OB Exam 1

umbilical Cord

AVA structure: two smaller arteries, one large vein

Crucial for assessing newborn health

Arteries: carry unoxygenated blood an waste products away from the fetus to the placenta

Vein: carries oxygenated, nutrient rich blood from the placenta to the fetus

Whartons jelly: gelatinous substance within the cord that protects the blood vessels from compression

placenta

Provides oxygen and nutrients and removes waste product from the baby’s blood

-mother side: 15-20 lobes (cotyledons) and affixes to uterine wall

-fetal side: site of umbilical insertion, covered by thin membrane

Amniotic Fluid

Protective liquid contained by amniotic sac

-temperature regulation: maintains a stable, warm environment

-mm and bone development: allows fetus to move freely which is essential for musculoskeletal growth

-protection & cushioning: shield fetus from external shock and prevents pressure on umbilical cord

-lung development: fetus breaths in amniotic fluid, vital for proper development

Amniotic fluid abnormalities

Indicates potential issues

Polyhydraminos: excess fluid

• can cause over distended uterus Leading to hypotonic labor

Oligohydraminos: deficiency

• lack in protection so increase risk for cord compression

True labor signs

-contractions get longer, stronger, closer together

-consistent pattern forms of contractions and are felt across entire abd

-contractions continue regardless of position changes

-cervix progressively dilate and thins

-5-1-1: contractions 5 min apart, last 1 minute, for at least 1 hour

False Labor signs

Braxton Hicks

-contractions are irregular (some strong some weak)

-no consistent pattern and contractions eventually fade away

-contractions stop with position change

-cervix does not change

Rest and Hydrate, re-evaluate if things change

5 Ps affecting labor

Passageway: birth canal consisting of pelvis and soft tissues

Passenger: fetus and placenta, consider their size, position and presentation

Powers: uterine contraction

Position: mothers positioning can influence comfort and progress

Psychological: mother emotional state

maternal Position

Frequent changes are encouraged

-helps get baby into ideal position for birth and helps mother cope with pain

-upright positions allow gravity to help baby descend

-avoid supine b/c decreases blood flow to baby and makes pelvic outlet smaller

-leaning arms on birthing ball, kneeling on all 4s, walking, side lying

Psychological response

Positive and supportive environment can facilitate labor progress

-supportive relationship with staff and partners

-safe secure environment

-self confidence

-education and birth plan prep

-sense of control over body

Stress will activate SNS, catholamines released integer with labor

Signs that labor may be near

-cervix begins to soften, dilate, efface (cervical ripening)

-lightening- baby and uterus dropping lower into pelvis allowing less pressure on diaphragm but more on bladder

-energy burst- urge to clean and organize, nesting instinct

-mucus plug passage

-Braxton hicks- bodies practice for real labor

Rupture of membranes (water breaking)

AROM: artificially done by provider to induce or augment labor (monitor fetal HR for distress)

SROM: spontaneous

PROM: premature; before labor starts

-protection barrier for baby is gone, increased risk of infection

Limit sterile vaginal exams to reduce risk of introducing bacteria

Assessing rupture of membranes

TACO used to assess maternal and fetal well being

T: time of rupture to help determine risk of infection over time

A: amount; large gush or slow trickle? Can provide clues on baby’s position

C: color should be clear; green or brown indicates meconium (stool) and sign of fetal distress

O: odor; should be odorless, if one present, sign of infection

Sterile Vaginal Exams

Assess progress of labor by checking dilation of cervix (0-10cm), effacement (thinning of cervix 0-100%) And station of how far down baby;s head s in pelvis (-5 - +5)

-risk of infection versus benefit of information

-placenta previa is a contraindication

Electronic Fetal Monitoring

Monitors fetal HR and frequency of contractions.

-continuously or intermittently

• standard EFM is two belts on abdomen

• Wireless EFM are waterproof and allow for more mobility

• Handheld Doppler EFM for intermittent fetal HR checks

This is a TOOL NOT REPLACEMENT of hands on assessment

Nursing interventions during labor

-build connection and rapport

-understand and respect culture needs

-support and advocate for pt decisions

-encourage hydration and regular voiding

-educate pt and support people

-suggest repositioning and ambulation

-assist with hygiene

-pain control meds and holistic

2nd stage of Labor

Pushing and birth stage

-beings with cervix 10cm dilated and 100% effaced (complete) and ends with birth of baby

-can last up to 3 hours or longer (longer for 1st time)

-pelvic phase is initial resting period (laboring down) As baby descends

-perineal phase is the active pushing with contractions

-emotions of mom are focuses and exhaustion, empowered and nervous

2nd stage interventions

-continue EFM and palpating contractions

-provide comfort through position changes, coaching, and encouragement

-hydration and voiding

-prep for delivery (supplies, provider, meds)

-continuous family support and updates

Positions:

squatting uses gravity to open and pain relief

All 4s relives back pressure and helps position baby head

Side lying reduces back pressure and improves blood flow

Lean on partner to reduce tension, increase comfort and relaxation

Fourth stage

Immediate recovery period, first 1-4 hours after birth

-Focus: recover, bond, monitor

-skin to skin and breast feeding

-Pitocin to help uterus contract and stop bleeding

C-section

Surgical procedure to deliver a baby through incisions in abd and uterus

Classic incision : vertical, not candidate or TOLAC

Low transverse inscision: horizontal

Reasons for a planned C-section

Breech/position of baby

Size of baby

Infections

Comorbidities

Mother cannot tolerate vaginal deliverY

Multiples

Post operative care for C-section

Assess and monitor mom and fetus:

• vitals and O2

• Pain and sedation

• Incision and healing

• I&O

Postpartum care

• fundus tone, height and postion

• Lochia- bleeding amount, color, clot presentation

• Hemorrhage

• Bonding and breastfeed

Recovery & prevention

• early ambulation and SCDs (DVT)

• Cough, deep breathing, reposition

• Advanced diet

• Remove foley

Complication signs:

• excessive bleeding and uterine atony

• Infection

• DVT/PE

• Ileus

• Urinary retention

TOLAC & VBAC

Trial of labor following a prior C-section And if the trial goes well then results in Vaginal birth after C-section

-not everyone qualifies

-evaluate uterine incision type, prior successful delivers and inter pregnancy intervals

-risk of uterine ruptures and fetal distress

-vertical uterine incision is a contraindication for labor induction or augmentation b/c the incision is where the highest strain is during contractions so uterus can tear open at that previous site

Contemporary trends in maternity care

-pts are more involved in their care through education and shared decision making

-midwifes and doulas

-birthing centers and home births in addition to hospital

-family centered care, childbirth is normal and healthy that affects entire family.

Maternal mortality disparities

1. African American highest mortality

2. American Indian/ Alaska native

3. White

4. Hispanic

Maternal mortality disparities by age

Significant increase with age, especially women over 40

Factors to reduce mortality rates

-use antibiotics to prevent and treat infections- germ theory

-advances in medical knowledge and surgical skills for managing labor and delivery

-establishment of dedicated maternity care facilities and routine prenatal checks

Preconception risk factors for adverse pregnancy outcomes

Smoking and alcohol

Lack of folic acid

obesity (HTN, DM)

Medications RX and OTC

Hep B, HIV/AIDS, rubella, STI’s

Preexisting medical conditions

Risks are greatest for embryo in first 2-8 weeks of pregnancy

Nutrition for pregnancy

Increase caloric needs in 2nd and 3rd tri

-need more protein and iron

-prenatal vitamins

-folic acid

Folic acid and iron

Both are needed to form new blood cells. For the expanded maternal blood volume and to prevent anemia

-Iron is essential for fetal growth and brain development

-folic acid is needed to prevent neural tube defects

Vaccinations recommended

Flu vaccine (at higher risk for severe illness and complications)

TDAP: 27-36 weeks to maximize passive antibody transfer to infant but can give anytime in pregnancy

Covid and RSV

CONSIDER: HEP B and Meningococcal

Cardiovascular changes

-Increase blood volume by 50%(2/3 plasma and 1/3 RBC) To perfuse uterus and placenta

-physiologic anemia b/c not much inc in RBC (Dec H&H)

-increase in CO and HR

-increase in clotting factors so increase risk of DVT

-WBC increase

-BP stays same as pre pregnancy BP unless medical complication

Respiratory changes

-increased O2 consumption b/c inc metabolism

-chest circumference increases so inc tidal volume

-inc RR and deeper

-increased vascularity due to estrogen

• causes inc in nose bleeds and congestion

Renal changes

-kidneys need to adapt to increase blood volume and increase maternal and fetal waste

-kidneys enlarge to handle workload

-increased GFR so meds can be excreted faster so check on dosage for therapeutic range

-increase in renal pelvis size so urine sits longer, causing increase risk of UTI and nephritis

Psychological affects

1st trimester: ambivalence and conflicting thoughts, excited and anxious and fearful for change. Introversion for safety of baby

2nd: acceptance of fetus and that fetus is separate being from mother

3rd: mood swings, excitement and preparation for baby, accepting body image and new role as parent

Introversion to focus in behaviors that are safe and healthy

Fundal height measurement

Done during Prenatal appointments to omit or uterine growth and fetal development

Measured in cm from top of pubic bone to fundus

From week 20-36 the measurement should correspond to week number

Warning signs needing follow up appointiment during prenatal care

Preterm (prior to 37w) labor signs

Vaginal bleeding

Ruptured membrane

Decreased fetal movement

HTN

Infections: UTI, BV

Gravid

The state of being pregnant

Gravida

Number of times being pregnant

Nullgravida- never been pregnant

Primigravida- pregnant 1 time

Multigrtavida- pregnant mult times

Para

number of times given birth after 2 weeks (twins = 1)

-primipara- primip- has had 1 birth after 20 w

Multipara-multip- has had multiple briths after 20w

G TPAL

G= number of pregnancies

T= number of term infants (38-42w)

P= number of preterm infants (20-37w)

A= number of abortion (spontaneous or medical) before 20w

L= number of living children

Fetal movement

1st tri- 6-8w movement begins bit too tiny to feel

2nd tri- 16-24w quickening; gentle flutters, bubbles or taps felt

3rd tri- 28w+ movement is stronger and larger, tracking daily kicks for fetal well being

Supine hypotension

The weight from fetus and uterus compresses the inferior vena cava and aorta causing decreased blood flow to fetus and placenta

Maternal discomforts

urine frequency

N/V

Backache

Leg cramps

Varicosities

Hemorrhoids

Constipation

Heartburn

Maternal discomfort tx

-pelvic floor exercises, empty bladder at full sensation, avoid caffeine to avoid urine stimulation

-sleep without interruptions

-healthy diet

-naps

-avoid an empty stomach

-six small meals

-avoid greasy fried foods

• heating pads the back

• Avoid sitting or standing in on postion for longer period of time

• Elevate legs.

• Walking daily for variscosities

Dilation

How open the cervix is

0-10

0-6cm latent/early phase

6-10cm active phase

Effacement

How thin the cervix is

0-100%

0-40% early

40-100% active

Station

How far down the baby’s head is in the pelvis

-5 - +5

In relation to the ischial spines

Floating/high: -5 to -1 head above the ischial spines

Engaged: 0

Widest diameter of metal head is at level of ischial spine

Deep descent: 1 to 5

Fetus head is past the spines in =to lower pelvis 4-5=crowning and imminent birth

4 Stages of labor

1: dilation and effacement

0-6cm 0-40%

Contractions every5-10 min 30-45s

2:pushing and birth of baby

6-10cm 40-100%

Contractions are 2-5min 45-60 min

3: delivery of placenta

4: immediate postpartum recovery and bonding

Reason for regular bladder emptying

Distended bladder can cause narrowing of passageway And can cause weak, ineffective Contractions (power)

Frequent voiding can help fix either of these “P”s

Emotional support importance

If mom is shredded, anxious, worried, this will activate the SNS which released catcholemines. These interfere with uterine powers and can lead to labor Dystonia

Cervical ripening

The process of the cervix beginning to soften, dilate, and efface

Can happen days or weeks before labor begins

Induction vs augmentation

Deliberate initial of uterine contraction prior to their. Spontaneous onset

Augmentation is to help move labor along/ aid the labor progress

Indications for induction

-Past the due date, placenta decreases function after 42w

-Intra uterine growth restriction, fetus is smaller than expected

-PROM (water breaks but contractions do not start )

-fetal demise

Maternal disease (preeclampsia, sz, maternal age)

Elective (must be 39 weeks)

Oxytocin induction

Pitocin is man made oxytocin

Stimulates uterine contractions

Start small and increase q30-45min

AROM

Hole poked in amniotic sack

Allows baby’s head to move down to crevices and increase pressure to progress labor

-can asessamnioic fluid and can insert internal fetal monitoring

-risk of infection, decreased amniotic fluid can lead to cord compressing or prolapse

Epidural

In epidural space between L3-4

Complications: hypotension, respiratory depression, N/V, fever, pruritus

-Fetal comps: fetal distress secondary to maternal hypotension

Nursing actions after epidural

Vital signs, fetal heart tones, dermatology, asses, dressing, position changes, intermittent straight cath

General anesthesia

For emergent C-section, or contraindication for other types of anesthesia

-anesthesia crosses BBB so birth of baby needs to be within 3-5min

Complications:

Inc. risk of hemorrhage; uterus is a sm and needs to clamp down post partum it cannot b/c mediation

Vomiting and aspiration

Fetal depression

Opioids and labor

Fentanyl can be given but will cross placenta during labor so avoid giving opioids within 1 hour of delivery

-can cause respiratory depression in laboring pt

Baseline fetal heart

110-160

Baseline HR value will change if new HR is consistent for 10 min

FHR Variability

Th irregular baseline fluctuations in the fetal heart rate

Moderate variability is optimal

Based off of the baseline HR

Absent variability

Amplitude range is not detectable

This is a bad sign, likely to go to c section

Minimal variability

Slight changes in amplitude from baseline

< 5bpm in fluctuation

-baby could be sleeping

-reposition or give mom juice to wake up baby

Moderate variability

The optimal amount of change

6-25 BPM changes from baseline

Marked variability

Unknown cause, can be bad

>25 bmp in fluctuation

Acceleration

This is an abrupt increase from baseline determined by at least 15 bpm lasting at least 15 seconds

-sign of baby moving and is doing well

15 by 15

Early Deceleration

This is not a bad sign, it is a benign issue

-This is fetal head compression from a contraction, the squeezing of fetal head causes the heart rate to drop.

-these will mirror contractions and be a gradual decrease in HR

Interventions: reassurance, nothing needed

Variable Deceleration

Umbilical cord compression

-an abrupt decrease in heart rate

-15bpm by 15 seconds

Interventions: change maternal position, lying on left side, fluids, administer O2, stop or decrease pit

Late Deceleration

Poor placenta perfusion

-a gradual decrease in HR after the start of contraction, return to baseline hr after end of contraction

-interventions: change maternal position, fluids, O2, stop pit

Contractions

Measuring the pressure of the uterus

Duration: how long one contraction is so start to end of 1 contraction

Frequency: how often are they happening so timing from the start of one contraction to the start of the next contraction