe cephalic fetal presentation

• Types: Vertex, military, face, shoulder

• Full flexion is chin to chest (vertex presentation) MOST preferred

• Moderate flexion is looking straight ahead (military presentation)

• Poor flexion, also called partial or complete extension is head hyperextended (face or brow presentation)

List the cardinal movements of labor

1. Engagement

2. Descent

3. Flexion

4. Internal Rotation

5. Extension

6. External Rotation (Restitution)

7. Expulsion

What is the “power” part of labor, and how do we monitor it?

Power of labor = uterine contractions

1. External: TOCO or MONICA

2. Internal: IUPC

3. Palpation: mild, moderate, strong

Regarding uterine contractions, how are they described?

• Frequency: how often

• Duration: how long

• Intensity: how strong

Differentiate false and true contractions.

What is the job of contractions during labor? Why is this important?

• The job of contractions is to push the baby downward and apply pressure to the cervix, allowing it to open and the baby to move through the birth canal

• An effective contraction pattern is very important for labor progression

How are vaginal exams performed during labor? What is measured?

• Vaginal exams are performed using a sterile glove and water-soluble jelly

We measure 3 things:

1. Dilation: Opening or enlargement of the external cervical os

2. Effacement: Thinning of the cervix

3. Fetal Station: Location of presenting part in relation to the ischial spines

What are the 3 phases of dilation during stage 1 of labor?

1. Latent: 0-5 cms

2. Active: 6-7 cms

3. Transition: 8-10 cms

How is effacement during stage 1 of labor described?

• 0% is long & thick

• 100% is completely thinned out

What should be reviewed/completed by the nurse during stage 1 of labor?

1. Review records to identify risks and potential complications

2. Review birth plan

3. IV and consents for admission, lab work

4. Identify psychosocial needs

—>Religious, cultural needs, support system, etc.

5. Vaginal exams to determine labor progression

6. Interpret fetal monitor strips to identify reassuring or nonreassuring status

7. Educate patients on each step of the process; good communication skills!

8. Pain management & comfort measures

—>Repositioning helps with pain relief and aids baby in navigating the pelvis

—>Breathing techniques

9. Chart, chart, chart! OB is one of the most libelous fields of nursing

What should the nurse assess to get a read on fetal health during labor and birth?

1. Analysis of amniotic fluid

2. Analysis of the FHR

3. Umbilical cord analysis

What should the nurse assess regarding an analysis of amniotic fluid during labor and birth?

Use the Acronym COAT: COAT: Color, Odor, Amount, Time

1. Color

• Green: meconium

—>Could be from transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction (IUGR), maternal hypertension, diabetes, or chorioamnionitis

—>Watch for meconium aspiration syndrome

2. Odor

• Cloudy or foul-smelling indicates infection

3. Amount

• Small or large amount leaking

4. Time

• We want to know what time

• Longer ROM=higher risk of infection (chorioamnionitis)

5. When the water breaks:

• The nurse should immediately assess FHR for signs of distress

• Possible SVE

—>Limit SVE’s with ROM due to increased risk of infection

• Clean patient up

What should the nurse assess regarding an analysis of FHR during labor and birth?

• Monitoring can reduce the risk to fetus by identifying ominous signs of distress

—>Controversial topic

—>Monitor variability, accelarations/decelerations

• Doppler, External, Internal,

• Continuous vs Intermittent

What should the nurse assess regarding an analysis of the umbilical cord during labor and birth?

Analyze: Cord pH and Blood type/Coombs status

Cord pH

• Acid-base analysis “cord gas” evaluates hypoxemia and acidosis

—>Norm pH range is 7.14-7.4

• Fetal acidosis may lead to deficits, including cerebral palsy & seizures

Blood type/Coombs status

• Perform infant blood typing when mom is O or any negative blood type

—>Rh incompatibility

—>ABO incompatibility

• Perform Coombs done to determine if baby has developed antibodies from exposure to mom’s blood in utero

—>Indicates a higher risk for hyperbilirubinemia (jaundice) or anemia

What should be discussed regarding a patient’s birth plan?

1. Delivering location

2. Educational classes

3. Comfort measures/Pain management

4. Interventions

5. Infant care

When discussing a patient’s birth plan, what are the possible delivery locations?

1. Home birth

2. Hospital

3. Birth center

When discussing a patient’s birth plan, what educational classes are available?

1. Coping skills

2. Educates on pain management options

3. Changes the body goes through during pregnancy and labor

4. Educates patients so they can make a more informed decision and know their options during birth and labor

5. Educates on what to expect postpartum and with infant care

6. Breastfeeding support

When discussing a patient’s birth plan, what comfort measures should be discussed?

1. Pharmacologic vs Nonpharmacologic

2. Support system

—>Partner, family/friends, doula

When discussing a patient’s birth plan, what interventions should be discussed?

Interventions: Discuss with patient, and they will need to consent or decline

1. Induction of labor

2. Augmentation of labor

3. Artificial rupture of membranes

4. Forceps/Vacuum

When discussing a patient’s birth plan, what should be discussed regarding infant care?

1. Breast vs Bottle

2. Circumcision

3. Skin to skin

4. Declining medications

What pharmacological comfort measures are available for labor?

1. Epidural

2. Spinal (c-section)

3. General (only if unable to place spinal)

4. Opioids

5. Pudendal Block

6. Nitrous Oxide

What non-pharmacological comfort measures are available for labor?

1. TENS unit

2. Acupuncture/Acupressure/Reflexology

3. Hot/Cold therapy

4. Aromatherapy

5. Hydrotherapy

6. Hypnobirthing

7. Guided Imagery

8. Focal Point

9. Breathing Techniques

10. Positioning

11. Therapeutic touch/Massage/Effleurage

What factors cause pain in labor?

1. Physiological

2. Contractions, dilation, birth

3. Emotional

4. Fetal position

—>Occiput posterior “sunny-side up” babies tend to cause back labor

What emotional factors can influence pain perception during labor?

• Previous birth experiences can affect fear and anxiety, which can increase pain intensity

• Having a good support person present throughout the childbirth process reduces the need for pain relief and helps with coping skills

• Temperament affects pain management

• Trust in healthcare team is beneficial, too; makes the patient feel more at ease

—>ALWAYS communicate with your patients!!!

What are special considerations of labor for obese patients?

Obese patients are harder to position, harder to get epidural/spinal anesthesia due to body habitus

What are special considerations of labor for substance addicted patients?

Those with addictions will become more anxious and less capable of coping as their craving hits

What are special cultural considerations of labor for obese patients?

Culture plays a part in coping, acceptance of pharmacologic options, comfort with using male providers, and specific birth practices

List risks for the use of epidurals and spinals (used for c-sections) during labor.

1. Swift drop in BP

2. Numbing too high, leading to respiratory depression

3. Spinal headache

4. Nausea/Vomiting

5. Allergic reaction

What is a last resort for pain management during labor? Why?

General anesthesia is an absolute last resort

• Crosses over and depresses infant

• Aspiration of vomit and stomach contents

• Intubation

What should the nurse promote during labor?

1. Promote movement

2. Promote regular voiding

How can movement help during labor? List examples of movements that can aid labor.

Changing positions during labor can shift the pelvic diameter and allow baby to navigate it better

Example Movements:

1. Squatting

2. Hands & knees

3. Standing/Dancing

4. Side-lying

5. Peanut ball

6. Birth ball

7. Birth bar

8. Spinning Babies

What does the mother’s psychological state affect?

1. Self-confidence

2. Self-esteem

3. View of life

4. Relationships

5. Other children

How can a negative psych state affect a woman’s pregnancy? How can this be managed?

• Anxiety and fear can decrease a woman’s ability to cope with pain and can inhibit uterine blood flow and placental perfusion

• Empower patient to be involved in her care

List factors that promote a positive birth experience for the patient

1. Clear information about the procedure (vaginal birth, C/S, etc.)

2. Support

3. Sense of accomplishment

4. Trust in caregivers

5. Positive reaction to the pregnancy

6. Personal control over breathing

7. Preparation for the childbirth experience

What is the 2nd stage of labor?

• It’s GO time

• Dilated 10cms until birth

What is nursing care for the 2nd stage of labor focused on? List nursing interventions for this stage.

Focus:

• Nursing care during this phase is focusing on supporting the woman and her support person

Nursing Interventions:

1. Clear communication, laboring down, guidance with pushing and positions for pushing

2. Monitor for Tears: Rated 1st-4th

3. Episiotomy

4. Continue fetal and maternal monitoring

5. Continue efforts to support mother with pain and anxiety

6. Prepare for birth and newborn support

What is the 3rd stage of labor? What occurs during this stage? What hormones control this stage of labor and how?

3rd stage of labor: Birth to delivery of the placenta

1. Strong uterine contractions continue

2. Placenta begins detaching from the uterine wall and is expelled

• Signs of detachment include a change in the uterine shape to globular ovoid and a sudden gush of dark blood

• May require manual extraction

3 Hormones:

1. Oxytocin: Contractions

2. Endorphins: happy, excited

3. Adrenaline: increases during pushing and decreases after delivery

What does nursing care of the 3rd stage of labor focus on?

Nursing care includes:

1. Focusing on documenting birth

2. Time of placental delivery

3. Monitoring postpartum bleeding

What is the 4th stage of labor? List nursing care for this stage

4th Stage: Postpartum period, including mother bonding with baby

Nursing Care:

1. Assist with breastfeeding/bonding

2. Monitor VS of mother and infant

3. Monitor blood loss of mother/for signs of postpartum hemorrhage

• Fundal rubs on schedule

• Administering Oxytocin, Cytotec, Methergine, Hemabate, etc. to control PP bleeding

3. Ice packs to the perineum

4. Warm blankets for shivering from adrenaline decreasing

5. Clean up post-delivery

Define bradycardia in FHR monitoring.

A sustained FHR less than 110 bpm for greater than 10 minutes

Define tachycardia in FHR monitoring.

A sustained FHR greater than 160 bpm for greater than 10 minutes

Define baseline in FHR monitoring.

The average FHR during a 10-minute segment, excluding periodic or episodic changes

Define variability in FHR monitoring.

The beat-to-beat fluctuations in the FHR

Define an acceleration in FHR monitoring.

Abrupt increase in FHR, onset to peak <30 sec, <2 min duration

Define an early deceleration in FHR monitoring.

Gradual decrease beginning with contraction and ending with contraction

Define a variable deceleration in FHR monitoring.

Abrupt decrease >15 bpm with abrupt return to baseline

Define a late deceleration in FHR monitoring.

Gradual decrease starting after contraction begins and returning after contraction ends

A nursing instructor is teaching about non-pharmacological techniques used for pain relief in labor. What are some techniques that the nurse would include in the teaching?

Some techniques to use for relief of pain during labor besides medications are relaxation, controlled breathing, effleurage, focusing, and imagery

The nurse is caring for a client in early labor with 3 cm cervical dilation. Which statement will the nurse use when teaching the client consciously controlled breathing during contractions at this stage of labor?

“Take slow, deep, full breaths.”

A nurse is discussing the benefits of childbirth education courses to a client who recently learned that they are pregnant. What are generally accepted as benefits of such classes?

• Preparation courses can increase satisfaction, reduce the amount of reported pain, decrease risky behaviors such as smoking, and increase feelings of control during childbirth

• It is documented that by attendance in discussion of breastfeeding, the proportion of new parents who breastfeed can be increased

The nurse is leading a prenatal education class for a group of pregnant clients in the third trimester. What should the nurse include in this education?

• Third-trimester classes are primarily focused on preparation for labor and birth

• Signs of labor, pain management in labor, and warning signs of complications in late pregnancy are all important education topics

Regional anesthesia is usually administered in advance of a cesarean birth. List the characteristics of spinal anesthesia.

Regional anesthesia is usually administered in advance of a cesarean birth. List the characteristics of epidural anesthesia.

What anesthesia has the highest risk of aspiration pneumonia (when you inhale food, stomach acid, or saliva into your lungs, causing pneumonia)?

General anesthesia

During a cesarean birth, the surgeon can use either a classical or a low transverse incision to enter the uterus and deliver the baby. Identify the characteristics of a classical incision.

1. Higher incidence of uterine rupture

2. Less blood loss

During a cesarean birth, the surgeon can use either a classical or a low transverse incision to enter the uterus and deliver the baby. Identify the characteristics of a low transverse incision.

1. Potential for bladder injury

2. Better healing of the uterine incision

What are the indications for a cesarean birth for a patient with spontaneous onset of labor at full-term gestation?

Fetal distress and failed descent

Which side effects are commonly associated with epidural anesthesia?

1. Nausea

2. Shivering

3. SOB

During a cesarean birth, the circulating nurse is responsible for the instrument count. When is the instrument count performed?

1) As soon as skin closure is initiated

2) Prior to the skin incision

3) When closure of the peritoneum is initiated.

What are the reasons for early ambulation following a cesarean birth?

1) To promote passage of flatus

2) To promote lung expansion

3) To prevent blood clots

Which type of uterine incision has the lowest risk for rupture during a trial of labor in a subsequent pregnancy?

Low transverse

A cesarean birth is scheduled or planned in situations where labor and vaginal birth are contraindicated. Which conditions are contraindications to labor and a vaginal birth?

1. Active genital herpes

2. Complete placenta previa

There are four stages of labor: dilation, birth, placental, and recovery. The first stage is the longest and is divided into the latent and active phases.

Identify characteristics associated with the latent phase of labor.

1. Mother is talkative

2. Mother prefers to ambulate or sit

3. Mother is an active participant in care

4. The intensity of contractions is mild to moderate

There are four stages of labor: dilation, birth, placental, and recovery. The first stage is the longest and is divided into the latent and active phases.

Identify characteristics associated with the active phase of labor.

1. Mother turns inward

2. Mother may prefer to lie down

3. Mother experiences feelings of less control

4. Mother prefers a quiet environment

What interventions are beneficial in the plan of care for patients anticipating a vaginal birth?

1. Continuous support during labor and birth

2. Delayed pushing in the second stage of labor

3. Universal screening for GBS at 35-37 weeks' gestation

4. Delayed admission to the hospital until the active phase of labor

List the cardinal movements of labor in the order in which they occur.

1) Engagement

2) Descent

3) Flexion

4) Internal rotation

5) Extension

6) Restitution

7)Expulsion

What is the correct technique to determine the strength of the contractions?

Palpate the uterine fundus during a contraction, noting the degree of firmness

How is the frequency of contractions determined?

The time from the beginning of one contraction until the beginning of the next contraction

The nurse teaches the patient to take a deep breath with each contraction and hold it for a count of 10, exhale, and repeat 3 to 4 times with each contraction. The nurse has taught the patient which pushing method?

Closed glottis pushing

During the third stage of labor, when is oxytocin administered?

After delivery of the placenta

What is the criterion for a prolonged third stage of labor?

Greater than 30 min