Reproductive Health Exam 2

order of birth

engagement- descent- flexion- extension- external rotation- restitution- expulsion

fetal position maternal

right anterior, left anterior, right posterior, left posterior

the direction the baby's head (occiput) is facing relative to the mother's pelvis.

Anterior: The baby's head is facing the mother's back (towards the sacrum).

Posterior: The baby's head is facing the mother's abdomen (towards the pubic bone).

Left/Right: Refers to the side of the mother's pelvis where the baby's head is located. Left Occiput Anterior (LOA): The baby's head is down, facing the mother's back, and slightly rotated to the left. Right Occiput Anterior (ROA): The baby's head is down, facing the mother's back, and slightly rotated to the right. Left Occiput Posterior (LOP): The baby's head is down, facing the mother's abdomen, and slightly rotated to the left. Right Occiput Posterior (ROP): The baby's head is down, facing the mother's abdomen, and slightly rotated to the right.

fetus presentation

4 quadrants:

vertex: occiput

face: mementum

breech: sacrum

Shoulder: acromiom

ideal fetal position

left occiput anterior

if baby's position needs changed

have mom change positions

5 factors essential for a successful vaginal birth

power, passage, passenger, psyche, position

power

contraction frequency, duration, intensity affect power

pirmary: involuntary contractions leading to dilation and effacement

secondary: voluntary pushing

oxytocin best thing to promote contractions

passage

bony pelvis and soft tissue of the cervix

station of the baby

types of pelvis will affect this

gynecoid pelvis

most favorable pelvis for successful labor.

platypelloid pelvis

pelvis that is flat in its dimensions with a very narrow anterior-posterior diameter and a wide transverse diameter; this shape makes it extremely difficult for the fetus to pass through the bony pelvis

android pelvis

the typical male pelvis; in the woman, the heart shape of the android pelvis is not favorable to a vaginal delivery

anthropoid pelvis

oval shaped, with a wider anteroposterior diameter

passenger

fetal skull shape and size

fontanels are used to identify poisition

fetal attitude: head should be tucked onto chin

fetal lie: should be longitudinal (in relation to mom's spine)

cephalic, breech, or transverse

fetal position

fetal size

psyche

stress and anxiety can cause long labor

position

***avoid supine

upright is good

contractions are best felt at the

fundus

increment phase of contractions

period of increasing strength. longest phase, begins in fundus and spreads through uterus

acme peak of contractions

peak intensity, shortest phase

decrement phase of contractions

relaxation

order of contraction phases

increment- acme- decrement

purpose of vaginal exams

determines dilation, effacement, station

**risk of infection

station of baby

-4 still floating, -3, -2, -1 above pubic symphysis, 0 head is engaged, 1, 2, 3, 4- out.

**IF CERVIX IS DILATING BABY SHOULD BE MOVING DOWN.

signs of impending labor

lightening: fetus descending into pelvis 2 weeks before labor. leads to easier rr, increased urination

braxton hicks, cervical effacemnent, loss of mucous plug, hormone changes, oxytocin, prostaglandin

fetal triggers that lead to birth

fetal cortisol changes, placenta aging, prostaglandins in baby

true labor

regular contraction, increase in frequency and intensity. changes in dilation and effacement

**GO TO HOSPITAL WHEN CONTRACTIONS ARE 5 MINUTES APART, LAST 60 SECONDS, AND ARE REGULAR FOR 1 HOUR

false labor

Irregular contractions without cervical changes.

amnisure ROM test

confirms rupture, very accurate, swab in vaginal canal tests ph

risks r/t c section

PLACENTA ACCRETA IS BIGGEST WITH REPEAT C SECTION

hemmorrahge, VTE, death, newborn respiratory issues, alteration to gut microbiome in newborn

emergent c section

prolapsed cord, rupture of uterus, abnormal FHR patterns

urgent c section

fetal malrepresentation, placenta previa with mild bleeding

non urgent c section

related to complications such as failture to progress and failture to descend

operative vaginal delivery

with forceps or vaccum. use is declining

vaccuum is better

head must be engaged and cervix must be dilated

c section classification

scheduled vs unscheduled

arrest of labor and indeterminate FHR main reasons for unscheduled

1st stage arrest

under 6 cm dilated, membranes ruptured, over 4 hours of adequate contraction or over 6 hours of inadequate contractions

2nd stage arrrest

lack of continuing progress for nulliparious women

3 hours with anestethia or 2 hours without anestethia

fetal indications for c section

breech presentation, brow presentation, occiput transverse position, transverse lie, FHR decelerations/distress, shoulder dystocia, macrosomia

maternal indications for c section

failure to progress, hematologic dz, HIV, active HSV infection, Leiomyomas, eclampsia, placenta previa, post-term, pre-term, vasa previa, multiples, suspected macrosomia, previous uterine surgery, preclampsia, herpes (genital), impediment of labor or arrest of active labor

VBAC

risk of uterine rupture

must be done in a facility that can do a c section

60-80 percent success

induction indications

only when doing so would improve health of mom and baby

if over 41 weeks

risk of uterine rupture and premature seperation of placenta

conditions that must be met before induction

- fetus in longitudinal lie

- no supsected cephalopelvic disproportion

- vertex is engaged

- cervix is ripe and ready for birth

- EGA is at least 39 weeks

oxytocin

most common med for induction

onset of contractions 3-5 minutes after iv is started

continually monitor fhr

monitor fetal and mom response to it and titrate accordingly

TACHYSYSTOLE MOST CONCERNING SIDE EFFECT (can cause fetal hypoxemia and abnormal fhr

most concerning side effect of oxytocin

tachysytole

biggest risk with repeat c section

placenta accreta

cervical ripening

stripping of membranes, manually seperating

mechanical: when little to no effacement and pharm c/i. hydroscopic dilators, transcervial balloon dilators

pharm: when bishop score is under 6. cervidal, misoprostol, c/i if vbac, uterine scar

continue to monitor FHR

bishop score

A Bishop score assesses cervical readiness for labor induction by evaluating dilation, effacement, station, position, and consistency, with scores ranging from 0 to 13, where higher scores indicate a more favorable cervix.

0-1 cm: 0 points

2-3 cm: 1 point

4-5 cm: 2 points

>5 cm: 3 points

Effacement:

The thinning or shortening of the cervix, expressed as a percentage. 0-30%: 0 points 40-50%: 1 point 60-70%: 2 points >70%: 3 points

Station:

The position of the baby's head relative to the ischial spines of the pelvis. -3 to -1: 0 points 0: 1 point +1 to +2: 2 points +3: 3 points

Position:

The position of the cervix relative to the fetal head. Posterior: 0 points Middle or anterior: 1 point

Consistency:

The feel of the cervix on examination. Firm: 0 points Medium: 1 point Soft: 2 points

preciptous labor

labor that lasts less than three hours from the start of uterine contractions to birth

increased anxiety and pain

fetus at risk for hypoxia

carefully examine cervical changes, don't leave patient

amniotomy

artificial rom to augment labor

done by provider

FETAL HEAD MUST BE ENGAGED FIRST

risk for cord prolapse, infection, decels

monitor FHR, contractions, amniotitc fluid

risks with amniotomy

cord prolapse, infection, decels

cephalopelvic disproportion

size/shape/position of fetal head or shape of maternal pelvis prevents going through birthing canal

needs c section

labor dystocia

slow, abnormal progression of labor. leading indicator for c section

leading indicator for c section

labor dystocia

risk factors for labor dystocia

congenital uterine abnormalities, occiput posterior malposition of the fetus, maternal fatigue/dehydration, fear and exhaustion, analgesia and anesthesia early in labor

hypertonic uterus

uncordinated contractions, frequent, painful, ineffective. nulliparious women more likely to have. can lead to low birth weight

encourage rest

part of labor dystocia

hypotonic uterus

not strong enough contractions to dilate. indentiable even at acme phase of contractions. weaker and less frequent during active stage of labor. ambulate often.

fetal dysocia

fetus can't go through birth cancal

risk factors: macrosomia, malposition, twins, abnormalities

most effective position is occiput anterior with head flexed

causes facial bruising on fetus, maternal lacerations, neonatal asphyxia.

pelvic dystocia

small/inadequate pelvic shape

sucess of labor relies on relationship between fetal size, presentation, position, size and shape of pelvis, and quality of contractions

in order for labor to be sucessful what must be correct?

fetal size, presentation, position, size and shape of pelvis, and quality of contractions

what can shoulder dystocia do to the baby?

can cause compression of neck by the pelvis, anoxia, neurological injury, brachial plexus injury, clavical fracture, death

how to fix shoulder dystocia

mcroberts manuever

ensure bladder is empty, straight cath

dont let mom keep pushing

risks for shoulder dystocia

fetal macrosomia, dm, prolonged labor, increased maternal weight gain, previous shoulder dystocia

complications for the mom from shoulder dystocia

severe lacerations

pph

normal fhr

110-160

accerleration

increase in fhr by 15 bpm for 15 seconds or more, can be caused by maternal changes in position

INDICATE HEALTHY AND RESPONSIVE FETUS

decel

temporary decrease in fhr below baseline by 15 bpm

early decel

follows contraction patterns, sign of baby coming into pelvis and vagal response to head compression

not concerning

nadir of contractions and of decel match up

which decels are most concerning

Early decels are generally the most acceptable and typically require no intervention.

Variable decels can be acceptable if they are mild and intermittent but need monitoring.

Late decels are concerning and need prompt evaluation and intervention.

Prolonged decels are also worrisome and indicate the need for immediate assessment and intervention.

variable decel

v shape, means cord compression, could be due to baby or moms position

late decel

placental defiency, over 41 weeks, htn, ect

nadir of decel after nadir of contraction

WORST ONE

nursing interventions for variable decel

Reposition the mother: Move to lateral (side-lying) position to relieve cord compression. If not effective, try other positions like knee-chest or Trendelenburg.

Administer oxygen: 8-10 L/min via a non-rebreather mask.

Amnioinfusion (if ordered): Infuse warm saline into the uterus to cushion the cord (often used if repetitive and severe).

Discontinue oxytocin (Pitocin) if applicable: To reduce uterine contractions.

Increase IV fluids: To improve placental perfusion.

Notify the provider: If the decels are severe or recurrent.

nursing considerations for late decel

Reposition the mother: Move to a left lateral position to improve blood flow.

Administer oxygen: 8-10 L/min via a non-rebreather mask.

Stop oxytocin (Pitocin): To decrease uterine activity.

Increase IV fluids: To improve maternal blood volume and placental perfusion.

Administer a tocolytic if ordered: To decrease uterine activity.

Notify the provider immediately: Continuous late decels indicate fetal distress and may require delivery.

Prepare for emergency delivery: If the situation does not improve.

catogory 1 FHR tracing

normal, continue routine monitoring

category II FHR tracing

FHR factors indeterminate, continue to observe and reevualate

stage III FHR tracing

prompt evaulation needed. resolve situation. provide o2, change postion, ect

DUE TO ABNORMAL FHR TRACING

involution

return of uterus to prepregnancy state, takes 6-8 weeks

uterine atony

boggy uterus, uterus will not contract. do fundal massage first and empty bladder. also breastfeed to release oxytocin

if none of those work: manually provider will do bimanual uterine compression or enter a giant catheter into the uterus to compress

fundal massage

every 15 minutes after birth, use one hand to support pubic bone and the other to press down. risk for postpartum hemmorage is highest in the first hour so this is essential

empty bladder, lower hob

descent of the uterus

1 finger= 1 cm, descends 1 cm/day

immediately after birth it will be halfway between umbulicus and pubis symphysis, then will be palpated at level of uterus within one hour of birth

causes of PPH

tone, trauma, tissue, thrombosis

risks for PPH

multiple gestation, prior PPH, multiparada, placenta previa, placenta accreta, ecclampsia, hemmorrage, intrauterine fetal demise, increaseed amniotic fluid, induction, BASICALLY ANYTHING STRETCHING THE UTERUS AND TISSUE

measuring blood

1 gram= 1 ml of blood

warning signs for pph

low bp, high hr, low oxygen, dizziness, pale, oliguria, not a/o x 4

tone (PPH)

uterine atony.

trauma (PPH)

laceration. visible or cervical. presents as firm midline uterus, increased bleeding without clots, high hr, low bp

hematoma: ruptured blood vessel. usually happens at home. casued by forceps use or long labor. pressure, pain, swelling

tissue (PPH)

part of placenta left. PRIMARY CAUSE OF SECONDARY PPH

occurs after ggoing home. increased risk of endometritis

uterine tenderness, FEVER, abnormal discharge

thrombosis (PPH)

body breaking down clots faster then it can form them, depletes clotting factors. can be caused by HELLP, placental abruption, ecclampsia, hemmorage, intrauterine fetal demise

rubra

red bloody lochia, 1st 3 days

sebrosa

pink/brown, scant, days 4-10

alba

white/clear, scant, day 10

1st degree tear

vaginal mucosa

2nd degree tear

perineal muscles torn

3rd degree tear

anal sphincter torn

4th degree tear

rectum torn

REEDA Perineal assessment

Redness

Edema

Ecchymosis

Discharge

Approximation

*cold sitz baths for first 24 hours, then warm

use peri bottle after using restroom

topical anestesthia

scant bleeding

only when wiped, 1-2 inch stain

light bleeding

4 inch or less stain

moderate bleeding

under 6 inch stain

heavy bleeding

saturated pad in 1 hr or less

endometritis

infection of utuers, USUALLY DUE TO RETAINED PLACENTA

also can be caused by internal fetal monitoring

usually occurs after mom goes home

postpartum psychosis

alteration in perception of reality

very rare

hallucinations, disorganized speech, disorganized and bizzare behavior, can onset within a few days of birth

**highest risk if already bipolar

NEEDS HOSPITALIZED

postpartum blues

Seen early postpartum, peaks by day 5, resolves by 2 weeks usually

Emotional lability, crying for no reason

Requires no treatment, self-limiting

May feel fatigued, restless

Periods of sadness with periods of joy

*self resolving

*still able to care for self and baby

no minumum number of symptoms needed to diagnosis