OB
Module 1:
Stages of labor
First → onset of contractions to full dilation of cervix
Cervix can dilate all the way to 10cm - want to support and educate pt on full dilation and what to expect during delivery
Who will deliver baby, what they can eat, who they can have in room with them
Do they have a Birth plan?
Difference in length of stage 1 labor between nullipara and multipara
Second → full dilation to birth
10cm dilation = fully dilated
Ready to start pushing!
Nursing role: support pt
1 to 1 nursing
Third → birth of fetus until delivery of placenta
Baby is born!
There will be a placental sac surrounding baby in utero
Nurse role: gather supplies and medications for pt
At this point: 1-1 nursing; one nurse for baby and one nurse for mommy
Monitor pt for bleeding, bonding with infant, help use bathroom, assist with placenta (whether fam wants to keep it, needs to be discarded, or needs to be sent to lab)
Coordinate w baby’s nurse to keep the mother/family updated
Fourth → 2 hrs post delivery of placenta
Factors affecting labor (5 p’s).
Power → involuntary uterine contraction & maternal pushing
Passage → birth canal
Cervix
Pelvis
Passenger → Fetus & Placenta
Psyche
Position
Cervical changes (define dilation and effacement)
True vs. False Labor
True labor | False labor |
Regular contraction increases in frequency and intensity Changes in cervix Causing effacement and dilation Onset → cannot be ascribed to single causes Contractions occurs every 5 min for 1 hr Progressive cervical change |
|
Braxton Hicks → “practice contraction” that can start as early as 2nd trimester (more common in 3rd)
Irregular contraction
Doesn't get closer together
Usually goes away with hydration
Priority nurse assessments of a term patient in labor
Nursing triage
Priority
FHR
Woman’s nearness to birth
Maternal VS
Indications to be assessed/go to hospital
If water breaks early → pt needs to stay at hospital until delivery → can be months
Water break ⇒ causes leakage throughout bc nothing to hold it
Water break = rupture of membrane
Doesn’t equate to labor
Module 2 and 3:
Genetic Disorders –autosomal recessive, autosomal dominant, x-linked traits
Patterns of single gene inheritance
Autosomal dominant
Autosomal recessive
X-linked
Normal → (46 total)
44 autosomes
2 (23rd) sex chromosomes
Numerical abnormalities
Trisomy → extra chromosomes
(47 total)
Associated w down syndrome
Monosomy → missing of chromosomes
(45 total)
Mostly seen in Turner syndrome
Polyploidy → chromosomes that doesn't separate or fertilized by 2 sperms
Sometime results in miscarriage
Maternal Nutrition – recommended dietary supplements, weight gain, PICA
General recc → Weight gain should be
~ 1.1 - 4.4 lbs (during 1st trimester)
~0.8 - 1 lb weekly (2nd trimester)
Food needed
Food to Avoid
Fish w high level of mercury
Raw fish
Soft cheese
Unpasteurized milk products
Undercooked meats and poultry
Unpasteurized eggs
Raw, undercooked, unwashed fruits/veggies
Lactating women
Require higher nutrients than non-preg adult women
Recommended balanced diet
Non-lactating women
Can return to normal diet
Recommended diet → contains protein, Vit C, calcium, iron
Prenatal development
Gametogenesis
Requires a special cell division called meiosis
Each gamete receives 22 autosomes and 1 sex chromosome from each parent\
At conception the “halves” form a new cell with 46 chromosomes
Oogenesis
Formulation of ova (female gametes) begins during prenatal life
By the 30th week of gestation the female fetus has all of the ova she will ever have
Many ova regress during childhood
Primary oocytes (with a follicular layer) mature at puberty
Spermatogenesis
Refers to the formation of sperm
Man can continuously produce sperm from puberty through the rest of his life
Man determines the baby’s sex, since sperm carry with an X or Y chromosome
Woman contribute only an X chromosome to baby
SEX!
Requires correct timing between release of the mature ovum (ovulation) and ejaculation of enough healthy, mature sperm into the vagina
The ovum has the capacity to be fertilized no longer than 24 hours after ovulation
Most sperm survive no more than 2 days
Sperm remains in the female tract up to 80 hours
Pre-embryonic period
Initiation of cell division
Morula
Blastocyst → creates the placenta
Thus why ppl get nauseous as the hormones are being secreted
Entry of the zygote into the uterus
Implementation in the decidua
Have enough HCG → for pregnancy
Maintaining the decidua
Location of implementation
Should be in the upper uterine segment
Top of the uterus
Can have implantation bleeding → might mistake of period bleeding
Mechanism of implantation
Embryonic period
Extends from the beginning of the 3rd week until the 8th week after conception
Heart begins beating around 21-22 days
Signs of preg: breast tenderness, missed periods
Common accurate ways: ultrasounds; dopplers (heart beat)
Embryonic disc develops 3 layers
Ectoderm, mesoderm, endoderm
By the end of the 8th week, all major organ systems are in place
Teratogens during this period may cause major structural and functional damage to the developing organs
Ex. fluoride in toothpaste
Fetal period
Beginning 9 weeks after conception and extending until birth, the rapidly dividing cells become a fetus
The head is large, the body is growing fast
First fetal movements begin
The eyes are closed, the ears are low
Blood forms in the liver then shifts to spleen by 12th week
Fetal gender can be determined by the end of 12th week
Weeks 13-16 2nd trimester
Head becomes smaller in portion to length
Fetal movements known as quickening
Weeks 17-20
Fetal movements described as fluttering or “butterflies”
Vernix caseosa protects the skin from exposure to amniotic fluid
Vernix → white cottage cheese all over the baby; goes back into the skin (like a moisturizer)
Lanugo is present, eyebrows and hair appear
Lanugo: very fine hair covering fetus
Brown fat is deposited on the back of neck, sternum and around kidneys
Helps neonates maintain temperature stability after birth
Brown fat → help insulate the baby
Weeks 21-24
Skin is translucent and red
Lungs produce surfactant - surface active lipid that makes breathing easier after birth
Weeks 25-28
Fetus is more likely to survive after 24 weeks
The skin becomes less red
The eyes open
Blood shifts from spleen to bone marrow
weeks 29-32
The skin is pigmented to race and is smooth
Toenails and fingernails are present
Used a soft filer for it
The fetus has more subcutaneous fat
Chances of survival are good during this period
Week 33-38
The fetus is gaining weight
Pulmonary system continues to mature
Growth of all body systems continues until birth
Testes are in the scrotum
Breast of both male and female are enlarged
Full term ranges from 36-37 weeks
37 = TERM
<37 WEEKS = PRETERM
Surfactant is matured in the lungs
Fetal circulation
Course of blood circulation
From the fetal heart to the placenta
Exchange of oxygen and waste products takes place
Back to the fetus for delivery to fetal tissues
Umbilical cord is cushioned Wharton’s jelly
Fetus → placenta = deoxygenated
Changes in blood circulation after birth
Three fetal circulatory shunts partially bypass the fetal liver and lungs → baby been panini pressed; pressure closed the ducts when it breathe O2 for the first time
Ductus venosis →
Foramen ovale →
Ductus arteriosus →
These structures close functionally after birth
Close permanently several weeks or months after birth
Multifetal pregnancy
Twins are the most common form of multifetal pregnancy
May be monozygotic (identical) or dizygotic (fraternal twins)
Common to have NG tube
Are often NICU baby bc is preterm
Dizygotic twins are more likely to occur in
Certain families
Specific racial groups
Older mothers
Women who undergo infertility therapy
Twins are more common in mother bc of mitochondria in mother is passed down more? Or something like that but it’s not important
Nagele’s rule -determine EDD
formula used to estimate the due date of a pregnancy
Formula: last menstrual cycle (LMP) + 7 days - 3 months + 1 year
Function of placenta and other auxiliary structures; blood flow
Auxiliary Structures
Placenta → transfer of nutrients in to baby/ waste out of the baby
Thick disc-shaped organ
Mother side: bereft red meaty looky
If smoking = can see in the placenta
Baby side: more blue, veins of the baby
Have amniotic sac around the baby
When it rupture = water breakage
Baby is swimming in fluids, baby urine, and regulated temps.
Major functions
Metabolic
Transfer of substances between mother and fetus
Endocrine
Normally inserted on the fetal side near center
Fetal membranes
Amnion (inner membrane)
Chorion (outer membrane)
Amniotic fluid
Derived from fetal urine and maternal blood cells
Protects the fetus and promotes development
Umbilical cord → two arteries and one vein
Prenatal screening & Diagnostics- Ultrasound, multiple marker, fundal height
Ultrasound
Used to determine a variety of fetal and placental conditions
Presence of location of pregnancy
Multifetal gestation
Gestational age
Viability confirmation
Identifying fetal abnormalities
Emotional responses
Not always possible to determine fetal sex
Not 100% of the real gender indicator → can be mistaken
Doppler ultrasound blood flow assessment → doesnt need to know
Ultrasound is used to perform the test
Doppler shift
Used in pregnancies complicated by placental insufficiency from: HTN and fetal growth restriction
Measures systolic to diastolic (S/D) ratio
Should be decreasing throughout pregnancy (for baby)
Alpha-fetoprotein screening → main protein in the baby
Assessment is performed on maternal serum or amniotic fluid to identify
Open body wall defects (neural tube defects)
Chromosomal anomalies (trisomy 21)
Ideally performed between 16 and 18 weeks of gestation
Requires only a blood sample
Must be viewed as a first step in screening
High level = neural tube defects and spina bifida
Low level = down syndrome
Multiple marker screening
Two other markers have been added
Human chorionic gonadotropin (hCG)
Unconjugated estriol
Increases the detection of trisomy 18 and 21
If testing is positive
Amniocentesis is recommended
Amniocentesis
Aspiration of amniotic fluid from the sac for further examination
Invasive → can accidentally poke the baby
Second trimester amniocentesis
Performed between 15 and 20 weeks
Chromosomal or biochemical abnormalities
Indications for 2nd trimester amniocentesis
Can look at lung maturity
Maternal age 35 or older
Birth of previous infant with chromosomal abnormality
Chromosomal abnormality in a close family member
Pregnancy after multiple spontaneous abortions
Maternal Rh sensitization of maternal Rh-negative blood to fetal Rh-positive blood
If accidentally poked the baby and the blood doesn't match, then produce med (Rho Gam)
Gender determination for maternal carrier of X-linked disorder
Unexplained elevation of maternal fetal-alpha protein
Third trimester amniocentesis
Used to determine fetal lung maturity or hemolytic disease
Percutaneous umbilical blood sampling → don't need to know
Also called cordocentesis or PUBS
Involves the aspiration of fetal blood from the umbilical cord near the placenta for prenatal diagnosis or therapy
Used to detect blood disorders, acid-base imbalance, infection or fetal genetic disease
Antepartum fetal surveillance
Nonstress Test (NST)
NST evaluates fetal heart rate accelerations, with or without fetal movement
2 accelerations (15x15) in a 20-min period
15 min high and 15 min long = good baby
0 points of NST ⇒ the biophysical profile test thingy (in the picture)
Reactivity is associated with adequate fetal oxygenation and intact neural pathways
Maternal assessment of fetal movement
Movements by the fetus are assessed by the mother
They are often called “kick counts”
5-10 per hour? But based on the wake-sleep cycle
Several methods for the mother to count
Assessment of pt who has diagnostic testing
Gravida, para, gestational age
Maternal health problems
current/prior obstetric problems
Hx of substance abuse, including alcohol and tobacco
Pt understanding of test and reasons for it
Pt’s emotional response to test
Pt’s and partner's expectations of test
Module 4:
Interpreting fetal monitoring strips
FHR reflects clinical status of fetus; normal FHR → 110-160 BPM
Steps to assess FHR pattern:
determine baseline
assess variability
assess for accelerations
assess for decelerations
Baseline
Average HR calculated during a 10-minute interval
Minimum of 2 mins of data within the 10-minute period is needed to calculate the FHR
2 min of on interruption to get appropriate data
Mean heart rate is rounded to the closest multiple of 5 beats/min
Fetal variability
Absent
Undetectable
Emergency c-section to try and resuscitate that baby
Could be fetal death
Minimal
-/< 5 beats/min
Could be because babies are sleeping (normally 20- 40 min) → but if continuous for 3 hours then monitor
Moderate → normal
6-25 beats/mun
Marked
>25 beats/min
Some type of distress
Ex. baby that passed its stool in amniotic fluid → meconium
Baby can have trouble breathing due to choking on stool
Acceleration
Indicator of fetal wellness and normal acid-base balance
Baby is cheering us on! Yay!
Accelerations are visible, abrupt increases of at least 15 beats/min above the baseline FHR and lasts at least 15 secs
15x15
Early decelerations
Sometimes called: mirror image of a contraction
Mirrors the lowest FHR with the highest (peak) contraction (on the strip)
Cause: head compression → the fetal head is pushed further into the birth canal by contractions
Priority nursing interventions for non-reassuring strips
Variable decelerations
FHR varies in duration, intensity and timing
Abrupt deceleration in FHR, typically causing “U” “V” “W” shape
Cause: umbilical cord compression
Get clamps (for some reason) →
Clamp can be bc of the positioning → NURSE #1 interventions to reposition the mother
Tx: can added sterile water into the amniotic fluids → to help the baby to float around
Late decelerations
Slowing of the FHR after the contraction started and has prolonged time before returning to baseline
Onset of fetal HR deceleration after the peak of contraction
Cause: uteroplacental insufficiency (decrease in uterine blood flow = decrease in fetal oxygenation)
= baby can have acidemia = depressed cardiac function = decrease variability in fetal strip
Interventions
Respoitiontioning
Give IV fluids → bc might be dehydrated
Give O2
Contact HCP
Indication for induction of labor
Induction (forced delivery when not in labor) and augmentation (speeding up labor for someone already in labor)
Indications
Fetal compromise
Intrauterine growth restriction, Rh incompatibility
Spontaneous rupture of membranes near term
Post-term pregnancy
Over 42 weeks gestation
Chorioamnionitis
Hypertension associated with pregnancy
Maternal medical conditions
Fetal death
Nursing considerations for induction
Don't do unless medically necessary!
Module 5:
Pain Management: non-pharmacologic
Pain =
Stress hormone increase = decrease BP (don't want this in labor)
Difficulty breathing (bc of anxiousness
***Breathing technique → helps feel relax (mind calm, HR slows down, breathing stabilized)
***Counterpressure
Put pressure on the hips → helps relieve pressure( from outside in)
ONLY doing w contraction
Bc contraction is causing that pain
Types of pain
Somatic pain = usually the ring of fire (usually during the crowning of the baby)
Pharm
Systemic analgesia effects
Nitrous oxide → laughing gas
Tasteless odorless gas, most used in the US
Helps reduce anxiety, improves feelings of well-being
Clears body through lungs minimal risk for overdose
Opioid analgesics
Reduce perception of pain w/o LOC
Injectable: fentanyl, butorphanol, nalbuphine
Monitor the mother and fetus welling bc can pass through the umbilical cord
Look for respiratory (RR when there born) and ETM
RR <10 = toxicity
Make sure the mother doesn’t LOC → IF DO, CALL RAPID
Edu mother on potential SE → drowsiness, N/V, prutitus, dysphoria
Adjective med
Reduce N w opioid drugs and reduce anxiety to promote rest
Common drug: promethazine and metoclopramide
Neuraxial analgesia
Doesn’t call sedation
Combo opioids and local anesthetics
General anesthesia
Intubated
LOC
Make sure they didn't way → risk for aspiration
Complication → malignant hyperthermia (due to meds from gen. anesthesia)
Possible complication: hypothermia due to cold environment in OR
Calling the NICU team to look at APGAR score
Nursing actions for epidural preparation
Before epidural
Get BP → maternal HTN (prevent it)
Anesthesia consented
IV access → for fluid bolus (LR)
Left side lying position → bc better BF to uterus, decrease pressure in inferior vena cava
Have lidocaine to numb the area before the injection
L3 - L4; leave cather there (similar to peripheral IV)
Catheter is taped in their skin → may need to call anesthesia to look at it to ensure it still working (if pt dont feel it anymore)
Epidural block → blocks from the umbilical down
Bed bound
Reposition the pt every 30 min to dilate the pt
Offering toileting → bc continuous peeing
Either bedpan or foley
Empty bladder is important bc dont want it to stretch
~ 2 hours or pushing
Common epidural side effects and interventions
LOS in lower body
Maternal distention
Bladder distention
Prolonged second stage of labor
Migration of epidural catheter fever
Contraindications for epidural
GP and GTPAL
Spinal block
C-section medication
Similar to epidural → but nipple down; little stronger to the epidural
If doesnt work → used fixed w blood patch (takes blood from ur hands and put it into their back)
Infants → metabolism drugs/alcohol but very slow
Stages of Labor
First Stage: Onset of contractions to full dilation of cervix (up to 10 cm). Important to provide support and education on the process. Considerations include who will deliver the baby, dietary allowances, and companions in the room. Check for a birth plan. Length varies between nullipara and multipara.
Second Stage: From full dilation (10 cm) to birth. Nursing role is to support the patient during pushing.
Third Stage: Birth of fetus until delivery of placenta. Nurse gathers supplies and medications, monitoring for bleeding and facilitating bonding with the infant. Coordination with the baby's nurse is crucial.
Fourth Stage: First two hours post delivery of placenta.
Factors Affecting Labor (5 P’s)
Power: Uterine contractions and maternal pushing.
Passage: Birth canal, cervix, and pelvis.
Passenger: Fetus and placenta.
Psychology: Mental state can influence labor.
Position: Maternal positioning may impact labor progress.
True vs. False Labor
True Labor: Regular contractions that increase in frequency and intensity, causing cervical changes (effacement and dilation).
False Labor: Contractions without cervical change, often relieved by hydration or sedation.
Braxton Hicks: Irregular "practice contractions" that do not progress.
Key Assessments for Laboring Patients
Fetal Heart Rate (FHR): Essential for monitoring fetal well-being.
Maternal Vital Signs (VS): Important indicators of maternal health.
Indications for Hospital Admission: Includes ruptured membranes, which may risk infection if labor is delayed.
Pain Management During Labor
Non-Pharmacologic Pain Management
Breathing Techniques: Help reduce anxiety and stabilize heart rate.
Counterpressure: Apply pressure on the hips during contractions to relieve pain.
Heat and Cold Therapy: Use heating pads or cold packs to ease discomfort.
Position Changes: Encourage maternal movement and different positions to find comfort.
Relaxation Techniques: Incorporate visualization, massage, and mindfulness to promote relaxation.
Pharmacologic Pain Management
Systemic Analgesia: Includes medications like nitrous oxide and opioids (fentanyl or nalbuphine) to reduce pain perception but maintain consciousness.
Neuraxial Analgesia: Epidurals provide anesthesia for pain relief from the waist down, requiring careful monitoring and positioning.
General Anesthesia: Used in emergencies, leading to loss of consciousness and requires close monitoring due to risks of complications.
Considerations
Maternal Assessment: Monitor maternal vital signs and inform about potential side effects.
Fetal Monitoring: Ensure fetal well-being while administering pain relief measures.