Exam 2 Study Guide
Hormones
Hormones
What
secretes this
hormone?
When is it secreted? When does it
peak?
Estrogen
Ovary (follicle)
Follicular and luteal phase
- Uterine enlargement - Breast glandular hyperplasia - ↑ fallopian tube peristalsis - when estrogen
reaches certain level → ↓ LH output - "Ovulatory mucus" to nourish sperm
Leutenizing
Hormone (LH)
Anterior pituitary
gland
Follicular phase and peaks right
before ovulation
Affects final development and subsequent rupture of mature follicle
Follicle Stimulating
Hormone (FSH)
Anterior pituitary
gland
Follicular phase and peaks right
before ovulation
Stimulates the ovary to produce five to 20 immature follicles
Progesterone
Corpus luteum
After ovulation and peaks during luteal
- Forms mucous plug - Breast glandular hyperplasia - Slows GI peristalsis - Prepares
phase
endometrium for implantation
After implantation and peaks ~8-14
- Ensures the endometrium will be receptive to the implanting embryo - Maintains corpus luteum
wks after conception
until week 11 - During pregnancy test: detects presence/absence of hCG
Hormone
human Chorionic
What does it do?
Gonadotropin
(hCG)
Trophoblasts
GnRH
Hypothalamus
Pulsates slowly during follicular phase
and increases during luteal phase
Induces release of LH and FSH to assist with ovulation
Human Placental
Lactogen (hPL)
Placenta
~2 wks GA and rises slowly
throughout to peak ~34 wks GA
- Helps mediate fetal/maternal glucose metabolism during pregnancy (lactose) to ↓ maternal glu
utilization & ↑ glu availability to fetus - Participates in breast development for lactation
Hypothalamus
During labor and breastfeeding
Prostaglandins
Oxytocin
- ↑ follicular maturation - assist with ovulation - assists in transport of sperm
- Stimulates labor and breastfeeding (contraction of womb and lactation)
Summary of Menstrual Cycle Hormones
1. ↑ LH → follicle produces estrogen
2. As ↑ estrogen → inhibiting the output of LH → ovulation after LH surge damages estrogen-producing cells
3. Ovulation → ↓ estrogen
4. LH surge → corpus luteum → produces estrogen and progesterone
5. ↑ Estrogen and progesterone → suppresses LH output → promote degeneration of corpus luteum
6. Cessation of the corpus luteum → ↓ estrogen and progesterone output
7. ↓ ovarian hormones ends their negative effect on the secretion of LH
8. ↑ LH → menstrual cycle begins again
Absence of fertilization → menstruation (on avg = 28-day cycle)
Conception, Fetal Development, and Substance Abuse
1) Follicular Phase
Goal: produce ovum for fertilization
Length: variable
2) Ovulation
3) Luteal Phase
Follicle rupture → corpus luteum → ↑
Occurs when ovum is released from
follicle → fallopian tube → uterus
progesterone (prepares endometrium for
implantation)
Hypothalamus: initiator of this phase (PG →
LH/FSH)
Proliferative Phase:
↑ estrogen = ↑ endometrial glands
Typically takes place ~10-12 hrs after LH
peak and ~24-36 hrs after estrogen peak
Absence of fertilization: corpus luteum
degenerates & ↓ ovarian hormone levels → ↓
estrogen & progesterone → endometrium
Egg produced: ~14 days before
menstruation
involution
Secretory Phase:
blood vessel dilation = ↑ endometrial
thickness
Endometrium: ↑ thickness, vascularity, and
glandular
Prepares endometrium for implantation
Fetal Development Overview
Exam 2 Study Guide
🤰
Stages of Pregnancy:
1
🤰
Pregnacy averages: 10 lunar months, 40 weeks, 280 days (first day of LMP to birth)
Pre-embryonic stage (0-2 wk)
Embryonic Stage (2-8 wk)
Fetal stage (8 wk - birth
Fertilization usually occurs 14 days after LMP; actual gestation = 266 days
Most born within ±14 days of EDD
Conception
Pre-Embryonic Stage: First 2 Weeks
1. ↑ estrogen → ↑ fallopian tube peristalsis
1. Cleavage: Rapid cell division
2. Prostaglandins in semen help transport sperm
Blastocyst (inner cell mass) → embryonic disc + amnion
3. Sperm + ovum (in outer 1/3 off the ampulla) = diploid zygote
Trophoblast (outer cell mass) → placenta + chorion
4. Zona pellucida forms: prevent entry of other sperm
2. Implantation: Blastocyst burrows into endometrium
Nuclei of sperm and ovum unite
Sex of zygote is determined at this time (fertilization)
Occurs 7-10 days after fertilization
Trophoblasts now secrete hCG
Embryonic Stage: Week 2-8
3. Cellular Differentiation
Tissues differentiate into essential organs
Chorion + amnion → amniotic fluid
Wks 3-4: heart, vertebrae, heart, eyes, arms begin to develop
Primary germ layers give rise to all tissues:
Wks 6-8: lung, ↑ RBC, digits develop, fetal circulation established
1. Ectoderm → CNS, special senses, skin, glands
2. Mesoderm → skeletal, urinary, circulatory, reproductive organs
Functions of Placenta:
Metabolic: glycogen, cholesterol, fatty acids
3. Endoderm → respiratory, liver, pancreas, digestive system
Transport: diffusion, facilitated/active transport
Endocrine: produce hormones vital to fetal survival (hCG, hPL,
progesterone, estrogen)
Functions of Amniotic Fluid: allows for mvmt, proper lung
development, ↓ pressure on umbilical cord, constant temp around
the baby, protect baby from injury
Fetal Stage: Week 9-Birth
Every organ system & structure is present; organ systems develop during this stage
At 9 weeks:
Weeks 12-16:
Week 20:
Week 24:
Week 28:
Week 32:
Week 38:
Every organ
system & structure
Fetal
tones
can be heard
Quickening felt
by all mothers
Alveoli begin to
form +
Rapid brain
development
Rhythmic
breathing
Fetus is flexed
Genitals well
differentiated
BAT appears
are present
🖤
Active
Fetal heartbeat
heart by
movements
fetoscope
surfactant
production
Fingerprints set
movements
↑ body fat
↑ CNS function
(quickening may
be present)
Fraternal Twins
Identical Twins
2 ova + 2 sperm
1 ova + 1 sperm → split into two
2 chorion + 2 amnion
1 chorion + 2 amnion
Earlier split = good b/c ↓ resources are shared
Later split = bad b/c ↑ competition for resources
Substance Abuse
Factors Influencing Development: vulnerability timetable (exposure <9 wks are most damaging), Teratogens (physical agents, metabolic conditions,
infection, drugs/chemicals), Medications (first trimester = greatest risk)
Plan for L&D (pain meds shouldn't be withheld
Goal: help mother recover from illicit drug abuse to optimize long-term health of self and baby (non-judgemental approach)
Exam 2 Study Guide
2
Alcohol Use in Pregnancy
Maternal Effects: malnutrition, BM suppression, ↑ infections, liver disease, WD/DTs
Neonatal Effects: WD, fetal alcohol spectrum disorder (FASD), long-term complications
FASD: physical, behavioral, cognitive effects
Long-term: delay in oral feeding, CNS dysfunction (most common), learning disabilities, impulsivity, cognitive/speech
impairment
S/S EtOH WD: hyperactivity, jitteriness, hyperreflexia, hypertonia, poor suck, seizures, poor sleep patterns, diaphoresis
Nursing Implications: Educate elimination & detrimental effects of EtOH during pregnancy; find Tx program; no safe amt EtOH they can consume
Tobacco Use in Pregnancy
Maternal Effects: infertility, spontaneous abortion, IUGR/low birth wt, preterm birth
Neonatal Effects: 3x SIDS risk that of non-smokers, chronic respiratory illness
Nursing Implications: Consider nicotine replacement for those who can't quit; educate about smoking cessation & other coping strategies
Heroin Use in Pregnancy
Maternal Effects: poor nutrition, iron-deficiency anemia, abruptio placentae, PTL/PROM, IUGR/low birth wt,
meconium staining, ↑STIs/HIV
Neonatal Effects: WD, neonatal abstinence syndrome (NAS)
S/S of NAS: restlessness, lack of habituation, shrill/high-pitched cry, irritability, seizures, V/D
Nursing Implications: Tx = Methadone (blocks WD symptoms and cravings; crosses the placenta)
Educate about effects; assess use of other substances; don't abruptly stop heroin; methadone maintenance
program
Infertility, Women's Health, Nutrition, & Special Populations
Infertility
Woman <35 yoa unable to conceive after >1 yr of
attempting
Woman >35 yoa unable to conceive after >6 mo of
attempting
Anything that prevents the egg to meet up with the sperm and fertilize the
egg (Ex: scar tissue = pelvic inflammatory disease (PID; chlamydia,
gonorrhea, endometriosis)
Infertility Factors
Male
Category
Factors
40% of cases (↓ sperm
count/viability), Sperm blocked
from release
Possible
Causes
Female
40% cases (ovarian dysfunction,
tubal/pelvic pathology)
Prolonged periods of high heat,
Over-/underwt, AIDS, chronic
heavy EtOH, MJ, cocaine use,
cancer Tx, STI scarring
illnesses, PID/STIs, hormonal
imbalances, smoking/EtOH
Treatment
Early 20s = peak fertility for women
Lifestyle Δ's
After 35 (especially 40) = ↓↓↓ fertility
Ovulatory factors (basal body temp recording, induce ovulation via
Clomid)
Preconception Care
Immune to preventable diseases? (update if not)
Use of folic acid?
PMHx: DM, thyroid disease, anemic
PSHx: appendectomy, any abd. Sx
Hormonal agents (impacts FSH, LH, Progesterone)
Therapeutic insemination: intrauterine insemination (IUI)
In vitro fertilization (IVF)
Embryo donation/transfer
Surrogacy & Adoption
Gyn: LMP, regularity of menstrual periods, STIs, PID, endometriosis
Work-Up
Nursing Considerations
1. Emotions more difficult than testing/therapy
Semen analysis (less invasive)
Exam 2 Study Guide
3
Evaluation of ovarian function
2. Explain procedures, listen to concerns, answer Qs, support the family
Cervical mucus adequacy for sperm receptivity
3. Provide accurate information about infertility and dispel myths
Tubal patency
Uterine structure evaluation
Women's Health
STIs
Name
Organism
Chlamydia
Symptoms
Pregnancy Implications
Notes
Routine screening at 1st
ABx for both partners, expedited
Chlamydia
d/c, urethritis (men/women), salpingitis,
prenatal visit, ROM → vert
partner treatment (EPT) in IL,
trachomatis
uterine bleeding; 50% men & 70%
transmission → ophthalmia
abstain from sex for 7 days
asymptomatic
neonatorum
following Tx
Neisseria
Greenish-yellow d/c, dysuria, and
gonorrhoeae
frequency; 80% women asymptomatic
Pelvic
Chlamydia
B/L sharp cramping pain in lower
Inflammatory
trachomatis,
quadrants, >101 fever, chills, N/V,
Disease
(PID)
Neisseria
gonorrhoeae
malaise, mucopurulent cervical or vaginal
d/c
Gonorrhea
Treatment
Impaired fertility, mucopurulent vagina
Most common bacterial STI in the
US, Screen: <25 yoa females and
>25 yoa females at risk, all pregos
ABx for both partners (EPT),
As above
Often occurs with Chlamydia
abstain from sex until cured
Inflammation of female upper
post-infection → tubal
damage → infertility or
ectopic pregnancy
ABx, hospitalization may be
genital tract, Risk factors: multiple
necessary, treat partner
sex partners, h/o PID, sex at
young age
HSV-1 and
HSV-2
Herpes
(recurrent
lifelong
infection)
Syphilis
Treponema
pallidum
Primary outbreak with lesions, then
Risk for SAB, PTL, C/S if
dormant, recurrent
active lesions present
Congenital syphilis (IUGR, PT birth,
stillbirth, CNS/intellectual disability,
heart/lung/liver damage
No cure, but treatment available:
acyclovir, valacyclovir, famciclovir
(can be given in 3rd trimester)
Screen VDRL or RPR blood
test
ABx
Transmission: skin-to-skin contact
with an infected site
Transmission: transplacental
Cervical Abnormalities
Abnormal pap smear results → Bethesda System for specimen findings
Atypical Squamous Cells (ASC)
Surgical treatment:
Loop electrosurgical excision procedure (LEEP): electric wire loop
excises lesion
Low-grade Squamous Intraepithelial Lesion (LSIL)
Cryosurgery: freezing → tissue necrosis
High-grade Squamous IntraEpithelial Lesion (HSIL)
Abnormal cytology → colposcopy (SSE with acid solution, abnormal cells
visible, biopsy)
Laser therapy
Conization: cone biopsy
Nutrition Considerations
Maternal Weight Gain
1. General nutritional status before pregnancy
Based on pre-pregnant BMI
2. Common discomforts of pregnancy (N/V)
Avg wt gain distribution
3. Maternal age
Obesity in pregnancy
4. Maternal parity
5. Not all foods have to be avoided (well varied, balanced)
6. Cravings, sensory Δ's, cultural variations
7. Pica, eating disorders, food safety
8. Nutrition impacts fetal well-being & birth outcome (PTD, low
birthwt, macrosomia, development)
Nutritional Requirements
Name
Value
Calories
Protein
Fluids
Folic Acid
Iron
+300 cal/day (pregnancy) +500
80
8-10 glasses (8 oz) of fluid 4-6 glasses of water
400-800 mcg/day (start 2-3 mo prior to pregnancy and
27
cal/day (BF)
g/day
Caffeine (diuretic effect)
through pregnancy)
mg/day
Foods that can be eaten in pregnancy
Foods to avoid in pregnancy
1. Swordfish, tilefish, mackerel, shark, ahi tuna (Risk: methylmercury)
Exam 2 Study Guide
4
1. Cooked shellfish, canned fish, small ocean fish, farm-raised fish
(salmon)
2. Cooked fish
2. Raw or undercooked fish like sushi or ceviche (Risk: bacteria or viruses)
3. Raw sprouts (Risk: bacteria can't be washed out)
4. Unpasteurized products, soft cheeses (Risk: bacteria may be present)
3. Pasteurized products, hard cheeses
5. Raw/undercooked meat, poultry, runny yolk (Risk: salmonella, E. coli)
4. Cooked eggs
6. Cold hot dogs, deli meat, refrigerated smoked seafood, deli salads (Risk: Listeria)
5. Heated or grilled deli meats, smoked seafoods, deli salads
Special Populations
Care of LGBTQI Families
1. Birth parents/adoptive families
Ask pt how they prefer to be addressed (gender pronouns) → gender neutral terms if unsure
2. Cultural differences
Involve partners in care per pt wishes
3. Differently abled families
Caring demeanor and open-ended Q's as much as possible
4. LGBTQI families
Consider fertility options: surrogacy and adoption
5. Adolescent families
6. Families >35 yoa
Pregnancy Changes & Antepartum Assessment
Pregnancy Changes
Body
Changes
System
Intervention
Notes
Cervix: mucous plug with progesterone stimulation of tissue, Goodell's sign (softening),
Reproductive
Chadwick's sign (bluish-purple discoloration) Vagina: ↑ vascularity, leukorrhea (whitish d/c)
Cotton underwear/underpads,
Ovaries: ovulation ceases Breasts: glandular hyperplasia + hypertrophy, tenderness, ↑
supportive bra (may need re-fit)
estrogen/progesterone, darkened areolae, striae, colostrum (3rd trimester)
N/V (d/t hCG levels), friable gums (d/t estrogen), heartburn (d/t relaxation of cardiac sphincter),
Gastrointestinal
↓ GI motility, uterus displaces stomach, Hemorrhoids, constipation (d/t intestinal displacement,
progesterone ↓ peristalsis, Fe+ is constipating), cholestasis of pregnancy
BV +50% (1500 mL), physiologic anemia (↑ plasma volume > RBC), ↓ vascular resistance (to
Cardiovascular
accommodate for BV), ↑ fibrin/fibrinogen (↑ hypercoagulable state), ↑ CO, ↑ HR, edema, VV,
hemorrhoids, supine hypotensive (vena caval) syndrome (postural hypotension)
Musculoskeletal
Genitourinary
Respiratory
Integumentary
Endocrine
Immune
Pelvic joints relax → waddling gait, ↑ lumbodorsal curve → backache, round ligament pain
(pelvic pain from stretching to support the uterus)
↑ frequency (d/t ↑ pressure of gravid uterus) → dehydration, ↑ GFR → ↑ glycosuria (d/t ↓ renal
threshold for glu excretion) → DM, ↑ risk of UTIs
Diclegis/Vit B6, soft toothbrush,
↑ fluids, fiber, mvmt, Tucks pads
Elevate legs/hips/pelvis, support
hose, avoid constipation, side-
BV ↑ in 1st trimester & peaks
at ~32 wks; +10-15 bpm HR
lying position, sit breaks, Δ
in 2nd trimester (fluctuates,
position slowly
should not be elevated)
Good body posture/mechanics,
Relaxin: helps to loosen up
support garments, low-heeled
shoes, counsel pt, heating pad
joints → baby has more room
to move
Frequent voids, sufficient fluids
(↓ in the evening), ↓ caffeine,
Kegels
↑ O2 consumption (hyperventilation: faster/deeper), dyspnea (diaphragm pressure, endures
elevate HOB, slow/deep
until lightening), vascular congestion of nasal mucosa (stuffiness/epistaxis d/t ↑ estrogen)
breaths, saline spray, humidifier
Hyperpigmentation (linea nigra), striae, facial chloasma (darkening of skin around the face like
use sunscreen, elevate legs,
butterfly effect), varicose veins, spider veins
support hose
↑ thyroid activity, ↑ insulin needs from pancreas (d/t hPL), latent deficiency → GDM, ↑ oxytocin
& ADH (from hypothalamus/pituitary), ↑ ALD (from adrenal glands)
Lightening: presses down on
uterus to relieve pressure off
the diaphragm
Screen thyroid activity
↑ innate immunity, ↓ adaptive immunity (persisting x2 mo after delivery)
Δ's in sleep pattern/disturbances (bladder & gravid uterus) → fatigue, "pregnancy brain" (↓
General Δ's
Small/frequent meals, avoid
fatty foods, ginger, antacids,
attention, concentration, memory), maternal psychologic & emotional reactions (mood swings,
ambivalence, acceptance), partner Δ's (feeling left out, emotional swings, Couvade Syndrome)
Use pillows, promote relaxation,
rest when possible (naps),
provide anticipatory guidance
and support for partner
Fatigue 1st, more E 2nd,
fatigue returns in 3rd
trimester; Couvade: partner
has symptoms like pregnant
partner
Antepartum Assessment
Maternal & partner Hx, PMHx, PSHx, FHX, OB/gyn Hx, immunization record are collected
Nägele's Rule: 1st day of LMP, subtract 3 mo, and add 7 days (only accurate if a woman has a regular 28 day cycle)
Note: US is the most accurate to determine when the EDB will be (used in the 1st trimester)
Measurement of fundal ht (symphysis pubis to fundus)
Exam 2 Study Guide
5
20 wks = 20 cm = umbilicus
+1 cm/wk until ~36 wks (lightening can occur at 36 wks)
Screening: Initial Prenatal Labs
1. Pap Smear
Bloodwork Tests:
1. ABO/Rh/Ab screen
2. HIV (Neg or Pos)
3. Rubella titer (Immune or Non-Immune)
4. HepB (Neg or Pos)
2. UA/Culture
3. Bloodwork
4. Glu testing for high risk
5. VDRL or RPR (NR or Reactive) for Syphilis
6. CBC
Screening: Subsequent Prenatal Labs
1. GDM at 24-28 wks
2. RhoGAM evaluation at 28 wks (given for Rh- mothers)
3. GBS at 35-37 wks
📆
Visit Schedule:
q4 wks in first 28 wks
q2 wks until 36 wks
q1 wk after 36 wks
4. Based on risk:
Immunizations
Ideally given prior to becoming pregnant
Should be given: inactivated IM flu vaccine & Tdap booster (given in EVERY pregnancy → fetus benefits from Ab
Should NOT be given: attenuated live viruses (MMR, varicella, chickenpox)
Intimate Partner Violence (IPV)
Warning signs: unexplained bruises/injuries, vague complaints, missed visits, noncompliant with Tx, h/o depression, substance abuse, suicide attempts
"Yes" response: validate pt ("this is NOT your fault, no one deserves to be treated like this, help is available"; plan for safety)
"No" response: document and screen again
☣
Complications:
Maternal: HTN, pre-eclampsia, ROM, infection
SAVE Model:
SCREEN all pts for risk from violence
Neonatal: preterm birth, IUGR
ASK questions in a non-judgmental manner
VALIDATE the pts experience
EVALUATE, EDUCATE, & refer
Antenatal Testing and EFM
Antenatal Testing
1st Trimester:
Viability confirmation: 2 levels, 48 hrs apart → should double
IUP vs ectopic
Establish GA
Examine crown-rump length (most accurate at 6-12 wks)
Transvaginal US
Transabdominal US: requires full bladder (position = L lateral/tilt)
2nd Trimester:
Cardiac motion
Alpha-fetoprotein (AFP): elevated = ↑ risk of neural tube defects; deficiency = ↑ risk of trisomy 21 or 18
Fetal # & presentation
Amniocentesis: tests for chromosomal abnormalities, metabolic disease, NTD (amniotic AFP level), Rh assessment after
exposure
Placental position
Cord & vessels
Triple or Quad Screen: AFP, hCG, unconjugated estriol (and inhibin A)
Chorionic Villus Sampling (CVS): tests for chromosomal/genetic abnormalities, enzyme deficiencies, metabolic disease
Exam 2 Study Guide
6
Fetal anatomy
Amniocentesis & CVS
Indications:
Advanced maternal age (>35 yoa) → ↑ risk for
chromosomal abnormalities
H/O neural tube defect
Risks
Management:
Vaginal spotting, cramping
Give support before, during, and after testing
ROM
Give RhoGAM PRN (if pregnant pt is Rh-)
Other abnormal screening
Chorioamnionitis: infection of the
lining of the BOW
Carrier for metabolic disease
Spontaneous abortion
3rd Trimester:
Pt should self-monitor for mvmt (should be consistent timing and amt per day) → tells you fetal CNS function & oxygenation
Amniotic Fluid Index (AFI): normal = 5-25 cm using the 4 quadrant deepest pocket method; DM have ↑ risk of polyhydramnios
Non-Stress Test (NST): assesses uteroplacental function (Reactive vs. Nonreactive)
Reactive = 2+ accels in 20 mins, no, decels, normal baseline FHR with mod variability
Nonreactive = no accels(or <2 accels in 40 mins), more testing needed
Biophysical Profile (BPP): detects hypoxia (uteroplacental insufficiency) to guide early intervention
1. FHR acceleration (NST)
2. AFI
Test Interpretation:
8+ = no intervention; <6 = possible
mgmt (consider whole picture)
3. Fetal breathing
4. Fetal movements
5. Fetal tone (flexed or flaccid)
If 1 or 2 are abnormal, the others don't really
matter
EFM
1. Contraction pattern (frequency & duration)
2. Baseline FHR (during "non-event" section b/t UC; # in 5 bpm increments)
3. Baseline FHR variability: fluctuations in HR from baseline (b/t UC and excludes accels/decels) → indicates CNS functioning
Absent = 0 bpm
Minimal = 0-5 bpm
Moderate = 6-25 bpm
Marked = 25+ bpm
4. Accelerations (present vs absent): ↑ FHR above baseline +15 bpm x15 seconds (but <2 mins) → indicates fetal well-being & adequate oxygenation
5. Decelerations: consider timing of ↓ FHR wrt UC
Absent → good
Early = head compression → fine
Late = uteroplacental insufficiency → BAD
Variable = cord compression → BAD
Normal Labor
Main factors of whether or not baby will be able to fit through pelvis & vagina safely: passageway, passenger, powers, position, psychosocial response
1) Passageway
Bony Pelvis: Inlet (baby going into pelvis), outlet (baby coming out of pelvis), shape (gynecoid vs anthropoid are best)
Soft Tissues: cervical dilation & effacement, vaginal canal & introitus distention
Birth Course: uterus → pelvis → cervix → vagina → introitus
2) Passenger
Exam 2 Study Guide
7
Fetal Head
Fetal Attitude
Largest D: Suboccipitobregmatic (9.5 cm) & Biparietal (9.25 cm)
Relation of fetal body parts to one another (general flexion
Frontal, parietal, occipital bones overlap during birth (molding)
= good!)
Fetal Lie
Good: chin/knees/heels tucked, back curved, arms crossed
Relation of fetal spinal column to mother (cephalocaudal axis)
Bad: general extension
Fetal Presentation
Longitudinal (98%) = vertical or parallel to maternal spine (only way to
get out of the pelvis by NSVD)
Presenting part: body part that enters the pelvis first
Cephalic = head down
Normal = cephalic (vertex) & occiput presenting (head flexed)
Breech = butt down
Fetal Malpresentation
Transverse (2%) = horizontal (will require C/S)
Cephalic (brow & face)
Shoulder presentation
Breech (frank, incomplete/footling, complete)
Clinical Implications of Fetal Malpresentation
Name
Cephalic (Brow)
Presenting Part
Forehead (extended head)
Contributing
Uterine anomaly, ↑ parity, ↓ birth wt,
Causes
pelvic shape
Maternal Risk
Prolonged labor, C/S, episiotomy
Cephalic (Face)
Face (hyperextended head)
Same as brow
Same as brow
Edema/bruising to face, head, and
Fetal Risk
Birth injury
Clinical
None indicated if labor progressing;
C/S recommended, NSVD possible in
Therapy
C/S if not
some cases
airway
Breech
Transverse
Sacrum or feet
Shoulder
Previa, uterine anomaly, ↑ parity, multiples, prematurity
Same as
(footling), previous breech
breech
Prolonged labor, C/S
C/S
Cord prolapse, head entrapment, neuromuscular disorders
External cephalic version, C/S, CAM
Cord
prolapse
Same as
breech
3) Powers of Labor
Primary Force (Involuntary Work of Labor): UC, cervical Δ's, "laboring down" (pushing baby down w/o mom voluntarily pushing)
Secondary Force (Voluntary Work of Labor): Pushing during 2nd Stage, coordinate with primary force
4) Position
Relationship b/t the passageway and the fetus
Fetal occiput relative to maternal landmarks
Maternal position: ambulatory vs back-lying
Cardinal mvmts: specific mvmts to allow ↓ diam to pass through pelvis
Head extension & external rotation under mother's symphysis pubis
Ex: ROA → maternal right, fetal occiput, maternal anterior
Fetal Malposition
Occiput posterior (OP) vs occiput anterior (OA): may be more common w/ smaller pelves
OP: baby's occiput is facing posteriorly → NOT IDEAL
OA: baby's occiput is facing anteriorly → IDEAL!
Maternal Risks of OP:
Intense pain in the small of back ("back labor")
🏥
Clinical Therapy of OP:
Hands/Knees position to allow fetal rotation;
Vaginal birth possible: spontaneous, forcepsassisted, forceps rotated, manual rotation;
C/S possible
Prolonged labor
↑ risk of assisted vaginal delivery, perineal laceration, C/S
5) Psychosocial
1. Birth experience factors (+/-): Locus of control, Pain or anxiety, Labor support (doulas), Previous experience
Exam 2 Study Guide
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2. Preconceived ideas or expectations about birth
3. Readiness
4. Cultural view
5. Birth plan = wish list (things might not go as expected) → provide support
Labor Experience
Maternal Response to Labor:
CV: stressed by UC/pain/anxiety/pushing; ↑HR/BP during UC; ↓ BP with CLE (continuous labor epidural)
Resp: ↑ O2 demand at labor onset
GI: ↓ GI motility & gastric emptying → N/V
Fluid/E- Balances Challenges: Sweating, IV fluids, and meds
Labor Onset: exact cause is unknown
Possible causes: ↑estrogen, ↓progesterone, ↑prostaglandins (myometrial gap junctions ↑), oxytocin receptors ↑ in the uterus
Premonitory signs of labor:
Initial cervical Δ's
Bloody show (slimy blood)
Braxton Hicks contractions
Backache
Sudden burst of energy (nesting)
Lightening (mom can breathe again)
ROM (1 in 4 women)
NVD
Is It Time?
True Labor
False Labor
Progressive dilation/effacement (cervical Δ's) in response to...
Lack of cervical Δ
Regular contractions
Irregular contractions (do not ↑ F/D/I)
↑ UC F/D/I (even with comfort measures)
Contractions mainly in front of abd
↑ Intensity with ambulation
Pain relieved w/ ambulation, position Δ, rest, hot bath/shower
Pain usually starts in back → radiates to abd
Nursing Care During Admission:
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1. Maternal Assessment
- VS & wt/wt gain
- Prenatal records (PMHx, OB Hx, ↑ risk conditions)
- Psychosocial
- Labs
2. Establish (+) relationship & rapport
Nursing Response:
Education: s/s true labor
Reassurance: false labor is common, difficult to distinguish from true labor
Interventions: ↓ anxiety & discomfort; REST (labor will use all of E)
3. Labor Assessment:
- UC
- Membranes/BOW (+ R/O SROM)
- Fetal movement
- Vaginal bleeding
- EFM
- SVE
4. Notify Provider: SBAR & Plan of Care
Stages & Phases of Labor
First Stage: Dilation
Third Stage: Placental Delivery
Latent Phase (0-6 cm): UC q5-10 mins, x30-45 secs, ~5-9 hrs
5-30 min post delivery
Active Phase (6-10 cm): UC q2-5 mins, x40-60 secs, ~4-6 hrs
>30 mins = retained placenta → manual extraction
Baby is still in the uterus; ends with 10 cm dilation
Baby is out and ends with placenta out; provide newborn care if only
Anticipatory guidance, pain mgmt, fluids, comfort measures, discourage
pushing until fully dilated, bladder assessment
nurse
Signs: gush of blood, cord lengthening, bulge at perineum, fundal rise in
abd
Second Stage: Delivery
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UC q2-3 mins, x60-90 secs
"Golden Hour": emotional time, complete assessments w/ baby, BF,
attachment
Ends with baby out of the uterus
Fourth Stage: Recovery
Bloody show, coach to bear down with UCs, remove catheter prior to
pushing
1-4 hrs after birth
Warm packs to perineum, encourage rest b/t contractions, ice chips
Profound hormonal & hemodynamic shift
Episiotomy not recommended for routine intervention (emergency now)
EBL NSVD = 500 mL
EBL C/S = 1000 mL
Palpate fundus, assess bladder, and VS q1h → massage fundus if boggy
Tremors are common, food & liquids, rest, transfer to postpartum unit
Intrauterine pressure catheter (IUPC): UC intensity & resting
tone
Fetal scalp electrode (FSE): accurate FHR tracing
Disadvantages:
Contraindications:
Must be s/p ROM & adequately dilated
low-lying placenta
Invasive: ↑ risk of uterine infection or perforation
HIV+
HebB+
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