OB Exam 1 Study Guide (Labor and Delievery)

Station

Relationship of presenting part to the ischial spines of the maternal pelvis

+ or - number to describe how high or low the baby is to the pelvis

Level is “station ZERO”

"-” means above

“+” means below

Cervix

The cervix plays a significant role during pregnancy. It is the lower part of the uterus that connects to the vagina and undergoes various changes throughout pregnancy.

How do you note a cervical exam

dilation/effacement/engagement

Dilation

The opening and widening of the cervix

0-10 dilated

Effacement

Thickness or thinning of the cervix

0% - 100%

Attitude

Degree of flexion or extension

Leopold’s

A four-step process aids the nurse or provider in identifying the fetal lie, attitude, and position of the fetus to determine the best fetal monitor location

Best done before starting FHR assessment

BOW

Bag of water

What does the BOW do?

protect the baby
maintain baby's temperature
allow for the baby to move
nutrient exchange
infection barrier

When do you expect the BOW to break?

ANY TIME
it can break before or during birth, either naturally or by the MD

AROM

artificial rupture of membrane

*when the women's water breaks artificially, by the MD

*the baby's head must be engaged in order for the MD to break her membrane

*can be done to stimulate labor

*known as a amniotomy

How can AROM stimulate labor?

because when the women's water breaks, oxytocin is naturally released, which helps with uterine contractions

SROM

spontaneous rupture of membrane
*when the women's water breaks naturally, not from the MD

Amniotic fluid

A clear (or slightly yellowish) fluid that surrounds and protects the fetus during pregnancy

Presentation 

cephalic/vertex = head first
*the most common
transverse lie = acromion first
*laying sideways
*cannot deliver vaginally, needs C-section
complete breech = butt first, legs crossed
frank breech = butt first, body doubled
footling breech = foot/feet first

Position (Passenger)

relationship of the presenting part to the pelvis
*1st letter = maternal body (R or L)

*2nd letter = presenting part (O = occiput, S = sacrum, A = acromium/shoulder, B = brow)

*3rd letter = position of the presenting part (A = anterior, P = posterior, T = transverse)

2 stages of the first stage

latent phase
active phase

latent phase of 1st stage of labor

from onset to 5cm of dilation
UCs mild and infrequent but increasing to every 5-30 mins and lasting 30-45 seconds
menstrual cramp like feeling
women tend to be sociable excited and cooperative

active phase of 1st stage of labor

6-10 cms dilation
75% effacement
fetal station often "0"
duration of UCs 45-60 seconds
women begin less sociable and begin to turn inward, still cooperative, request analgesia

stage 1 of labor

dilation
*onset of true labor
*ends with complete dilation (10cm) and 100% effacement

nursing interventions for stage 1 labor

encourage frequent urination or urinary catheter
* Full bladder prevents fetal descent into birth canal
* Filled bladder is at risk for trauma/injury from fetal descent
monitor vaginal exams Q2h or PRN
monitor FHR and UC pattern
monitor fetal station and presentation
encourage deep breathing and relaxation

second stage of labor

complete dilation and effacement to delivery
can last 5 mins - 2 hours
average 20 mins for multip and 50 minutes for primip
mom feels urge to push with UCs
women regain control
tired but excited

nursing interventions for 2nd stage of labor

monitor FHR Q5-15 mins
monitor BP, pulse, and RR Q5-30 mins
monitor frequency and strength of UCs
evaluate pushing eefforts
assist in positioning
assist support person in being involved
provide ice chips
promote rest between UCs
note for shakiness or quivering
*from adrenaline, not coldness

delivery cares for stage 2 of labor

suction mouth and nose after baby's head is delivered
baby's face wiped with sterile gauze
deliver body by pulling down then up
keep baby at level of mom's heart
cord is cut when pulsating stops
*delayed cord clamping
APGAR score at 1 and 5 minutes after delivery

signs of placenta separation

uterus rises anteriorly and abdomen takes on an oval (globular) shape
small gush of blood precedes expulsion
cord lengthens
*This is bad if it happens during pregnancy

stage 4 of labor

fundus can be felt as a round ball the size of a grapefruit - midline initially half-way between symphysis pubis and umbilicus
*if uterus is deviated = bladder is full
placenta is delivered
monitor blood loss closely
cleanse perineum and apply pads
clean, dry gown and linens
initiate skin to skin and breastfeeding ASAP
provide privacy for hour of bonding

how often do you do VS and final massage after birth

Q15 mins x 8
Q30 mins x 2
Q1 hr x 2
MD order

what do you do if the fundus is boggy

administer oxytocin as ordered
*mom may be hemorhaging

APGAR

Must score a 7 or higher

APGAR: Activity

Muscle tone

Active - 2 points

Flexed arms and legs - 1 point

Absent - 0 points

APGAR: Pulse

Heart pulse

Over 100 bpm - 2 points

Below 100 bpm - 1 point

Absent - 0 points

APGAR: Grimace

Reflex irritability

Prompt to respond to stimulation - 2 points 

Minimal response to stimulation - 1 point

Floppy - 0 points

APGAR: Appearance

Color of skin

Pink - 2 points

Pink with blue extremities - 1 point

Blue and pale - 0 points

APGAR: Respiration

Breathing

Vigorous cry - 2 points

Slow and irregular - 1 point

Absent - 0 points

true labor signs

regular rhythmic UCs
UCs become closer together and stronger
usually start in lower back and radiate to abdomen
UCs don't stop with walking/relaxation
* UCs do not stop no matter what
cervix thins and dilates
blood show
fetus moves downward and engages in pelvis

false labor

irregular UCs
duration and intensity vary
UCs lessen with walking
UCs lessen with relaxation or position changes
minimal cervical change
no change in fetal position
pain usually in groin and abdomen
no bloody show
braxton hicks contractions

when should moms go to the hospital?

regular contractions q5 mins or closer
gush or leakage of bag of water
bright red vaginal bleeding - active bleeding
decreased or zero fetal movement - could be fetal demise

Expected newborn vital signs

Temp: 36.5 to 37.5 C (97.7 to 99.5

Bonding

Unidirectional, rapid, and facilitated or optimized by physical contact

Engrossment

term for dad bonding
look at baby
smile at baby
skin to skin
talk to baby
make positive statements about baby

Positive bonding behaviors

responding to the baby's needs
holding the baby
calling the baby by name

Thermoregulation

To help maintain the body’s stable level of heat despite changes

In pregnancy, the baby is held skin-skin to the mother’s body to keep it warm

4 ways of heat loss for newborns

convection
radiation
evaporation
conduction

convection

air currents

radiation

surfaces near body that are cooler than body
heat radiates out

evaporation

moisture is converted to vapor
*this is why we dry them immediately after birth

conduction

heat is transferred through touch
*ex: baby is touching cold surface

GTPAL: G

# of times pregnant

GTPAL: T

# of term deliveries (over 37 weeks)

GTPAL: P

# of preterm deliveries (20 - 37 weeks)

GTPAL: A

# of abortions or miscarriages (under 20 weeks)

GTPAL: L

# of living children

Naegel’s Rule

LMP (last menstrual period) minus 3 months plus 7 days

Provides EDD (estimated date of delivery)

Leopold’s Manuvers

determines the baby's position in the mom's uterus

what must you have the mom do before doing the Leopold's maneuver

void then lay on their back with knees slightly flexed

maneuver 1 in Leopold's maneuver

determines shape, size, consistency, and mobility of presenting part

maneuver 2 in Leopold's maneuver

determines fetal back and side 

maneuver 3 in Leopold's maneuver

determines what fetal part is lying above the pelvic inlet

maneuver 4 in Leopold's maneuver

determines the fetal attitude

what are the five P's of labor

power
passageway
passenger
psyche
position

powers of labor

contractions - 1st stage of labor, involuntary

dilation and fetal descent - active phase of 1st stage, involuntary

maternal pushing - 2nd stage, voluntary

contractions

involuntary smooth muscle contractions that efface and dilate the cervix

pushing

voluntary action to propel the fetus down through the pelvis

passageway of labor

bony pelvis
soft tissue - cervix vagina, vaginal opening, muscles, ligaments, & fascia

passenger of labor

the baby and the placenta

psyche of labor

anxiety

culture

great expectations

can increase pain perception and activate stress hormones which inhibit blood flow to the placenta

stress, tension, and anxiety can produce physiological changes that impair the progression of labor

what is rupture of membrane (ROM)?

when the membrane containing amniotic fluid and the baby ruptures
*aka their water breaks

tests to assess for rupture of membrane

1. nitrazine
2. ferning
3. amnisure

nitrazine test

pH paper that will turn blue if it comes in contact with amniotic fluid
*blood can also turn the paper blue
*if paper is blue = positive result

ferning test

A noninvasive test diagnostic test that analyzes vaginal secretions to identify the presence of amniotic fluid. When amniotic fluid dries on a microscope slide, it forms a distinctive fern-like crystalline pattern due to the crystallization of sodium chloride and proteins. This pattern is unique to amniotic fluid and helps differentiate it from other bodily fluids.

when you collect vaginal liquid then put it under the microscope, it should crystalize
*DO NOT use lubricant when collecting the vaginal fluid because the lubricant from the sample can ALSO crystalize, creating a false positive
*crystalizing = positive result

amnisure test

when you collect vaginal fluid and place it on a stick that detects amniotic fluid
* 2 pink lines = positive result
* 1 pink like = negative result

when a women's water breaks what complications should you look for?

cord prolapse
infection

what is a cord prolapse

when the baby's umbilical cord comes through the birth canal before the baby does

why would ROM cause infection?

if a women's water is broken for a long time, bacteria from the vaginal canal can travel up to the uterus, which was previously protected by the amniotic fluid's antibacterial characteristics

what is usually done for mothers with ROM and an increased risk of infection?

they are given broad spectrum antibiotics

PROM

ROM occurs prematurely - before uterine contractions begin

what is at risk with PROM?

Infection, if over 24 hours before delivery
cord prolapse and cord compression (because baby can compress cord due to gravity, etc)

PPROM

preterm premature rupture of membrane
ROM before 37 completed weeks of pregnancy

what are signs that mom is infected due to ROM?

abdominal tenderness
bad odor

how often should the nurse assess fetal heart rate after ROM

immediately after ROM and again 5 minutes later

what should the nurse note after ROM

the color and odor of the fluid
*notify MD or CNM if meconium present

how often should the nurse monitor temperature after ROM

Q 1-2 hours / per hospital protocol

vaginal exams after ROM

should be LIMITED
Q2H