Exam 1 review
Presumptive
 Amenorrhea: No period
 Fatigue
 N/V
 Breast tenderness: Burning
 Urinary frequency
 Quickening: Fetal movement
Probable
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LOW Heager’s sign – lower uterine segment softens: 6-12 weeks
SOFT Goodell’s sign- cervical softening
BLUE Chadwick’s signs- bluish discoloration of vagina, cervix
Positive pregnancy test: 4-12 weeks
Braxton hicks’ contraction or ballottement: 16-28 weeks, baby bounces in cervix (passive
movement)
Positive (HEAR SEE FEEL)
 Hearing fetal heart tones: 6 weeks
 Visualization of the fetus: 5-6 weeks
 Palpation of fetal movement by examiner: 19-22 weeks
BP stays the same during pregnancy** slight or no increase**
Mom never on her back***
Pregnancy terms
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Gravida- # of pregnancies
Preterm- 20-37 weeks
Term- 37-40+ weeks
Abortion- any pregnancy that ended prior to 20 weeks.
Living- # of living children.
PRIMA: pregnant or 1
Multigravida: Pregnant and 2
Nutrition
 Protein: Beans, Nuts
 Iron needs to double, take with VIT C, empty stomach and not with milk
 Calcium for babies’ bones: TUMS
Neagle’s Rule
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calculating estimated due date (EDD)
1st day of last menstrual period (LMP)
Subtract 3 from month
Add 7 to the day and adjust the year.
Fetal assessment
 Fetal heart rate 110-160: First 10-12 weeks
 Uterine height in cm should equal gestational ag +/-2
 Fetal movement: should feel constantly every day after 18 weeks
Cardiac changes: Palpations: HR (increases by 15-20)
 Blood volume increases 40-50% result in physiological anemia.
 Cardia output increase 30-50% increased risk for blood clot due to increase in clotting
factors and decrease in circulation.
 Possible DVT In low extremities
 Multiple gestation causes cardiovascular stress
 Increased risk for clothing due to increased clotting factors
Respiratory changes: Slight increase in RR because of HR
 Increase oxygen requirements to meet maternal and fetal needs.
 Ligaments of rib cage relax
 Diaphragm is displaced due to enlarging uterus, chest breathing vs. abdominal breathing
 Upper respiratory more vascular: Nasal congestion, epistaxis (nosebleed), changes in voice.
(Upper respiratory infection)
 SOB common
 Vascular resistance
Integumentary changes:
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Linea Nigra: Belly button line
Striae Gravidum: stretch marks
Palmar Erythema: Red palm
Sweating Increased, Increased metabolic rate
Vascular Malformation: spider veins
Renal Changes
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Ureters relax
Bladder displacement
Decreased bladder tone
BUN, Creatinine, uric acid
Glucose
Gastrointestinal changes: Everything slows down
 N/V increased HCG should subside 1st trimester.
 Hyperemesis gravidarum: excessive vomiting **complication: IV hydrate Phenergan, home
with it also: Diet: High protein low fat- meals, more frequent small meals, bland foods, dairy
settles better, eat a popsicle after you throw up**
 Changes in taste and smell
 Ptyalism: excessive saliva
 Pica: food with no nutritional value** PICA ** can cause anemia (ice, clay, starch)
 Decreases tone and motility in GI tract (reflux and constipation)
 Flatulence, constipation, hemorrhoid
 Epulis: Raised nodule on the gums**
First trimester labs
 Hgb: >11 and Hct: >33 (CBC)
 Blood type and Rh = + or - **RH Rogram administered 28 weeks, book: RH administered to
RH negative women to prevent formation of antibodies by destroying fetal RBC’s. (Can lead
to hyperbilirubinemia: jaundice) **
 RH negative women receive the RH immunoglobin after an amniocentesis
 Antibody screen
 Rubella titer (may offer booster after pregnancy) **Rubella & Varicella can cause
congenital anomalies**
 Urinalysis
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Pap smear: if not last 3 years
Screening for HIV and Hep B
VDRL and RPR
Offer sickle cell
Offer cystic fibrosis
Gonorrhea/chlamydia: common and curable
Platelets low? HEMORRHAGE >100,000
**Group B beta strep culture**
First trimester discomforts
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Breast changes: enlargement, pain, tingling, tenderness*
Urinary frequency
Fatigue
N/V
Ptyalism
Gingivitis and epulis (gum hypertrophy, bleeding)
Nasal stuffiness
Leukorrhea (clear or light-colored mucus)
***First Trimester Complications***
 Severe constant abdomen pain
 Vaginal bleeding (saturating the pad in 30min-1 hour)
Second trimester discomforts
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Acne, pigmentation changes (hormonal)*
Palmer erythema
Pruritus
Palpitations
Supine hypotension (vena cava syndrome) NEVER flat on back** Rule out hypoglycemia*
Faintness, syncope
Heartburn
Constipation, flatulence
Headaches
Carpal tunnel syndrome
Periodic numbness, tingling of fingers.
Round ligament pain
Joint pain, backache, pelvic pressure
NO NSAIDS or aspirin**
Third trimester discomforts
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Shortness of breath and dyspnea
Insomnia
Mood swings, increased anxiety
Urinary frequency and urgency return
Perineal discomfort and pressure
Leg cramps
Ankle edema
Third trimester labs
 1 hour glucose test, elevated? 3-hour glucose
o If 2 are elevated: indication of Gestational diabetes mellitus
o 1 hour is non fasting 3 hour is 8-14 hours?
 Group B strep vaginal/rectal swab
Second and third trimester complications
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Persistent severe vomiting
Sudden discharge of fluid from vagina: Can be preterm rupture of membranes
Vaginal bleeding; severe abdominal pain: Miscarriage, Placenta previa, abruptio placentae
Chills, fever, burning on urination, diarrhea: infection
Severe backache or flank pain: kidney infection/stones or pre-term labor
Change in or absence of fetal movement: fetal jeopardy or intrauterine fetal death
Uterine contractions: preterm labor
Symptoms of preeclampsia: HTN, Visual disturbances (photophobia) swelling of face &
fingers, Headache, seizures, and abdominal pain
 Glycosuria: positive glucose tolerance test (3 hour): Gestational Diabetes
 Mother is immunocompromised**
Anemia
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Normal value during pregnancy
Hbg >11** HCT >33**
Occurs in 20% pf pregnant women
Associated with increased incidence of miscarriage, preterm labor, preeclampsia, infection,
postpartum hemorrhage, and intrauterine growth restriction.
 Can cause PICA
 What diet??**: High in Iron: red meats, spinach (GLV), broccoli, dark chocolate, egg, liver,
beans, legume, cashews
Hypertension
 Chronic: <20 weeks’ gestation
 Gestational: after 20 weeks
 Risks:
o Placental abruption
o Growth restriction (fetus)
o Preterm birth
Incompetent cervix: Stays open during pregnancy without contractions
 Passive and painless dilation of the cervical without labor or contraction of the utterer
 May occur in late 2nd or early 3rd trimester
 Related to cervical trauma, excessive cervical dilation, ingestion of DES by a woman’s
mother.
 Management:
o Bedrest (temporary) hydration, tocolytics (smooth muscle relaxer) Ibuprofen
(NSAID), Pelvic rest
o Cerclage may be placed at 11-15 weeks, removed at 37 weeks***: requires sutures
o Risk with cerclage: premature rupture of membranes, preterm labor, infection. (May
be on antibiotics)
o GOAL: Get to 37 weeks
HELLP syndrome
 Can occur with severe preeclampsia (but not everyone), because of the mag sulfate
 Lab diagnosis: Hepatic Function***
o H – hemolysis
o E- elevated
o L- liver enzymes
o L- low
o P- platelets
o AST, ALT (4-20) (3-21)
 R/F:
o Acute Renal failure & acute respiratory failure
o Hemorrhage
o Pulmonary edema
o Maternal death
o Disseminated cardiovascular coagulation (DIC)
o Stroke
o Sepsis
Placenta previa: Placenta is covering the cervix ***PAINLESS BRIGHT RED***
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Low-lying (c): vaginal
Partial or marginal (A): cesarean
Complete (B): cesarean
Painless bright red vaginal bleeding: *will know the dangerous amount to go to ER
Never perform vaginal exam on a woman who is bleeding unless you know location of
placenta.
Can never deliver baby through placenta: cesarean
ALWAYS tell doctor you have this** NOTHING IN
Pelvic rest: NOTHING IN
Possible Bed rest
NEED IV ACCESS
Abruptio placentae (abruption)
***CONSISTANT RIGID ABD & DARK RED (WINE) ****
 Premature separation of placenta from implantation site after 20 weeks: Uterine Wall
 Signs: vaginal bleeding, severe abdominal pain (rigid board-like abdomen) *****,
uterine contractions (hypertonus), port wine strained amniotic fluid**** (depends on
which part of placenta)
 ABD TRAUMA can cause this***
 Emergency Cesarean**
 PRIORITY IS MOM**
 Multiple gestation can cause this
Preeclampsia
 Mild: outpatients until severe
o BP 140/90 or greater
o Urine dipstick protein > 1+
 Severe: Gets worse and worse
o BP 160/110 or greater
o Urine dipstick protein > 3+
o Persistent or severe headache: even after Tylenol
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o Blurred vision; photophobia
o Epigastric pain: Right upper quadrant
o Intrauterine growth restriction of fetus
Only cure is delivery: induce her
A lot of weight gain is a red flag, can be R/T facial edema or edema in feet
Seizure changes is from pre to eclampsia
Decreased placental perfusion and organ perfusion
Clonus ticks = sicker mom (+3)
Decrease stimulation
Seizure precautions: Suction, Padded rails, 02
Mom might be combative or confused after a seizure**
Can have chronic HTN or cardiovascular disease later in life**
R/F:
o Family HX or previous preeclampsia
o Twins
o African American
o Obesity
o Younger than 19 or older than 46
Labs
o Creatinine, BUN (CMP)
o AST, ALT (CMP)
o Platelets (CBC)
o Urine analysis
Medications
 IV Magnesium sulfate with Bolus: CNS depressant, smooth muscle relaxant; used to
prevent seizures. Usually on taken for a max of 4 days due to relaxation of the heart
muscle. ***
 Check BP for Baseline before administration***
o Loading dose: 30 minutes stay at bedside for reaction, can become nauseous
o Maintenance dose
o ANTIDOTE: Calcium Gluconate
o Still on mag 24 hours after delivery
o FALLS RISK
 Steroids, Labetalol
 Assessment: RR (12 or >), LOC, DTR, Urine output (foley, which is assessing the kidney
function as well) serum mag levels (4-7mg/dL is normal) **, Check o2
Mag Toxicity: Stop immediately, Loss of LOC, Low B/P, can make the uterus relax too
much*, prevent respiratory or cardiac arrest. DC immediately. ** 7+ is toxic
 Interventions:
o Seizure precautions, Foley catheter, falls risk, safety, bedrest, decrease stimulation,
monitor FHR, ask about fetal movement
o Teach to take B/P at home, weigh herself at home (same time same scale), count kick
counts, 10-12 movements over every 2 hours, report worsening symptoms
Pregestational diabetes
 Type 1 or type 2 (more common)
 Glucose crosses placenta; insulin does not.
 Fetus produces insulin around 10th week.
 First trimester (weeks 7-15) prone to hypoglycemia due to metabolic changes related to
hormones.
 Second and third trimester insulin needs may double or quadruple.
 SELF monitoring should be reviewed at every visit*
 A1C if for 3 months because RBC last 3 months** : Anemia can falsely increase**
 Risk factors:
o Early pregnancy loss
o Macrosomia (infant >4000gms): big baby
o Comorbidities (especially hypertensive disorders): preeclampsia
o Preterm labor
o Polyhydramnios: too much amniotic fluid
o More common & serious infections
o Postpartum hemorrhage
o Increased risk of cesarean delivery.
 Fetal risk factors:
o Unexplained fetal death
o Congenital anomalies
o Macrosomia
o Hypoglycemia
o Respiratory distress
o Prematurity
Gestational diabetes
 Risk factors:
o Obesity
o Family history
o Age >35
o Comorbidities
o Having a previous infant >9lbs at birth
 Screenings:
o 1 hour glucose tolerance test 24-28 weeks
o If abnormal followed by 3-hour OGTT: Test before glucose, then at 1 hr, 2 hr and 3
hr: 2 elevated? = Gestation Diabetes
 Treatment:
o First step: dietary modifications (diabetic diet) and exercise ** (uterine contractions
can occur during this) **
o Step 2: insulin
o Oral antidiabetics not often used because they cross the placenta insulin does not cross
the placenta.
 Complications: can be same as with pregestational diabetes
o At greater risk of developing diabetes later in life. (Type 2) *
o Cesarean**
o Encourage breast feeding**
o Birth control (Contraceptives)
Preterm labor (Spontaneous) - Most common
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 Spontaneous abortion: Complete cerclage, early pregnancy bleeding
Diagnosis based on 3 factors: MUST have all 3
o 20-37 weeks’ gestation
o Uterine activity (contractions)
o Progressive cervical change (effacement and/or dilation)
Risk factors: history of PTL, multiple gestation, 2nd trimester bleeding, African American
race, low pre-pregnancy weight, genital tract infections.
UNTREATED BACTERIAL VAGINOSIS can cause preterm labor****
Signs:
o Painful or painless contractions every 10 minutes for 1 hour or more***
o Lower abdominal cramping
o Painful menstrual-like cramps
o Dull, intermittent low back pain (below waist): coming and going & bloody show
o Suprapubic pain or pressure
o Pelvic pressure or heaviness (feels like baby is pushing down)
o Changes in character of cervical discharge or amount
o Rupture of amniotic membranes “preterm rupture of membranes”
o Signs of UTI
Treatment:
o Lifestyle modifications: decrease in activity, lifting, riding long distances
o Pelvic rest, bedrest
o Tocolytic medications- (relax smooth muscle) OFF AT TERM
 **Terbutaline: oral or SC (must take pulse rate, if >120 hold) (Tachycardic)
 Magnesium sulfate: smooth muscle relaxer but can also decrease chance for
Cerebral Palsy in a per term baby** Used if Terbutaline doesn’t work or given
for 48 hours already, or if 3-4 cm dilated. ***
 Indocin
 Procardia (nifedipine): Headache*
 Corticosteroid (Betamethasone): Develops premature lungs in preterm baby*
 Nifedipine and Magnesium given together can cause skeletal muscle blockade
(paralyze) the transmission of nerve impulses at the myoneural junction*****
Tocolytic Therapy
 Contradictions: FETUS
o More than 37 weeks
o Fetal Demise: Still Birth*
 Contradictions: MOM
o Preeclampsia
o HTN
o Hemorrhage
The five P’s
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Passenger (fetus)
Passageway (birth canal)
Powers (contractions)
Position (mother)
Psychologic response
Passenger
 Presentation- part entering pelvic inlet first.
o Cephalic (vertex) HEAD**
o Breech (buttocks, feet, or both)
o Shoulder (scapula)
 Fetal lie, attitude, and position (all factors that determine presenting part)
Fetal lie
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Relation of long axis (spine) of fetus to long axis (spine of mother
Longitudinal/vertical: parallel
Transverse: at a right angle
Oblique: at an angle.
Fetal attitude
 Fetal head flexed or extended.
 Typically flexed, chin to chest, allows easy passage through maternal pelvis
 If extended may not be able to fit through pelvis.
Fetal position
 Relationship of reference point on presenting part (occiput, sacrum mentum) to the four
quadrants of the maternal pelvis
 Denoted by 3 letters:
o 1st- location of presenting part (right or left)
o 2nd – specific presenting part
o 3rd location of presenting part in relation to pelvis (anterior, posterior, or transverse).
Fetal position
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Occiput – back of head***
Mentum- face
POST: head to back (A)NTERIOR: head to (A)abdomen
Transverse: back to the side of the mom
Station
 Relationship of presenting part to an imaginary line drawn between the maternal ischial
spines.
 Engagement
 Largest diameter of presenting part
 Is at level of ischial spines. (=0) **
 “+” = closer to delivery***
 **test doesn’t state epidural = no epidural**
Problems with passageway
 If mother’s pelvis is not gynecoid shape may not accommodate baby
 Macrosomia: Big baby
 Cephalopelvic disproportion (CPD)- baby’s head unable to fit through maternal pelvis.
Powers
 Primary- involuntary contractions.
o Effacement- thinning of cervix (0-100%)
o Dilation- opening of cervix (0-10cm)
 Secondary- mothers bearing down or pushing with contractions.
 Ineffective primary powers: **Mom might be too tired**
 Amniotomy- puncture hole in amniotic sac; fetal head applies pressure to cervix:
breaks water*
 Priority assessment – FHR; also assess amount, color, odor.
 Augmentation- IV Pitocin; increase amount until contractions are every 2-3 mins &
moderate intensity.
Fetal movement
 10 kicks in 2 hours
 Eat before counting
 Concentrate
Induction of labor: **Cervix must be soft to efface and dilate**
 Chemical or mechanical initiation of uterine contractions before their spontaneous onset.
 Chemical: prostaglandins to ripen (soften) cervix may stimulate contraction (Cytotec,
cervidil, prepidil) Pitocin: Causes contractions**
 Mechanical
o Foley catheter balloon
o Laminaria
o Stripping of membranes: Breaking the water manually
o DON’T want a firm Cervix**
 Indicated if continuing the pregnancy can be dangerous to mom or baby
 Rupture the membranes (amniotomy) or starting oxytocin (Pitocin)
 Woman must know the risks, benefits, and alternatives as part of the consent
Maternal position
 Change positions frequently- helps to relieve fatigue, promotes comfort: Improves
circulation and helps baby maneuver thru the cervix***
 Positions for second stage of labor (pushing) dependent on condition of mom and baby and
PHCP preference.
Mechanism of labor
 Seven cardinal movement:
o Engagement
o Descent
o Flexion
o Internal rotation
o Extension
o External rotation
o Expulsion
Rupture of membranes
 Methods to determine ROM
o Nitrazine paper
o Fern test
o Amnisure swab
 Increased risk of infection if >24 hours
 What do we assess? Priority FHR****
 Monitor temperature q2 hours
 **Amniotic fluid: Should be clear and odorless (maybe meconium stained) **
o Polyhydramnios: too much fluid
o Oligohydramnios: too little fluid
o Meconium stained:
 1st stool before birth
 Place infant at risk for meconium aspiration
 Requires skilled neonate CPR at bedside
 Suction meconium below cords before their 1st breath
 The FHR should be assessed immediately to detect any changes, Tachycardia is
common.
 Chorioamnionitis: Bacterial infection of the amniotic cavity
o S/S:
o Maternal fever
o Fetal tachycardia
o Uterine tenderness
o Amniotic fluid with an odor (foul smell)
Phases and stages of labor
 Stage 1: 0-10 cm
o Phase 1: Latent – Dilate 0-3 cm
o Phase 2: Active – Dilate 4-7 cm
o Phase 3: Transition – Dilate 8-10 cm
 Stage 2: From complete dilation and effacement to delivery of the baby
 Stage 3: From delivery of the baby to the delivery of the placenta
 Stage 4: The first hour after delivery
Monitoring
 TOCO: measures pressure changes with uterine contractions
 Duration: how long it lasts
Stage 1: latent phase:
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Dilates 0-5 cms
Contractions: 5-30 min apart, 30-40 seconds long, mild intensity.
Promote comfort, ice chips, empty bladder q2h, encourage breathing and relaxation.
Assess FHR, VS q4h (unless ROM then q2h) and emotion of mom*
Usually, happy, excited, nervous.
Stage 1: Active phase: active pushing and urges to bear down
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Dilates 6-10 cm
Contractions: 1.5-5 min apart, 40-90 seconds long, moderate to strong intensity
Becomes more labor focused, may ask for and receive pain medications.
Promote comfort, position changes, ice chips, assist with breathing techniques and
relaxation, empty bladder frequently (full bladder can inhibit fetal descent)
 Monitor FHR, VS Tachycardia can be associated with infection**
 Assess frequency, duration, intensity, and resting tone**
Stage 1: transition phase
 Dilates: 8-10 cm
 Contractions: 2-3 min apart, 45-90 seconds long, strong and intense.
 May feel rectal pressure and urge to push. (CANNOT PUSH UNTIL 10 CM, IF SHE
PUSHES BEFORE THIS THE CERVIX MAY SWELL, A SWOLLEN CERVIX
DOES NOT DILATE!): can lacerate or tear: Risk for Hemorrhage***
 Common to have N/V, mood very intense, irritable
 Offer ice chips, cool wash cloth, lots of encouragement, keep bladder empty, encourage deep
breaths to avoid hyperventilating.
 May note early decelerations on fetal monitor strips.
Pain management in labor (NO IV DRUGS DURING TRANSITION PHASE)
 Epidural is a regional anesthesia that blocks pain in a particular region of the body. The goal
is to give pain relief and not anesthesia.
 Epidural blocks the nerve impulses from the lower spinal segments, resulting in
decreased sensation in the lower half of the body. (STERILE) This will not remove the
pressure sensations when the fetus descends the pelvis**
o Side effects: Numbness and Tingling below waist (no intervention)
o Hypotension: Bolus and oxygen. FHR can drop so reposition**
o Low platelets: below 100,000 Anesthesia will decide to proceed or not
 Drug class called local anesthetics.
 Spinal= Immediate
 Epidural= 10 minutes
 Check BP**
 SPINAL TATTOO? Don’t initiate**
IV narcotics: Start with Nitrous Oxide
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Demerol
Stadol
Assess dilation before administration
Respiratory distress in fetus
NARCAN
Don’t give to a drug dependent mom (Suboxone)
ASSESS FHR, RR, BP BECAUSE OF EFFECT ON 02 BEFORE
ADMINISTRATION**
General Anesthesia can cause:
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Abruption
Prolapsed cord
Fetal HR drops (decelerations)
Emergency Delivery or a C-section
Crosses placenta (resp distress in fetus)
Clotting problems (PT, PTT)
Low platelets
Side effects of an epidural
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Low BP
Loss of bladder control
Itchy skin
Feeling sick
Inadequate pain relief
Headache
Slow breathing
Temporary nerve damage
Infection
Permanent nerve damage
Check PT and PTT
Stage 2: delivery of infant
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Begins when 10 cm dilated, ends with deliver of infant: 100% effacement
Contractions may space out
Can last up to 2 hours
Require a lot of energy
May want to give up, needs lots of encouragement and support.
May feel burning when fetal reaches perineum (+4 station) Crowning**
Encourage mom because she can’t see progress**
Cesarean Section
 Delivery of infant through abdominal incision
o Low transverse (bikini cut) (invasive)
o Vertical- always a repeat c-section (invasive)
o History of uterine rupture must always have repeat c section
 Primary or elective: preserves life and health of mom or baby
 Trial of labor after cesarean (TOLAC)
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Vaginal birth after a cesarean (VBAC): 3+ sections, or vertical decisions always repeat
Breach Position**
Anesthesia
Foley
Have them up walking as soon as possible*
Check mom’s emotional response and promote bonding and comfort for mom and family
Watch baby safety may be drowsy from the procedure.
Stage 3: delivery of placenta
 begins with delivery of infant, ends with delivery of placenta
 spontaneous or manual: Spontaneous: 5 Minutes
 separation noted by firmly contracted uterus, sudden gush of dark blood (introitus) and
lengthening of umbilical cord
 examined to ensure it is intact
 fragment of placenta left in uterus can result in postpartum hemorrhage and infection
 fetal side (shiny Shultz), maternal side (dirty Duncan)
 cultural considerations.
 Vaginal Fullness
Stage 4: immediate recovery
 first 1-4 hours after delivery
 mother recovering from birth process, infant adapting to extrauterine life
 VS monitored q15 min first hour, q30 min second hours, temp at beginning and end unless
abnormal
 Assess fundus, lochia, perineum, incision site with cesarean section, keep bladder empty,
assess for return of sensation and movement if pat has epidural.
 Placenta Care
 Assess for bonding, baby adaption to the new world**
 At delivery: FUNDUS AT UMBILLICUS**
Cultural considerations
 Discuss any concerns or requests related to culture.
 Want to ensure best experience possible.
 Considerations:
o Some women may be very stoic during labor other very vocal.
o Fathers may or may not be present.
o May prefer alternate positions for deliver such as squatting.
o May prefer or request female caregiver: If available*
Contractions
 Duration is from the beginning of a contraction to the end of the same contraction.
 Frequency is from the begging of one contraction to the beginning of the next
contraction.
 Intensity is the strength of the contraction.
VEAL CHOP
V- variable decel
C- cord compression
E- early decel
H- head compression
A- Acceleration
O- OKAY, Oxygenated
L- late decel
P- Placental Insufficiency
Interventions: (must take action)
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put on oxygen. Nonrebreather*
turn off Pitocin stops contractions
turn to side: increases perfusion
increase IV fluids: BOLUS
Call PCP.
Actions to take for prolapsed cord: Loop of umbilical caught between vaginal wall and
baby’s head
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Rapid decent in fetal HR**
Prepare for emergency c section.
Bradycardia and Variable decelerations can indicate this**
Forceps: Because FHR can decrease. Assess, record and report before and after this
application
GET PRESSURE OFF CORD to restore blood flow**
Assess FHR closely and for several minutes after ROM to determine well-being of fetus &
document
Rupture of membranes can cause this*
Wrap cord in normal saline in an acute setting
Post term Labor
-More than 42 weeks*
Mom:
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Dysfunctional labor
Macrosomia injury
Hemorrhage
Infection
Fetus:
 Abnormal growth
 Oligohydramnios
 MD normally induces at 41 weeks
Dysfunctional Labor (Dystocia)
-Long, Difficult, or abnormal labor
 Ineffective contractions or maternal bearing down efforts
 Different pelvic structures: abnormal maternal bony pelvis or soft tissues abnormalities or
the reproductive tract (passage)
 Fetal causes: abnormalities of presentation, position. Or development
 Maternal position, fatigue, dehydration
 Shoulder Dystocia: Legs back FAR and head back FAR (McRoberts Maneuver)
o Can cause brachial plexus**
o The anterior shoulder can’t pass
o Shortens the birth canal
Moms who are at increased risk for:
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Over wt.
Short suture
Infertility
Uterine abnormalities
Macrosomia
Too much Pitocin (oxytocin)
Precipitous Labor: Less than 3 hours
 Placental abruption: hypertension? trauma?
cocaine?
Complications:
Fetus:
 Fetal hypoxia
 Changes in fetal HR
 Unnecessary CS for FHR patterns
Mom:
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Pain
Abruption
Uterine rupture
Postpartum hemorrhage
Infection
Peri-rectal injury
Obesity
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Increasingly serious problem for pregnant women
Likely to begin pregnancy with pre-existing conditions
HTN
Diabetes
Increased r/f of postdate pregnancy and complications
Nursing care has many challenges
Oxytocin: HIGH ALERT
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Hormone-posterior pituitary gland; stimulate contractions
Induce or augment slow labor r/t poor uterine contractions
HIGH alert 1mu/min: 1 ml/hr.
Placental abruption
Uterine rupture
Unnecessary c-section (she will keep bleeding, NOT good)
Post-partum hemorrhage (uterus isn’t clamping down)
Infection
Fetal hypoxemia acidemia (PH becomes more acidic) (they take ABG’s blood gases)
Oxytocin (Pitocin) Augmentation of labor requires careful monitoring of fetus
 Implement management of hypnotic uterine dysfunction
 Stimulation contractions/labor unsatisfactory progress
Oxytocin infusions or Amniotomy (rupture of membranes)
Contradictions:
 Unfavorable fetal position
 Contraindication of a vaginal delivery (Placenta previa, active herpes, macrosomia, fetal
distress, early preterm labor)
 Maternal Oliguria (little output): Notify MD (less than 30 ML an hour)
 Preeclampsia? Kidney problems?
 Don’t shut off Pitocin, Notify MD FIRST
Forceps
-Maternal indications: prolonged second stage of labor
-Fetal indications:
 Abnormal FHR tracing
 Certain abnormal presentations/arrest of rotation
 Delivery of head in breach presentation
Vacuum Assisted birth
Attachment of vacuum cup to fetal head using negative pressure to assist birth of head
Prerequisites:
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Completely dilated cervix
Vertex presentation/engaged head
Ruptured membranes
No suspicion of CPD (pelvic disorder)
Rupture of Uterus
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Multiple c-sections because of the scar
Overdistended uterus: multifetal or macrosomia
Augmented or induced labor with intense contractions
No previous vaginal births, Uterine trauma, Forceps delivery, Infection, Short
interpregnancy interval
 S/S
o Abnormal FHR and loss of contraction tracing
o Tetany (muscle spasms) of uterine muscle
o Loss of fetal station
o Abdominal pain/shock
LABS: Normal Values
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PTT: 60-70 seconds
PT: 12-14 seconds
BUN 10-20
Creatinine: 0.5-1.1
AST: 4-20 Units
ALT: 3-21 Units
Magnesium: 4-7 meq