OB Exam 2

Ch 16,17,18,19,27

how are contractions described?

involuntary and intermittent

what is the period between the end of one contraction and the beginning of the next?

an interval or resting tone of the uterus

• time when most fetal exchange of oxygen, nutrients, and waste products occurs

what does intermittent contractions do for the fetus?

allows placental blood flow and exchange of oxygen, nutrients, and waste products between maternal and fetal circulation during the interval

what is the strongest part of the uterus?

the fundus; it contracts actively during labor as it pushes the fetus down

when is the best time to check vitals during labor?

in between contractions

what are the three phases of contractions?

1. increment: occurs as the contraction begins in the fundus and spreads throughout the uterus

2. peak: or acme is the period during which the contraction is most intense

3. decrement: the period of decreasing intensity as the uterus relaxes

what happens to your GI system during labor?

gastric motility is reduced; most women are not hungry, but are often thirsty or have dry mouth

• ice chips can be provided in small amounts

• popsicles, clears, or hard candy

what happens to your urinary system during labor?

decrease in sensing a full bladder because of intense contractions or the effects of an epidural

• foley catheter is usually inserted for pts. with an epidural

• after birth, urine is excreted in large quantities

what occurs to the hematopoietic system during labor?

WBCs increase; averages around14000-16000

• may go up to 25000 or higher (this level might suggest an infection)

during strong labor contractions, maternal blood supply stops intermittently, what protective mechanisms does the fetus have against this?

1. fetal hemoglobin

2. high hematocrit

3. high cardiac output

what is effacement?

the thinning and shortening of the cervix

what are the components of the birthing process?

powers, passage, passenger, psyche, and position

what are the two powers of labor?

uterine contractions and the maternal pushing efforts

what is the passage component of the birthing process?

the bony pelvis and soft tissue

• gynecoid and anthropoid

what is the best pelvic shape for vaginal birth?

gynecoid

what pelvic shapes are not favored in vaginal births?

platypelloid and android

why might c-section babies become tachypneic after birth?

they are not able to absorb the lung fluid like naturally born babies

what intensifies the absorption of fetal lung fluid?

labor

• thoracic compression during labor aids in the expulsion of additional fluids

what is the passenger component of the birthing process?

fetus and placenta

how are the bones of the fetal head connected?

by sutures composed of strong but flexible fibrous tissue and the wider spaces at the intersections of sutures are called fontanels

• these move together, slightly changing the shape of the head called molding

what is fetal lie?

the relationship to how the baby is lying compared to the mother’s spine

• longitudinal or parallel

• transverse

• oblique

what is longitudinal lie?

either the head or the buttocks of the fetus enters the pelvis first

• in more than 99% of pregnancies

what is transverse lie?

“right angle”

• the long axis of the fetus is at right angles to the woman’s long axis

• lying horizontal rather than vertical

what is an oblique lie?

at an angle between the longitudinal lie and transverse lie

what is fetal attitude?

the relation of fetal body parts to each other

what is normal fetal attitude?

one of flexion, with the head flexed toward the chest and the arms and legs flexed over the thorax

the back is curved in a convex C shape as labor starts

what is presentation of a fetus?

the fetal part that enters the pelvis first is the presenting part

• cephalic (most common)

• breech

• shoulder

what are the four variations to cephalic presentation?

vertex, military, brow, and face

what is the most common and favorable cephalic presentation?

vertex

• the fetal head is fully flexed

what are the three variations to breech presentation?

frank, full (complete), or footling

what is frank breech?

the most common, the fetal legs are extended across the abdomen towards the shoulder

what is complete breech?

reversal of the usual cephalic presentation

the head is flexed, and the knees and hips are also flexed, but the buttocks are presenting

what is footling breech?

occurs when one or both feet are presenting

what is shoulder presentation?

transverse lie

• body part may be shoulder, arm, or trunk

• c-section is necessary

what is fetal position?

describes the location of a fixed reference point on the presenting part in relation to the four quadrants of the maternal pelvis

• position is not fixed but rather changes during labor as the fetus moves downward and adapts to the pelvic contours

what are the four quadrants of the maternal pelvis?

right and left posterior and right and left anterior

what does the first letter of the abbreviation refer to?

whether the fetal reference point is in the right or the left of the mother’s pelvis

• right R or left L

• if fetal point is neither, the letter is omitted

what does the second letter of the abbreviation refer to?

the fixed fetal reference point, which varies with the presentation

• occiput O- used in vertex presentation

• chin or mentum M- used in face presentation

• sacrum S- used in breech presentation

• fronto F or scapula Sc- for brow presentation

what does the third letter of the abbreviation refer to?

the fetal reference point is in the anterior or the posterior quadrant of the mother’s pelvis

• anterior A

• posterior P

• transverse T

what is the psyche component of the birthing process?

the mother’s mindset

• very important because marked anxiety, fear, or fatigue decreases a woman’s ability cope with pain labor

• mother should be relaxed

what do maternal catecholamines do?

they are secreted in response to anxiety or fear

• causes the inhibition of uterine contractility and placental blood flow

what is the position component of the birthing process?

the position of the mother that should allow for the pelvis to stay open

• use a peanut ball

• creative positioning

what are the premonitory signs that labor is near?

• braxton hicks contractions

• lightening

• increases in clear and nonirritating vaginal secretions

• “bloody show”

• energy spurt (nesting)

• small weight loss

what happens to the mother’s hormones during labor?

estrogen increases while progesterone decreases

• oxytocin receptors in the uterus increase

what are braxton hicks contractions?

irregular mild contractions that occur throughout pregnancy increase in frequency and are sometimes painful

what is lightening?

“dropping”

the fetus descends toward the pelvic inlet

• most noticeable in first time mothers (nulliparous)

what is “bloody show”?

a mixture of thick mucus and pink or dark brown blood

• this may occur as the cervix begins to soften, dilate, and efface slightly (ripening)

how much weight can a women lose before labor?

small weight such as 1-3 lbs

what is the true difference between true and false labor?

true labor has progressive changes in the cervix (dilation and effacement)

how is false labor described?

also called prodromal labor; contractions are inconsistent in frequency, duration, and intensity

• change in activity does not alter contractions

• felt in the abdomen and groin, more annoying than painful

• no significant changes in cervix

how is true labor described?

contractions are consistent pattern of increasing intensity, duration, and frequency; walking increases the intensity

• discomfort begins in the low back and wraps around the abdomen

• the cervix will dilate and efface

what is another name for the mechanisms of labor?

cardinal movements

what does station mean?

describes the descent of the fetal presenting part in relation to the level of the ischial spines

• the level of the ischial spines is zero station

• as the fetus descends it will go from high negatives numbers (-3, -2, -1) to zero to high positive numbers (+1, +2, +3)

how many stages of labor are there?

four

what is the first stage of labor?

three phases: latent, active, and transition

• also known as stage of dilation and longest stage

• begins with onset of contractions and ends with complete dilation (10 cm) and effacement of (100%)

what is the latent (early) phase of the first stage of labor?

lasts from the beginning of labor until 0-3 cm of cervical dilation (varies among women)

• best time to educate the women while she is calm and excited

what is the active phsse of the first stage of labor?

the cervix dilates more rapidly between 4-6 cm (dilation and effacement is complete)

what is the transition phase of the first stage of labor?

used to describe the intense contractions of fetal descent and final cervical dilation, approximately 7 or 8 cm to complete

• short but intense

when does bloody show increase?

with the completion of cervical dilation

what is a Friedman curve used for?

identify whether a woman’s cervical dilation is progressing at the expected rate

what is the second stage of labor?

expulsion begins with complete (10 cm) dilation and full (100%) effacement of the cervix and ends with birth of the baby

• mother may say she needs to have a BM or “the baby’s coming”

what is the third stage of labor?

placental stage; begins with the birth of the baby and ends with expulsion of the placenta

• expelled in two ways: Schultze or Duncan

the placenta should be delivered within how many minutes?

30 mins

what is the Schultze mechanism?

expelled with the shiny, fetal side first

what is the Duncan mechanism?

less common, with the rough maternal side presenting

what should occur with the uterus after birth?

it must contract firmly and remain contracted after the placenta is expelled to compress open vessels

• can result in in hemorrhage with inadequate uterine contraction

• make sure to check the fundus every hour after birth for any abnormalities!

what are 4 signs that suggest placenta separation?

• The uterus has a spherical shape.

• The uterus rises upward in the abdomen as the placenta descends into the vagina and pushes the fundus upward.

• The cord descends further from the vagina.

• A gush of blood appears as blood trapped behind the placenta is released.

what is the fourth stage of labor?

stage of physical recovery for the mother and infant

• lasts from the delivery of the placenta through the first 1-4 hours after birth

what is lochia rubra?

vaginal drainage during the 4th stage, usually blood (may have clots)

what can be done for discomfort in the 4th stage of labor?

discomfort usually from birth trauma or afterpains

• ice packs on the perineum limit discomfort and hematoma formation

what are the 4 reasons a women should be informed to go to the hospital?

• contractions

• ruptured membranes

• bleeding

• decreased fetal movement

how can you promote early family attachment after birth?

skin to skin contact for the first hour after birth

what can excessive pain cause physiologically?

• increase in metabolic rate and oxygen demand

• increase in production of catecholamines, cortisol, and glucagon

• les oxygen/waste exchange for fetus

what can excessive pain cause psychologically?

• difficulty interacting with infant

• unpleasant memories

• partner may feel inadequate

what are the two types of physical pain?

• visceral pain

• somatic pain

what is visceral pain?

described as throbbing, is related to initially the contractions of the uterus and dilation and stretching of the cervix

what is somatic pain?

described as sharp and localized, is directly related to the stretching of the perineal tissue and adjacent structures

what are the sources of pain with childbirth?

• tissue ischemia

• cervical dilation

• pressure and pulling on pelvic structures

• distention of the vagina and perineum

how can medicating a pregnant women affect her pregnancy?

• any drug will affect the baby

• drugs may have effects in pregnancy they wouldn’t have in a non pregnant person

• drugs can affect the course and length of labor

how does an analgesic affect a fetus?

decreases FHR variability

what are the cardiovascular changes in medicating a pregnant women?

cardiac output increase, which indirect affects hepatic and renal blood flow

what are the changes respiratory in medicating a pregnant women?

a full uterus reduces her respiratory capacity

• she will breath more rapidly and deeply

• more vulnerable to reduced arterial oxygenation

what should you watch for when giving narcotics for pain?

respiratory depression in the neonate

what are the GI changes in medicating a pregnant women?

stomach in displaced upward by her large uterus; the stomach’s interior also has a higher pressure

• decrease in gastrointestinal absorption of any oral medications

what are the nervous system changes in medicating a pregnant women?

circulating levels of endorphins and enkephalins, morphinelike natural analgesics, are high

• reduce requirements for analgesics

what problems may arise with other substances used for pain?

• women who use therapeutic or botanical agents may have fewer options due to interactions between these substances and analgesics

• women who have abused substances will also have fewer options

what are the disadvantages to regional pain management?

• maternal hypotension

• bladder distention

• migration of epidural catheter

• fever

• N/V

• pruritis

how should Benadryl be given?

slow IV push

• given for pruritis with epidural opioids

what can cloud, yellowish, foul odor amniotic fluid indicate?

chorioamnionitis

what is regional anesthesia?

comfort for 1st stage of labor, but doesn’t provide comfort for 2nd stage

• does not effect sensory or labor motor function

what is a pudendal block?

anesthetizes the lower vagina and part of the perineum to provide anesthesia for an episiotomy and vaginal birth

• second stage of labor right before delivery

what is local infiltration anesthesia?

infiltration of the perineum with a local anesthetic

• for episiotomy/lacerations

what is an epidural block?

local anesthetic in epidural space

• can cause slow labor, vasodilation, and hypotension

what actions should you take before giving an epidural?

• informed consent

• maternal VS, FHR before, during, and after

• assess bladder frequently

• IV bolus to reduce hypotension

what may happen if a dura is unintentionally punctured?

substantial leakage of CSF, which may result in a spinal headache

what can you do to relieve a spinal headache?

lowering HOB, lying flat, and hydration

• if those don’t work, anesthesiologist can perform a blood batch where 10-20 ml of moms blood is removed and injects her own blood back into the epidural space

  • this will clot and plug the hole in the dura to stop the leakage of CSF

what is a combined spinal-epidural?

injection of an opioid analgesic into the intrathecal space provided labor pain management w/ out sedation

what is a subarachnoid (spinal)block?

local anesthetic combined w/ opioid (fentanyl) in the subarachnoid space

• lose sensory and motor function

• bladder must be assessed frequently

• may need to use intermittent catheter

• s/s may include N/V, respiratory depression, and itching

what is duramorph?

type of subarachnoid (spinal) block

• commonly used for spinal block for c sections

• pain relief for 24 hours but the itching can be intense for 24 hours

  • pts. may scratch face and nose so much skin it rubs off

what is nitrous oxide?

inhalant via face mask in a mixture w/ 50% O2 - must be self administrated

• cleared from body through lungs, so there is minimal risk of overdose

• s/s: dizziness, N/V, and dysphoria