Maternal/Child Exam 1

FHR Pathophysiology

Fetal Factors

• fetal blood low

• autonomic nervous system

• acid/base balance

Maternal Factors

• oxygenation of mom

• maternal medications (cardiovascular, respiratory)

• uterine contractions

• maternal hormones (cortisol, catecholamines)

FHR Monitoring

Auscultation

EFM

Palpate

FHR Frequency

First Stage Labor

Onset of labor to 4 cm

• insufficient evidence to make recommendation, discretion of midwife or physicial

4 to 10 cm (complete dilation)

• every 15-30 mins

Second Stage Labor

Complete dilation (passive fetal descent)

• every 15 min

Complete dilation (active pushing)

• every 5-15 min

“The Strip”

• displays FHR, MHR, and contraction pattern

FHR: Leopold maneuvers

1. palpate the fundus

2. palpate sides of abdomen to determine location of fetal spine and extremities

3. area just above symphysis pubis to identify fetal presenting part

4. abdomen above pubic symphysis to determine engagement of fetal presenting part in maternal pelvis

The Monitor

can be used intermittent or continous

Internal Monitoring

Intrauterine pressure catheter (records uterine contractions) + fetal scalp electrode (records FHR)

EFM Interpretation

Differentiate tracings

Identify baseline

Identify accelerations

Identify decelerations

Categories of FHR

Category 1

• moderate variability

• early decelerations

• Accelerations

Category 2

• Minimal variability

Category 3

• recurrent

FHR Resuscitation

Accurate Tracing

• adjust monitor, reposition patient, look for patterns

Identify Stressor

• look for source of stress or lack of perfusion

Make Adjustments

• position, remove noxious stimulus, increase perfusion, increase O2 reassess

Intrauterine Resuscitation Actions & Reasoning

repositon patient (L lateral) - improves uteroplacental perfusion

administer O (10L via non-rebreather) - enhances fetal oxygenation

iv bolus - corrects maternal hypotension

discontinue oxytocin (pitocin)

tocolytics (e.g., terbutaline)

amnioinfusion

notify provider

GTPAL

Gravida (# of pregnancies)

Term (39 weeks)

Preterm (20-36 weeks)

Abortion

Living

Prenatal Care

Group B Streptococcus

• 36 to 37 weeks

• treated with antibiotics

Blood type and Rh factor

HIV

Hepatitis B surface antigen (HBsAg)

CBC

Rubella

STI screening

Chief Complaint/Signs of Labor

Lightening

Vaginal discharge

Nesting

Cervical change

Rupture of membranes

Vaginal Exam (VE)

Dilation (how many cm open the cervix is)

Effacement

Station

VE: Cervical Dilation & Effacement

Thinning or Retraction of the cervix into lower uterine segment

Decreasing length of cervix (2cm → mm)

Describes as a percentage (ex: 25%, 50%, 100%)

• primiparous: effacement precede dilation

• multiparous: occurs simultaneously

Amniotic Fluid/Membranes

Ruptured?

TACO - Time, Amount, Color, Odor

Clinical Assessment

FHR Nitrazine

Fern test

Immunoassay

Increased Vigilance For

Umbilical Cord Prolapse

• check FHR, look for cord, maternal position change, elevate fetal head

Infection

• check temp, GBS status & FHR (ROM > 12 hrs), limit caginal exams, administer antibiotics

Rapid Progression of Labor

• Prostaglandin release, increase strength and frequency of contractions, variable decelerations

Uterus & Fetus

Uterine Stretch

• mechanical distention

• sketch receptors

Fetal Signaling

• maturing HPA axis

• Cortisol surge

• Surfactant production

Placenta

• calcifications

• oxidation

Power

• uterine contractions

• maternal pushing effort

• positioning of client

• fatigue

• support

Passenger

• size and position of presenting part

• weight

• placental reserves

• fetal oxygenation

External Cephalic Version

a medical procedure where a doctor uses their hands on a pregnant person's belly to turn a breech baby (bottom or feet first) into a head-down position

Position of Passenger

Presentation (which part is coming first)

• cephalic

• breech

• shoulder

• compound

Position (presenting part to pelvis)

• identify denominator - occiput

• R or L

• Anterior or Posterior

Lie (spine to spine)

• longitudinal

• transverse

• oblique

Attitude (fetal head and spine)

• flexed (vertex)

• extended (face)

Passageway

• “birth canal”

• pelvis

• three levels

• soft tissues

4 types of pelvis

• gynecoid (most common)

• android (narrow shape)

• anthropoid (oval shape)

• platypelloid (least common)

Position

• static or still?

• semi fowlers and lithotomy

• upright

• lying down

• side lying

Birthing Stools

a low, backless, U-shaped seat designed to support upright, gravity-assisted positions like squatting or kneeling during labor and delivery; helps pelvis open and move naturally

Psyche

giving birth is a momentous event in a woman’s life, with the potential to strengthen her self-confidence and self-esteem in the long term

at least 1 in 10 women experience childbirth as negative, or even traumatic

Role of Oxytocin

reduces fear and pain, decreases physiological and psychological stress, promotes human social interactions

stress inhibits oxytocin secretion, leads to a dominance of SNS, leads to release of catecholamines, which can slow labor

rather than fight or flight, a woman can tend and befriend

Friedman Curve

a historical medical graph created in 1954 by Dr. Emmanuel Friedman to track the expected rate of cervical dilation during labor

Stage 1: Latent Phase

0-3 cm dilated, mild and irregular contractions every 5-20 mins lasting 30-45 secs

encourage walking, provide diversion

assess preparation for labor

• birth preferences

• comfort measures

explain hospital routines

• plan of care, visitor policies

void frequently, p.o. intake? IV access

Stage 1: Active Phase

4-7 cm dilated, regular moderate contractions q 3-5 min lasting 40-60 secs

teach coping strategies, breathing, experiment with carious comfort, positioning, light fluids/nourishment/IV management

Stage 1: Transition Phase

8-10 cm dilated, very strong contractions q 2-3 mins lasting 30-90 secs

remain with patient, breathing, confidence and empowerment, change positions, check bladder, discourage pushing (until FD)

Augmentation and Induction of Labor (IOL)

Indications

• inadequate uterine contractions (labor dystocia)

• prolonged latent or active labor phase

• arrest of cervical dilation or descent

• maternal or fetal issues requirng timely delivery

Common Methods

• amniotomy

• pitocin

• cervical ripening

• mechanical dilation

Amniotomy

• verify fetal engagement and position

• FHR

• VS

• prepare patient (empty bladder, positioning)

• gather equipment (sterile gloves, amnihook, absorbent pads)

• proivide comfort

• assess TACO

• continued assessment

Cardinal Movements of Labor

Engagement - fetal head reaches 0

Descent - fetal head continues to move down through maternal through pelvis

Neck flexion - chin to chest facilitate narrowest diameter through pelvis

Internal rotation - fetal head rotates internally to align occiput with maternal pubic bone (OA)

Extension - crowning occurs when head is visible and fetus begins to extend neck, moving occiput under pubic symphysis

External rotation - once head is birthed, it rotates back to align with fetal body position

Expulsion - shoulder facing pubic symphysis moves under bone and rest of body and umbilical cord follow simultaneously

APGAR

Appearance (skin color)

Pulse

Grimace (reflex irritability)

Activity (muscle tone)

Respiration

Newborn Temp Regulation

Evaporation - occurs when the newborn is wet

Conduction - occurs when a newborn comes into contact with a cold object

Convection - occurs when the newborn is in a cold environment

Radiation - occurs when the newborn is places near a cold object or environment, such as a crib next to a window

Lacerations

Perineal

Vaginal/urethral

Cervical

53% to 89% of vaginal births result in perineal laceration

Regional Anesthesia and Analgesia

Epidural analgesia

• gold standard

• continuous or intermittent

• bupivacaine

• quick onset

• last 90 to 120 mins

• cannot be titrated

• fewer effects than general anesthesia

Opioid Agonists

Morphine: 2-10 mg IV, Half-life: ~1.5 - 2 hr

Fentanyl: 25-100 mcg IV/IM, Parenteral half-life: ~3.6 hr

Hydromorphone (Diladid): 0.2 - 1 mg IV q 2-3 hr, PRN, Half-life: ~ 2-3 hr

Meperidine (Demerol): 50-100 mg IM or SQ q 1-3 hr for obstetrical analgesia

Half-life: ~ 2-5 hr

Opioid Agonist-Antagonists

Butorphano (Stadol): 1-2 mg IV or IM

Nalbuphine (Nubain): 10-20 mg IV, IM, SQ q 3-6 hr PRN, Half life: 5 hr

Opioid Antagonists

Naloxone (Narcan): OVERDOSE (0.4 - 2 mg IV), RESPIRATORY DEPRESSION (0.1 - 0.2 mg IV), Half life: 30-81 min

Local Anesthesia & Adjuvants

Pudendal block

Perineal infiltration

Nitrous oxide

• pros: non-invasive, works with breathing, short-lasting, minimal fetal risk, adjuvant

• cons: n/v, light-headedness, sore throat, diminished effectiveness