exam

1. OB Complications - risk factors, interventions, maternal/fetal/neonatal effects, post complication care

1. Uterine rupture 

   1. Risk factors:

      1. Prior uterine rupture

      2. Trauma

      3. Abortion

      4. Instrumental injury or uterine perforation

      5. Grand multiparity

      6. Uterine overdistention

      7. Fetal malpresentation

   2. Interventions:

      1. Start IV fluids

      2. Transfuse blood products

      3. Administer O2

      4. Prep for immediate surgery 

      5. Support the mom’s family and providing information about the treatment 

   3. Maternal/Fetal/Neonatal effects:

      1. Can result in ejection of fetal parts or the entire fetus into the peritoneal cavity

      2. Abrupt decrease in FHR, late or variable decels, absent variability or tachy/bradycardia

      3. Loss of fetal station/ descent 

      4. Mom may experience sudden sharp abdominal pain or a ripping or tearing sensation that is not associated with contractions 

      5. Fetal prognosis largely determined by whether significant placental abruption occurs and the degree of associated maternal hemorrhage and hypovolemia

   4. Post-complication care:

2. Shoulder dystocia

   1. Risk factors:

      1. Hx of shoulder dystocia in previous births

      2. Maternal diabetes

      3. Prolonged second stage of labor

   2. Interventions:

      1. C-section for newborn of mom w/ diabetes & estimated fetal weight of at least 5000g (11lb) or newborn of mom w/o diabetes & an estimated fetal weight of at least 4500 g (9 lb 15 oz)

      2. Stay calm

      3. Notify interprofessional team

      4. Help mom assume position(s) that may facilitate birth of shoulders

      5. Assist obstetric provider w/ maneuvers and techniques usually performed in this situation (ex. Mc Robers & suprapubic pressure)

      6. Document maneuvers & techniques performed and total amount of time required to resolve the shoulder dystocia

      7. If maneuvers fail attempt:

         1. Clavicle fracture - break of baby’s collarbone 

         2. Zanelli - push baby’s head back into uterus & perform C-section 

         3. Symphysiotomy - incision into cartilage between pubic bones to enlarge your pelvic opening 

      8. (Need to insert chart)

   3. Maternal/Fetal/Neonatal effects:

   4. Post-complication care:

      1. Newborn assessment → 1) examination of fracture of clavicle or humerus & 2) brachial plexus injuries and asphyxia

      2. Maternal assessment → 1) early detection of hemorrhage & 2) trauma to the vagina, perineum and rectum

      3. Family support → emotional support

3. Prolapsed cord 

   1. Risk factors:

      1. A long cord ( longer than 100 cm [39 in])

      2. Malpresentation (ex. Breech or transverse lie)

      3. Unegnaged presenting part

      4. Preterm labor

      5. Polyhydramnios

      6. External cephalic version procedure

      7. Induction of labor using a large balloon catheter

   2. Interventions:

      1. Prompt recognition → fetal hypoxia resulting from prolonged cord compression (i.e., occlusion of blood flow to and from the fetus for more than 5 minutes) usually results in central nervous system damage or death of the fetus 

      2. Relieve pressure off the cord by the examiner putting a sterile gloved hand into the vagina and holding the presenting part off the umbilical cord

      3. Assist patient into a position such as lateral recumbent, Trendelenberg, or knee chest [ gravity keeps the pressure of the presenting part off the cord] 

   3. Maternal/Fetal/Neonatal effects:

   4. Post-complication care:

4. Preterm labor 

   1. Definition: diagnosed clinically as regular contractions along with a change in cervical effacement or dilation or both or presentation with regular uterine contractions and cervical dilation of a least 2 cm that occurs at a preterm gestation

   2. S/S: change in vaginal discharge, increase in amount of vaginal discharge, pelvic or lower abdominal pressure, constant low dull backache, mild abdominal cramps with or without diarrhea, regular or frequent contractions or uterine tightening, often painless, and ruptured membranes 

   3. Risk factors: 

      1. degree of risk for an infant born prematurely is directly related to the gestational age at birth; fetal number, sex, use of antenatal corticosteroids, birth weight 

      2. Spontaneous preterm labor: Hx of previous spontaneous preterm birth between 16-36 weeks of gestation, hx of STIs, black race, bleeding of uncertain origin in pregnancy, uterine anomaly, use of assisted reproductive technology, multifetal gestation, smoking, substance use, pre pregnancy underweight, periodontal disease, limited education and low socioeconomic status, late entry in prenatal care, high levels of stress 

      3. Indicated preterm birth: preexisting or gestational DM, chronic or acute HTN, preeclampsia, OB disorders (previous C/S, cholestasis, placental disorders), medical disorders (seizure, blood clots, asthma, HIV, obesity, smoking), AMA, fetal disorders 

   4. Interventions:

      1. Prevention: programs aimed at health promotion and disease prevention encouraging health lifestyles, preconception counseling and care for women, smoking cessation, promotion of school attendance, food security, nutritional programs, job fairs

      2. Activity restriction, restriction of sexual activity, home care, suppression of uterine activity 

      3. Early Recognition/Diagnosis: transferring woman before birth to hospital equipped to care for preterm infant, administering antibiotics during labor to prevent neonatal group B strep, administering antenatal corticosteroids to prevent or reduce neonatal and infant morbidity and mortality of respiratory distress and intraventricular hemorrhage, administering magnesium sulfate to reduce incidence of cerebral palsy in infants

   5. Maternal/Fetal/Neonatal effects:

      1. Maternal: increased risk for infection, increased stress/anxiety/depression/PTSD, uterine rupture or injury during emergency C/S, PPH, increased risk for HTN, DM, or CV disease in the future

      2. Fetal/Neonatal: respiratory distress, intraventricular hemorrhage, temperature instability, developmental problems, increased risk for infection, low birth weight, jaundice, apnea, feeding problems 

   6. Post-complication care:

      1. Maternal: physical recovering and monitoring for hemorrhage, infection or uterine complications, psychological support, postpartum followup

      2. Fetal: NICU admission for respiratory support, feeding assistance or temperature regulation, long term follow up care for developmental delays, vision problems, hearing loss

5. Meconium-stained fluid 

   1. Risk factors: post-term pregnancies, fetal distress, AMA, maternal hypertension/preeclampsia, gestational diabetes, prolonged labor, induction of labor, use of assisted delivery devices, chorioamnionitis, fetal hypoxia, IUGR, multifetal pregnancy

   2. Interventions:

      1. Before birth:

         1. Assess amniotic fluid for the presence of meconium after ROM

         2. If amniotic fluid is meconium stained, gather equipment and supplies that might be necessary for neonatal resuscitation

         3. Have at least one person capable of performing endotracheal intubation on the newborn present at birth

      2. Immediately after birth

         1. Assess newborn’s respiratory effort, heart rate, and muscle tone

         2. Suction only the newborn’s mouth and nose, using either a bulb syringe or a large bore suction catheter if the baby has 

            1. Strong respiratory efforts

            2. Good muscle tone

            3. Heart rate greater than 100 beats/min

         3. Suction the trachea using an endotracheal tube connected to a meconium aspiration device to remove any meconium present before many spontaneous respirations have occurred or assisted ventilation has been initiated if the newborn has:

            1. Depressed respirations

            2. Decreased muscle tone

            3. Heart rate less than 100 beats/min

   3. Maternal/Fetal/Neonatal effects:

      1. Newborn at risk for developing meconium aspiration syndrome (MAS) 

      2. MAS causes severe form of aspiration pneumonia in term or post term infants who have passed meconium in utero and experienced intrauterine hypoxia

   4. Post-complication care:

6. Premature rupture of membranes

   1. Risk factors:

      1. Hx of prior preterm PROM

      2. Short (<25 mm) cervical length identified by transvaginal ultrasound

      3. Second-and third-trimester bleeding

      4. Low socioeconomic status

      5. Low body mass index (BMI <19.8)

      6. Cigarette smoking

      7. Illicit drug use

   2. Interventions:

      1. Q2hr temperature

      2. Fetal assessment

      3. Antenatal glucocorticosteroids for all women with PPROM between 24 0/7 and 34 0/7 weeks of gestation

      4. 7 day course of broad-spectrum antibiotics

      5. Administer magnesium sulfate for fetal neuroprotection

      6. Active pursuit of labor for PROM between 34 to 36 weeks gestation

      7. PROM before 32 wks results in hospitalization to prolong pregnancy

   3. Maternal/Fetal/Neonatal effects:

      1. Infection is the greatest maternal, fetal and neonatal risk

      2. PROM at 32-33 wk gestation may require immediate birth due to conservative management increasing the risk for complications such as umbilical cord compression

   4. Post-complication care:

2. Hypertensive disorders of pregnancy

1. Signs and symptoms 

2. Treatment 

   1. Chronic Hypertension

2. Magnesium Sulfate

   1. Magnesium sulfate for seizure prophylaxis is indicated for:

      1. Preeclampsia with severe features and severe gestational hypertension

      2. All cases of severe (≥ 160 mm Hg / ≥ 110 mm Hg), sustained (lasting 15 minutes or more) hypertension regardless of classification

      3. Medication alert: High serum levels of magnesium can cause relaxation of smooth muscle, such as the uterus.

   2. Magnesium sulfate is the drug of choice for seizure prevention in patients with preeclampsia

      1. Prevents calcium ion transport

      2. Cerebra; blood vessel dilation

      3. Platelet aggregation

   3. Should be initiated when diagnosed with preeclampsia with severe features

   4. Should continue until 24 hours post delivery or 24 hours after the last seizure if eclamptic

   5. Magnesium sulfate is not an antihypertensive medication

      1. Place the client on her side to maximize uteroplacental blood flow and ensure efficient uteroplacental oxygenation

   6. Primary effect is via CNS depression

   7. Improves blood flow to CNS via small vessel vasodilation

   8. Dose for magnesium infusion of 4-6 gm loading dose over 20-30 minutes, then 2 gm/hour 

   9. Ensure bedside safety measure are in place

1. Calcium Gluconate is the countermeasure for Magnesium Toxicity

   1. Give 1g IV over 3 minutes

   2. Repeat doses may be necessary (up to 3 doses)

   3. Calcium chloride can also be used in lieu of calcium gluconate

3. Treatment of HELLP

   1. Induction of labor regardless of gestational age

   2. Monitor labs closely Q 6 hours

      1. CBC

      2. Liver enzymes

   3. Magnesium infusion

   4. Blood pressure control if needed

   5. Consider early epidural placement

4. Treatment of sustained 160/110

3. Classifications of disorders

   1. Gestational Hypertension - Development of hypertension after week 20 of pregnancy in a woman with a previously normal BP

      1. >140/90

      2. Should be recorded on two occasions at least 4 hours apart after 20 weeks of gestation in a woman with a previously normal BP

   2. Preeclampsia - Development of hypertension and proteinuria in a woman after 20 weeks of gestation who previously had neither condition

      1. In the absence of proteinuria, the development of new-onset hypertension with the new onset of any of the following: thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms

      2. with Severe Features

         1. Thrombocytopenia- platelet count less than 100

         2. Impaired liver function- elevated ALT and AST

         3. Renal insufficiency- elevated serum creatinine greater than 1.1 mg/dl or doubling

         4. Pulmonary edema

         5. New onset headache unresponsive to medication and not accounted for by alternative diagnoses

         6. Visual disturbances

   3. Eclampsia - Development of seizures or coma in a woman with preeclampsia who has no history of preexisting pathology that can result in seizure activity

   4. HELLP Syndrome 

      1. Hemolysis, Elevated Liver Enzymes, Low Platelets

         1. Hemolysis develops from red blood cells that become fragmented when they pass through small, damaged blood vessels

         2. Reduced blood flow secondary to obstruction from fibrin deposits causing elevated liver enzyme levels

         3. Vascular damage, resulting from vasospasm, leading to low platelet count

      2. HELLP syndrome can occur without hypertension or proteinuria

      3. The most life threatening complication with HELLP syndrome is liver rupture

4. HELLP syndrome 

   1. Can lead to

      1. Liver hematoma or rupture

      2. Adult respiratory distress syndrome (ARDS)

      3. Sepsis

      4. Hypoxic encephalopathy

      5. Fetal death

      6. Maternal death

   2. HELLP associated with increased risk of adverse outcomes

      1. Placental Abruption

      2. Renal Failure

      3. Subcapsular Hepatic Hematoma

      4. Preterm Delivery

      5. Fetal or Maternal Death

      6. Recurrent Preeclampsia

5. Fetal changes

   1. Fetal changes

      1. Preeclampsia causes impaired uteroplacental blood flow

      2. Impaired uteroplacental functioning can result in

         1. Intrauterine growth restriction

         2. Oligohydramnios

         3. Placental abruption

         4. Nonreassuring fetal status

      3. Women with preeclampsia are at an increased risk for preterm labor

6. Delivery recommendations 

   1. Gestational Age and Preeclampsia

      1. Onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications

      2. Induction of labor at 37 weeks is indicated for women with preeclampsia without severe features and gestational hypertension

      3. In patients with preterm preeclampsia (< 34 weeks) with severe features, the disease can rapidly progress to significant maternal morbidity and/or mortality.

   2. Management of Suspected Preeclampsia with Severe Features < 34 Weeks Gestation: Proceed to delivery if any of the following are present:

      1. Recurrent symptoms of severe preeclampsia

      2. Recurrent severe hypertension despite therapy

      3. HELLP syndrome or other abnormal lab criteria

      4. Placental abruption

      5. Severe fetal growth restriction, oligohydramnios, or abnormal fetal testing

3. Hemorrhagic disorder

1. Hemorrhage

   1. Antepartum: medical emergency! → prompt assessment and intervention

      1. Maternal blood loss decreased oxygen carrying capacity and increases risk for hypovolemia, anemia, infection, preterm labor and impaired oxygen delivery to fetus 

      2. Fetal Risk: blood loss, anemia, hypoxemia, hypoxia, anoxia, preterm birth 

   2. Intrapartum: 

      1. Any bleeding that happens during labor or during delivery 

      2. Symptoms and causes: 

         1. Blood loss of 1000 mL or more, S/S of hypovolemia within 24 hours of birth, uterine atony, vaginal/cervical laceration, uterine injury during c-section, placental abruption, placenta accreta 

      3. Tx: prompt recognition of blood loss, identifying the source of the hemorrhage, resuscitation with crystalloid and blood products, surgical approaches including hemostasis and timely repair 

      4. Risks: rapid blood loss can lead to severe drop in blood pressure, shock, end organ damage and death 

      5. Prevention: recognizing signs and symptoms of shock, familiarizing with techniques for treatment and resuscitation, avoiding episiotomy unless urgent delivery is necessary 

   3. Postpartum: obstetric emergency

      1. Definition: cumulative blood loss of  >1000 mL or bleeding associated with S/S of hypovolemia within 24 hours of the birth process regardless of type of birth 

         1. Leading cause of maternal morbidity and mortality

         2. Classified as early or late with respect to time of birth 

            1. Early, acute or primary PPH occurs within 24 hours of birth → uterine atony, genital tract lacerations, retained or invasive placentation, uterine rupture, uterine inversion, coagulopathy 

            2. Late or secondary PPH occurs more than 24 hours but up to 12 weeks after birth → infection, retained placenta, coagulopathy

      2. Readiness, Recognition, Response, Reporting 

         1. Readiness: hemorrhage cart and team simulation 

         2. Recognition: Risk assessments and QBL (low, medium, high) 

         3. Response: standardized checklists and MTP protocol

         4. Reporting: debrief! Identify strengths, improvements, open communication, last 5-10 minutes 

      3. MTP Protocol: Keep putting blood in until blood stops coming out! 

         1. MTP = 3 units of blood in 1 hour or 10 units over 24 hours 

         2. Not based on labs but clinical assessment!

         3. AVOID coagulopathy 

         4. Goal near equal ratio of PRBC: FFL after 1st 2 units, one unit platelets given for every 4-6 units PRBCs  

      4. Blood Loss - Terms and Techniques: 

         1. EBL (estimated blood loss): done through visualization of blood soaked items; done at the end of case by multiple observers

         2. QBL gravimetric: quantitative blood loss determined by weighing items and subtracting dry weight of sponge, gauze and container to determine weight 

         3. QBL volumetric: quantitative blood loss determined by observing total amount of volume containing blood and subtracting the volume 

         4. QBL colorimetric: blood loss determined by device which scans items or containers and estimated the amount by the size of spots (pixels) and intensity of color 

         5. CBL (cumulative blood loss): ongoing blood loss is determined by adding up the individual EBL or QBL measurements for the events and is used to drive management steps and transfusion

      5. 4 T’s: Tone, Tissue, Trauma, Thrombin 

         1. Tone: Uterine atony → inadequate uterine contraction occurs, uterus remains flaccid and rapid blood loss can follow, leading cause of early PPH

            1. Associated with high parity, hydramnios, macrosomic fetus, obesity, multifetal gestation

         2. Tissue: retained placenta, uterine atony, trapped placenta, fragments of placenta remain, unusual placental adherence 

            1. Accreta: slight penetration of myometrium 

            2. Increta: deep penetration of myometrium 

            3. Percreta: perforation of myometrium and uterine serosa, possibly involving adjacent organs 

         3. Trauma: vaginal lacerations, hematomas, surgical complications 

         4. Thrombin: DIC, idiopathic thrombocytopenic, von Willebrand disease

      6. Subinvolution: late PPH can result in subinvolution of uterus, infection, retained placental fragments or coagulopathy

         1. S/S: prolonged lochial discharge, irregular or excessive bleeding, and sometimes hemorrhage

   4. Hemorrhagic Shock: 

      1. Management: restoring circulating blood volume, eliminating cause of hemorrhage, fluid or blood replacement therapy, restore oxygen delivery to tissues and maintain cardiac output 

2. Early pregnancy bleeding 

   1. Signs + Symptoms: depends on length of gestation

      1. Early pregnancy with threatened miscarriage: uterine bleeding, uterine contractions, or abdominal pain

      2. Before 6 weeks: heavy menstrual flow 

      3. Between 6-12 weeks: moderate discomfort, blood loss 

      4. After 12 weeks: severe pain (similar to labor)

   2. Molar Pregnancy (Hydatidiform mole): growth of placental trophoblast where the chorionic villi develop into edematous, cystic, avascular transparent vesicles that hang in grape like clusters 

      1. Complete: no embryonic or fetal parts → no embryo forms; sperm fertilizes an empty egg, placental tissue grows but is abnormal and contains fluid filled cysts 

      2. Partial: often have embryonic or fetal parts and an amniotic sac → abnormal placenta forms along with an embryo and two sperm fertilizes one egg, growing embryo has an extra set of chromosomes, generally don’t survive 

      3. Manifestations: anemia from blood loss, excessive nausea and vomiting, abdominal cramps, larger fundal height, preeclampsia occurs in approx 70% of women with large, rapidly growing moles 

      4. Diagnosis: transvaginal US and serum hCG levels  

      5. Management: abort spontaneously, suction curettage 

      6. Follow-up: monitor hCG levels → initially weekly until normal x 3 weeks, monthly measurements taken 6-12 months, instructed not to get pregnant x 12 months 

   3. Diagnosis criteria 

4. Treatment 

5. Late pregnancy bleeding 

3. Placental disorders

   1. Placenta Previa: placenta is implanted in the lower uterine segment such that is completely or partially covers the cervical os or is close enough to the cervix to cause bleeding when the cervix dilates or the lower uterine segment effaces 

      1. Complete: covers internal cervical os 

      2. Marginal: edge of the placenta is seen on the transvaginal US to be 2.5 cm or closer to the internal cervical os 

      3. Low-lying: exact relationship of placenta to internal cervical os has not be determined or in the case of apparent placenta previa in the second trimester 

      4. Manifestations: painless bright red vaginal bleeding 

      5. Outcomes: 

         1. Maternal complication: Hemorrhage; also morbidly adherent placenta or placenta accreta spectrum, hysterectomy 

         2. Fetal complication: preterm birth, IUGR, fetal anomalies 

      6. Management: 

         1. Initial Care: IV access, labs (H&H, platelets, coagulation), type and screen, <34 weeks give antenatal corticosteroids, tocolytics  

         2. Home Care: activity modification with pelvic rest, close distance to hospital, access to transportation

         3. Active: immediate birth if mother life in danger through C/S, maternal vitals, fetal assessment on EFM

   2. Premature Separation of Placenta (Placental Abruption): detachment of part or all of a normally implanted placenta from the uterus; occurs after 20 weeks of gestation and before birth of infant 

      1. Risks: maternal hypertension, cocaine/methamphetamine use, penetrating or blunt external trauma, cigarette smoking, hx of abruption, uterine anomalies, PPROM

      2. Classification: Grade 1 Mild Separation (10-20%), Grade 2 Moderate Separation (20-50%), Grade 3 Severe Separation (>50%)

      3. Outcomes: 

         1. Maternal: depends on placental detachment, overall blood loss, degree of coagulopathy, times that passes between placental detachment and birth; complications = blood loss, coagulopathy, need for transfusion, end-organ damage, need for C/S, peripartum hysterectomy, and death 

         2. Fetal complications: fetal growth restriction, oligohydramnios, preterm birth, hypoxemia, stillbirth all related to severity and timing of hemorrhage

      4. Management: 

         1. Expectant: depends of severity of blood loss and fetal maturity and status; mother and fetus monitored closely, fetal well being tests, corticosteroids

         2. Active: immediate birth is fetus at or near gestation, moderate bleeding or life in jeopardy, IV access, vital signs, lab studies, EFM monitoring, Foley catheter, 

   3. Vasa Previa: fetal vessels lie over the cervical os; vessels are implanted into the fetal membranes rather than into placenta 

      1. Variations: Velamentous insertion or succenturiate

         1. Velamentous: cord vessels begin to branch at the membranes and then course onto the placenta 

         2. Succenturiate: placenta divides into two or more lobes rather than remaining as a single mass, vessels run between lobes 

      2. Diagnosed after rupture of membranes followed by acute-onset vaginal bleeding caused from lacerated fetal vessel 

      3. Risk Factors: second-trimester placenta previa or low-lying placenta, pregnancies resulting from assisted reproductive technology, and multiple gestations 

4. Hemorrhage medications

   1. Uses

   2. Contraindications 

4. Fetal positioning

   1. Lie → the position of the long axis of the fetus and it is described as longitudinal, transverse or oblique

      1. (Pictures)

   2. Presentation → part of the fetus that lies closest to or has entered the pelvis, and it is described as cephalic, breech or shoulder

      1. (Pictures)

   3. Position → the relationship of the presenting part to the maternal pelvis and it is described as anterior, posterior, or transverse (left or right)

      1. (Pictures)

   4. Attitude → the relationship of the fetal parts to each other and is described as flexion or extension

      1. (Pictures)

5. Fetal heart rate tracing 

Three-Tier Fetal Heart Rate Classification System

• Category I: FHR tracings include all of the following:

  •  Baseline rate - 110-160 beats/min

  •  Baseline FHR variability - Moderate

  •  Late or variable decelerations - Absent

  • Early decelerations - Either present or absent

  •  Accelerations - Either present or absent

• Category II: FHR tracings include all FHR tracings not categorized as category I or category III. Examples of category II tracings include any of the following:

  • Baseline rate:

    • Bradycardia not with by absent baseline variability

    • Tachycardia

  • Baseline FHR variability:

    • Minimal baseline variability

    • Absent baseline variability not accompanied by recurrent decelerations

    • Marked baseline variability

  • Accelerations: No acceleration produced in response to fetal stimulation

  • Periodic or episodic decelerations

    • Recurrent variable decelerations accompanied by minimal or moderate baseline variability

    • Prolonged decelerations (≥2 min but < 10 min)

    • Recurrent late decelerations with moderate baseline variability

    • Variable decelerations with other characteristics such as slow return to baseline, "overshoots," or "shoulders""

• Category III: FHR tracings include the following:

  • Absent baseline variability and any of the following:

    • Recurrent late decelerations

    • Recurrent variable decelerations

    • Bradycardia

  • Sinusoidal pattern

6. Obstetrical procedures

   1. Operative vaginal births 

      1. Performed using either forceps or a vacuum extractor

      2. Increased risk for subgaleal hemorrhage in the neonate

      3. Increased risk to perineal trauma to the mother

      4. Forceps-assisted birth → piper forced used to assist w/ delivery of the head in a breech birth

   2. Vacuum Extraction

      1. Discouraged for gestational ages less than 34 weeks, although a safe lower limit for gestational age has not been established

      2. Sequential use of forceps in the setting of a failed vacuum attempt is associated with increased rates of newborn complications and should not be routinely performed

   3. Cesarean Birth

      1. Elective → maternal request w/o medical or obstetric indication

      2. Scheduled 

      3. Unplanned

   4. External cephalic version

      1. Attempt to turn the fetus from a breech or shoulder presentation to a vertex presentation for birth

      2. At 36-37 weeks, the success rate for ECV is approximately 65% and the risk for cesarean birth is reduced by 50%

1. Contraindications 

   1. Uterine anomalies 

   2. 3rd trimester bleeding

   3. Multiple gestation

   4. Oligohydramnios

   5. Evidence of uteroplacental insufficiency

   6. Previous cesarean birth or other significant uterine surgery 

   7. Obvious CPD

7. Intimate partner violence

   1. Definition: Behavior by an intimate partner or ex-partner that causes physical, sexual or psychological harm including physical aggression, sexual coercion, psychological abuse and controlling behavior 

   2. Four type of Behavior: physical violence, sexual violence, stalking, psychological aggression

      1. Physical: person hurts or tries to hurt a partner by hitting, kicking or using any type of physical force

      2. Sexual: partner forces or attempts to force a partner to take part in a sexual act, sexual touching, or a nonphysical sexual event when the partner does not consent 

      3. Stalking: pattern of repetitive, unwanted contact by a partner that causes concern or fear for one’s own safety or the safety of someone close to them

      4. Psychological: nonverbal and verbal communication occurs with the intent to do mental or emotional harm and/or to exert control over a person

   3. Persons having experienced violence have higher incidence of social and family problems, substance abuse, menstrual and other reproductive orders, STIs, MS or GI disorders, chest pain, abdominal pain, urinary tract infections, headaches or PTSD

   4. Violence Patterns in Pregnancy: commencement of violence with pregnancy, violence before and during pregnancy where violence is unchanged, decreases or increases, termination of violence during pregnancy, no violence during or after pregnancy 

   5. Care Management: 

      1. Does the woman feel safe at home with her partner, how do they resolve conflict, what happens when the woman’s partner becomes angry, does fighting occur during disagreements, and does fighting ever escalate to restraining or physical means? 

      2. Cues to abuse: delay in seeking medical assistance, missed appointments, vague explanations of injuries, nonspecific somatic complaints, social isolation, lack of eye contact, spouse or partner who does not want to leave the woman alone with primary provider, substance use 

   6. Nursing Interventions: ABCDES

      1. A: reassuring the woman is not alone

      2. B: expressing the belief that violence against the woman is not acceptable in any situation and that it is not her fault 

      3. C: confidentiality of the information that is shared, particularly because the woman may believe that if the abuse is reported, the person who has perpetrated the violence will retaliate 

      4. D: descriptive documentation including quoted statement, accurate descriptions of injuries, and women’s consent, evidence, or photographs 

      5. E: education

      6. S: safety, most significant part of the intervention

8. Transition to parenthood 

   1. Described as a time of disorder and disequilibrium, as well as satisfaction, for mother and fathers or co-parents

   2. Bonding: emotions and feelings experienced by the mother (or parent) in relation to the infant; most often discussed in relation to maternal-infant bonding 

   3. Attachment: two-way interaction between mother (or primary caregiver) and the infant that develops during the first year of the infant’s life

   4. Parent-Infant Interaction: 

      1. Early Contact: early skin-to-skin contact between the newborn and mother immediately after birth and during the first hour facilitates parental affectionate bonding behaviors and is recommended as a standard of care owing to many benefits and lack of adverse effects 

      2. Extended Contact: rooming-in is common in family centered care; nurse encourages father or co-parent to participate in caring for the infant in as active a role as desired 

   5. Communication between Parent and Infant: touch, eye contact, voice, scent 

   6. Care Management: modulation of rhythm, modification of behavioral repertoires, and mutual responsivity 

   7. Adjustments: 

      1. Issues parents might face are sexual intimacy, division of household and infant care responsibilities, financial concerns, balancing work and parental responsibilities, and social life 

   8. Social Support: both in-person and online settings; social network, types of support, perceived general support, actual support received, satisfaction with support available and received 

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