OB exam 2

What are the 3 ps of labor including the bonus

Psychosocial:

- people birth the right sized babies

- reassure, reaffirm, and normalize

- cortisol and oxytocin compete for receptors and disorganize labor

Passage

Power

Passenger

Fetal attitude

The relationship of fetal parts to one another

Normal:

- head flexion

- arms flexed onto chest

- legs flexed onto abdomen

Fetal lie

Relationship of baby's body to patients body

1. longitudinal: vertical

2. Transverse: horizontal

Fetal presentation

Fetal body part that presents into pelvis first

Cephalic: vertex, military, brow, face

Breech: complete, frank, footling

Shoulder: uncommon

Fetal position

relationship between maternal pelvis and fetal landmark

maternal pelvis:

- Right

- Left

Fetal landmarks

- vertex: occiput

- face: mentum

- breech: sacrum

- shoulder: acromion process

Position of Landmark in Pelvis:

- anterior: A

- posterior: P

- transverse: T

PASSANGER the leopolds maneuver

Goal:

Nursing priority:

Nursing care:

Goal: determine fetal attitude, lie, presentation

Nursing priority: placement of monitors

Care: lie on back with JOB elevated, ensure empty bladder

True vs False labor

True:

- cervical change

- contractions are at regular intervals, gradually shortening

- increased duration and intensity

- contractions do not slow down with rest or warm tub bath

False:

- no cervical change

- contractions are irregular

- hardening or balling up feeling without pain

- contractions slow with comfort measures

What are other signs of impending true labor

lightening

braxton hicks contractions increasing in frequency or pain

loss of mucus plug

bloody show

diarrhea, indigestion, N/V

"nesting" or sudden burst of energy

SVE

NO SVE with preterm labor, painless vaginal bleeding, or known placental previa

Exam in following format:

- dilation

- effacement

- station

Dilation

how wide cervical opening is measured in cm

Effacement

how long the cervix is from external os to internal os

Station

how low the fetus head is into the pelvis

measured in cm from ischial spine

Stages of labor

First Stage: Dilation

- begins with the onset of true labor and ends when the cervix is completely dilated at 10cm

Second stage: Baby

- begins with complete dilation and ends with birth of newborn

Third stage: Placenta

- begins after the birth of NB and ends with delivery of placenta

Fourth stage: Bleeding/Recovery

- begins with the delivery of placenta and lasts 1-4 hr during which the uterus contracts to control bleeding

Latent labor

1-5cm dilated

contractions increase in frequency and duration

mild-mod contraction intensity

FHR and contractions Q15-30min

BP Q hr

Temp Q4 hr if membranes not ruptured

Tempt Q1hr if ruptured

Encourage movement

Active labor

6-10cm dilated

increased bloody show

contractions Q2-5 min lasting 40-60 seconds

moderate-strong intensity

FHR Q15-30 min

BP hr

Temp 1-4hr

prepare for pain management

Transition stage

part of active labor

8-10cm dilated

increased bloody show

contractions Q1.5-2min lasting 60-90seconds

BP Q30min

ice ships

cool cloth

have emesis bag ready

have sterile table ready

prepare pain management

Second stage: active pushing/baby

BP Q 5-15 min

FHR and contractions Q5-15 min

stay in room

encouragement

instruct on effective pushing

ice chips

dry, stimulate, assess NB

APGAR scores at 1 and 5 min

Third stage: placenta

usually completed within 30 min after NB delivery

lessens surface area, detaches d/t uterine contractions

prepare to administer uterotonics

signs of placenta detachment

gush of blood

lengthening of umbilical cord

change in shape of uterus

Fourth stage: bleeding and recovery

- what sx do we expect

- physiologic readjustment of patients body from 0-4hr after birth

- normal blood loss is 250-500mL

- fundus is midline between umbilicus and symphysis pubis (LOW)

- shaking chills from hormone shift or epidural

BP Q5-15 min

fundal and lochia assessment

what factors are associated with a positive birth experience

planned pregnancy

education classes

empowerment

positive relationship with partner

support

not being left alone

trust in staff

communication

early success with breastfeeding

POWERS: spontaneous labor

1. brain stimulates pituitary gland to secrete oxytocin

2. oxytocin carried in blood to uterus

3. oxytocin stimulates uterine contractions and pushes baby toward cervix

4. head of baby pushes against cervix

5. nerve impulses from cervix transmitted to brain

Bishop score

used to determine cervix readiness for labor induction

if score

Induction methods

stripping of membranes

misoprostol

cervidil

catheters (transcervical, cook, foley bulb)

Childbirth education benefits

reduces anxiety, lowers stress, and lowers fear

proven to shorten labor

decreased need for pain meds

decreased need for interventions

empowers birthing person and partner

Non-pharmacologic pain management: Doulas

- emotional support: explain labor process and procedures

Non-pharmacologic pain management: patterned breathing

- oxygenates baby

- relaxes birthing person

Non-pharmacologic pain management: visualization

- re-frame current situation

- or take pt out of current situation (imagine sitting on a beach)

Non-pharmacologic pain management: hydrotherapy

decreases sensation of contractions

Non-pharmacologic pain management: therapeutic touch

hip squeeze, massage, effleurage

Non-pharmacologic pain management: TENS

blocks the c-fiber pain pathway of uterine contractions

Pain Medications: Fentanyl

- takes edge off but does not block pain

- can cause resp depression in newborn and decrease FHR

- pseudo-sinusoidal pattern

- antidote: narcan

- careful in pt with substance use disorder

Pain Medications: Nitrous oxide

- takes edge off

- must be self-administered and mask not strapped

- use at onset of contraction (peals at 30 seconds)

- does not impact baby breathing

SE: N/V, drowsiness, dizziness

Pain Medications: Continuous Lumbar Epidural (CLE)

- regional anesthesia

- not usually placed until active labor

- fewer adverse fetal effects

- temporary maternal hypotension

- decrease efforts of pushing

- catheter

CLE nursing care

- fluid bolus before placement d/t hypotension

- check platelets d/t coagulation concerns

- have pt bend back out like angry cat

- watch for itching

- void before placing

Pain Medications: Spinal block

Advantages and disadvantages

- placed in OR for non-emergent c-sections

- rapid onset

- allows for holding or breastfeeding at birth

- hypotension

- possible spinal headache

- one time dose, works for about 2 hours

Pain Medications: Pudendal block

- not commonly used because there is no visualization of pudendal nerve

- possible damage to broad ligament, perforation of rectum, trauma to sciatic nerve

- no systemic impact on patient or baby

Pain Medications: Local anesthesia

- common for vaginal laceration repairs

- no systemic impact

- requires large quantity and multiple injections

Pain Medications: General anesthesia

- emergency c-sections or special situations

- no memory

- increased blood loss d/t uterine relaxation

- intubation

- lower 1 minute APGAR

- possible aspiration

PASSENGER: FHR monitoring

Doppler

used in low risk births

listen before, during and after a contractions for 30 seconds

EFM interpretation: baseline

110-160, tells us oxygenation of fetus

EFM interpretation: variability

represents CNS function, best predictor of fetal compromise

- absent: undetectable change

- minimal: 1-5 bpm change

- moderate: 6-25 bpm change

- marked: >25 bpm change

EFM interpretation: accelerations

> or = 15 bpm increase from baseline for 15 seconds

EFM interpretation: Decelerations

Early: cord compression--> OK!

Late: placental insufficiency --> problem!

Variable: cord compression--> watch!

Deceleration patterns: consonants, vowels, sinusoidal

Consonants: periodic with contractions

Vowels: episodic independent of contractions

Sinusoidal: bad except if its pseudo-sinusoidal with fentanyl, then it is OK but monitor

POWERS: contractions

- frequency

- duration

- intensity

1. measured from beginning of one contraction to beginning of the next

2. measured from beginning to end of one contractions

3. nose=mild, chin=moderate, forehead=strong

When is POISONS implemented

category 2 and 3

if category 3 is not corrected, C/S needed

POISONS

Position change

Off pitocin

Increase fluids (bolus)

SVE

Oxygen

Notify provider

Stop labor (terb)

Cord prolapse presentation

- during SVE, pulsing of cord

- loop of cord visualized

- FHR prolonged, variable decelerations

- rapid fetal movement followed by cessation of movement

Cord prolapse nursing care

- SVE lifting head off cord until delivery complete

- pull emergency call light

- prepare for emergency delivery

- wrap cord in sterile saline soaked sponges/towels

- reposition

Shoulder dystocia

- shoulders stuck after the delivery of the head

- concern for lack of oxygen after head delivery

- not amount of time from head delivery to rest of body delivery

- assess for clavicle fracture and brachial plexus injury after delivery

maneuvers for shoulder dystocia

McRoberts: push knees up to chest

Suprapubic pressure: apply pressure to fetal anterior shoulder off pubic symphysis

Gaskin: hands and knees position

Intentional clavicle fracture

Zavanelli: flex head and push back into uterus and prepare for C-section

Retained placenta

- retained if delivery beyond 30 min after birth

- requires manual removal

- usually d/t uterus that fails to contract enough to expel the placenta

Laceration degrees

Vaginal:

1st degree: first layer around vaginal and perineal area

2nd degree: through skin and into muscular tissue of vagina

3rd degree: from vagina to anus: skin and muscular tissue of perineal area and damage to anal sphincter muscles

4th degree: from vagina into rectum

What is considered maternal death

death of a patient during pregnancy or within 42 days after

what is the 2023 US rate of maternal death and who have the highest risk of death

18.6

non-hispanic Black and non-hispanic Native Hawaiian and Pacific Islander are 2.5x more likely than non-hispanic White

non-hispanic American Indian and Alaska Native people 8.5x more likely

What was the trend of maternal mortality in US 2018-2023

in 2018 rate was "OK"

giant spike d/t covid

back down to a more reasonable number 2023

what is the relationship between advanced maternal age (AMA) and maternal mortality

increasing age of pregnant person has increased risk of death

Main causes of pregnancy-related death

infection

mental health conditions

CV conditions

hemorrhage

blood clots/embolis

AFE

HTN

what is severe maternal morbidity

unexpected outcomes of labor or delivery that have serious short or long-term health impacts

what is considered PPH

>1000mL loss

PPH risk factors

Hx of previous PPH

over distention of uterus

prolonged labor

precipitous labor (less than 3 hours from onset of contractions to birth)

grand multi-parity

placenta percreta, increta, accreta

infection

placenta issues

coagulation disorder

mag admin

S/S of PPH

- saturating a pad in less than 1 hour

- boggy fundus NOT responding to massage

- large clots

- high temp

- hematoma

- unusual pelvic discomfort or back ache

- trickle of blood with contracted uterus

- rise in level of fundus

- increases pulse or decreased BP

- decreased LOC

Early PPH causes- 4 Ts

tone

tissue

traumatic delivery

thrombin

PPH: Tone (uterine atony)

relaxation of uterus/failure to contract

No pressure on blood vessels of the placental site

Uterine stimulants (uterotonics)

Pitocin

Misoprostol

Methergine

Hemabate

What is methergine (methylergonovine maleate) contraindicated with

HTN

what is hemabate (carboprost tromethamine) contraindicated with

asthma

extreme diarrhea

what is tranexamic acid (cyklokapron)

NOT a uterine stimulant, it is an antifibrinolytic

Uterine Atony Management

Jada device: suction

bimanual massage

external abd aortic compression

bakri balloon

uterine suctioning

ligation of uterine and hypogastric arteries

what does the bakri balloon do

inserted into uterus to put pressure on the bleeding vessels

Jada device

a vacuum-induced hemorrhage control device that provides a rapid and effective treatment option for abnormal postpartum uterine bleeding and postpartum hemorrhage.

PPH: tissue

- retained placenta

- main cause of late PPH

- incomplete pressure on blood vessels of placental site

PPH: trauma: lacerations

- when do we suspect this?

- treatment

Suspected when uterus is firm but bleeding continues to ooze

Prompt suturing

PPH: trauma: hematoma

may have 250-500mL of blood and require incision and drainage

PPH: trauma: inverted uterus

uterus turned inside out

AVOID FUNDAL PRESSURE with cord traction at delivery

immediate repositioning of uterus

PPH: trauma: ruptured uterus

immediate surgery

PPH: thrombin

ineffective clotting at placental separation site

usually known and planned for

increased risk for DIC

PPH: prevention

Active management of 3rd stage

- oxytocin administration following delivery of anterior shoulder

- uterine massage (not fundal)

-umbilical cord traction

recognize and stage bleeding

PPH: nursing interventions

- call for help

- massage uterus and do not stop

- administer pitocin IV

- have all PPH meds available

- catheter

- O2

- anticipate CBC at time of PPH

- weight pads for blood loss

Endometritis

infection of uterine linine

higher risk for C/S

Endometritis s/s

fever of 101-104

foul smelling lochia

uterine tenderness

tachycardia

Parametritis

infection of connective tissue of broad ligament

more severe

Peritonitis

infection in peritoneal cavity

acutely ill

what is puerperal infections

infection of reproductive tract up to 6 weeks PP

Dehiscence and evisceration

Dehiscence:

- separation of c/s wound edges

Evisceration

- protrusion of internal contents thru separated wound edges

S/S of wound infections

worsening pain at incision site

warmth at site

erythema

edema

discharge

nursing care for wound infections

ABX, wound culture, wound care

high protein diet

hand hygiene

UTI/pyelonephritis

- why is it a risk

- S/S

- Tx

- dilated ureters during pregnancy and PP lead to UTI

- urgency, frequency, burning, cloudy/bloody urine, CVA tenderness, fever

- ABX, antispasmodics, urinary analgesic (pyridium)

Mastitis

infection of interlobular connective tissue in breast

Mastitis:

- S/S

- causes

- red area, warm to touch, fever, chills, body aches, fatigue

- blocked milk duct, bacteria from baby or pt hands entering through cracked nipple

Tx for mastitis

- warm packs and light massage before feeding

- analgesics

- ABX

- rest

- fluids

- keep feeding on affected side

Venous thrombosis

blood clot at area of impeded BF in superficial or deep veins

Thrombophlembitis

thrombus formed in repsonse to inflammation in vein wall

virchows triad

hyper coagulability of blood

venous stasis

injury to epithelium of BV

pregnancy and PP increases risk 2-6x

DVT:

- when does it occur

- S/S

- Dx

- Tx

- 10-20 days PP

- edema, redness, pain, swelling

- US, D-Dimer assay

- lovenox or heparin, bedrest and elevation

Perinatal major mood episodes

- PP depression, 10-20 % experience

- can last up to 2nd birthday

- lack of interest in normal activities, loved ones and BABY

Perinatal anxiety types

1. generalized anxiety: realistic worries but more intense than situation warrants

2. panic disorder: rapid onset of intense fear

3. OCD: intrusive thoughts with behavior compulsions

4. PTSD: unexpected birth outcomes

PP mood episodes with psychotic features

usually begins within first few days

HALLUCINATIONS: usually about baby being in harms way, sleep disturbance, confusion, psychomotor disturbances

- frequently results in harm to baby

why is PP psychosis so scary

because it frequently results in harm to patient or baby