OB Exam 1 Study Guide PDF

**Medications** - Rhogam - Blood product: 2 RN CHECK - Im injection - Mom gets another dose after baby is born - Methotrexate - [Nifedipine: suppresses contractions] but may cause hypotension, (give hypotensive education), do not give with mag sulfate - [Mag...

**Medications** - Rhogam - Blood product: 2 RN CHECK - Im injection - Mom gets another dose after baby is born - Methotrexate - [Nifedipine: suppresses contractions] but may cause hypotension, (give hypotensive education), do not give with mag sulfate - [Mag Sulfate: must have no contraindications, antidote is calcium gluconate ] - [contraindication] - [Active vaginal bleeding ] - [Dilation of cervix \> 6 cm ] - [Greater than 34 weeks ] - [Acute fetal distress ] - [Chorioamnionitis] - [Betamethasone: enhances fetal lung maturity,] may cause hyperglycemia in mom (bc its a steriod). Takes 3 days to take full effect - Ampicillin: commonly used to treat chorioamnionitis - [Epidural: causes hypotension: Ephedrine used to treat] **Gyne Exam** **Contraception** **Pregnancy and Antepartum** - 1^st^ trimester (week 1 --13): fetal organ development - Physical changes are no obvious, pt may look forward to changes so preg is more noticeable - 2^nd^ trimester (week14-27): maternal tissue growth - Rapid physical changing in abdomen and breast - May affect mobility, skin, balance, back or leg discomfort, & fatigue - Risk of negative body image - 3^rd^ trimester (week 28-42): fetal tissue growth - Changes in vital signs - HR increases 10-20 bpm around 32 weeks - RR slightly increases in third trimester - BP: sbp remains the same, dbp will decrease 5-10 mmhg in second trimester - Anytime there is a abnormal vital signs itll be obvious!! HR 120+, very low bp, rr will be very high / low - Side lying position relieves pressure on major blood vessels - *[Changes in body systems ]* - Reproductive: uterus grows up an out - 36 weeks: fundus is at xiphoid process pushing against diaphragm which can cause SOB - Mucus plug forms over cervix to provide a protective barrier - Chadwicks sign: dark blue color of cervix & vagina - Goodells sign: softening of cervix - Cardiovascular: - Increased blood volume and cardiac output - Increased HR (by 10-20 bmp) - Decreased systemic vascular resistance ( hormones cause vasodilation) - Lower extremity edema - INCREASED risk for blood clots and dvt - Interventions: ambulate, scds, dont sit cross legged - Supine hypotensive syndrome: mom goes HYPOTENSIVE from laying on back - s/s: dizziness, lightheaded, pallor, clammy, syncope - Educate: avoid laying flat on back, get up slowly, sit on side of bed prior to stand, [ lay on left lateral side for best perfusion] - Respiratory - Increased rr in the THIRD trimester as baby pushes against diaphragm (quicker shallow breaths) - GI - Common complaints: heart burn and acid reflux - Intervention: Stay upright after eating - Constipation - Intervention: stay hydrated, physical activity (20 -- 30 minutes walking), increased fiber intake, stool softener - Gallstones - Cholesystectomy - Morning sickness - GU - Increased urinary output / urinary frequency - Relaxation of muscles in ureters and bladder from progesterone = urinary stasis - Risk for UTI - Treat with antibiotic - Skin - Warmer and sweatier due to increased circulation - [Chloasma]: an increase of pigmentation on the face \"pregnancy mask\" (go away after preg) - [Linea nigra]: dark line of pigmentation from the umbilicus extending to the pubic area (go away after preg.) - [Striae gravidarum]: stretch marks mostly found on abdomen & thighs - Musculoskeletal - Posture, gait, and balance changed = risk for falls and sprains - Sway back - Waddling gate from relaxation of pelvic joints (from relaxin) - [Diastasis recti] is the separation of abdominal muscles (don't go back together after preg) - Endocrine - Hormones have two main purposes : maintain pregnancy and preparing the body for delievery - Human Chorionic Gonadotropin (hCG) - Progesterone - Estrogen - Human Chorionic Somatomammotropin (hCS) - Relaxin - *[Confirmation of pregnancy]* - Presumptive - changes that make Pt suspects they\'re pregnant - Amenorrhea (no period) - Fatigue - Nausea & Vomiting - Urinary Frequency - Breast Changes - Hyperpigmentation - Quickening (Fetal movement) - Uterine Enlargement - Probable - Changes that make examiner think pt is pregnant - uterine enlargement - Cervical softening - Changes in uterine consistency - Braxton Hicks contractions - Positive Pregnancy Test - Palpation of fetal outline - Ballottement (examiner taps uterus and feels baby fall against uterus - Positive - Signs that can on be 100% pregnant - Auscultation of fetal heart sounds - Visualization of fetus via Ultrasound - Fetal Movements felt by examiner - Verify pregnancy - Blood and urine tests based of of hcg level - High hcg = multifetal pregnancy, ectopic pregnancy, or genetic abnormalities - Low hcg = miscarriage occurred - *[Antepartum assessment, care, and education]* - Need baseline vitals \* - Verify pregnancy and determine any needs the family may need (psychosocial, teaching, counseling, etc.) - Establish GTPAL (term is 37 weeks) - Estimated delivery date: first day of last period - 3 months + 7 days - Routine Labs - CBC: detects infection & [anemia ] - Blood type & Rh factor: determines blood type to screen for maternal-fetal blood incompatibility - If rh doesn\'t match mom will make antibodies against baby\'s blood. Gets worse with each pregnancy - Venereal Disease (VDRL/RPR): screens for syphilis (mandated by law) - Rubella titer: determines immunity to rubella - Hepatitis B: detects hepatitis B carriers - HIV: detects HIV infection (so baby can get treatment if needed) - Urinalysis: confirms pregnancy, helps detect GDM, GHTN, infections, or renal disease - Vaginal/rectal cultures: detects chlamydia & gonorrhea (tested early pregnancy) and group B Streptococci (GBS, tested late pregnancy -- 35-37 weeks) - Multiple marker screen: screens for fetal anomalies - Glucose challenge test: screens for gestational diabetes (GDM, occurs only during pregnancy) 1 hour and 3 hour test - Danger signs of pregnancy - Vaginal bleeding - Leakage of fluid from the vagina - Swelling of the fingers (rings become tight) or puffiness of the face or around the eyes - Continuous pounding headache (worse than a migraine) - Visual disturbances (such as blurred vision, dimness, flashing lights, spots before the eyes) - Seizures - Persistent or severe abdominal or epigastric pain - Fever (infection present) - Painful urination - Persistent vomiting (cant keep anything down at all) - Change in frequency or strength of fetal movements - Signs of preterm labor: Uterine contractions, cramps, constant or irregular low backache, pelvic pressure, watery vaginal discharge - \*\*Signs of Hyperglycemia: Increase thirst, increase urination, increased hunger - \*\*Signs of Hypoglycemia: Clammy skin, pale, weakness, jitteriness, irritability, lightheadedness **Nutrition for childbearing** - 1st Trimester -- weight gain should be approximately 2-4 lb\*\* - 2nd & 3rd Trimesters -- gain approximately 1 lb per week\*\* - Client Edu - Increase calories - Increase protein intake - Folic acid: green leafy veggies (broccoli, kale, spinach) - Iron supplements: red meats, beef, turkey, chicken, fish, poultry, beans, peanuts) - Take with vitamin C (orange juice) to help absorption; milk & caffeine interfere with absorption - Calcium (milk, yogurt -- involved in bone & teeth formation) - Take with vitamin d to increase absorption - Drink 80 oz of water daily (8-10 glasses) - LIMIT CAFFEINE: less than 200 mg a day - Don't take calicum or caffiene with iron bc it decreases absorption\* - Caffeine increases excretion of calcium - Complications - Nausea - Small frequent meals every 2-3 hours - Avoid: alcohol, caffeine, fried, fatty, & spicy foods - Avoid: consuming excessive amounts of fluid - Help: ginger (ginger ale soda, ginger tea, ginger candies (sugar free)) - Help: herbal tea (peppermint, raspberry) - Constipation - Increase fluids - Increase fiber intake (fruits, veggies, whole grains) - Physical activity (walking and swimming) **Infections During pregnancy** - HIV - Hep B - Rubella - HSV - Need to start taking suppression medication at 36 weeks to prevent active outbreak and transmission to neonate - If pt actively has genital herpes, c-section is the standard to avoid transmission - Group B strep - Naturally bacteria found in GI and vagina - Life-threatening to newborns, screened for at 35-38 weeks - IV antibiotics are given during labor to decrease transmission to newborn. Also, the standard if GBS status is unknown. - Syphilis - Screen for using a blood test at initial pregnancy visit - Must be treated with antibiotics, need to COMPLETE all antibiotic then be retested - Partners must be tested - Chlamydia - If not treated during pregnancy, can cause PROM, preterm labor, & postpartum endometritis - Can cause conjunctivitis and pneumonia to newborn - Done at initial pregnancy visit, oral antibiotics given for 3 weeks then must be retested - Partners must be tested - Gonorrhea - If not treated during pregnancy, can cause PROM, preterm labor, & postpartum endometritis - Can cause neonatal sepsis and blindness - Trichomoniasis - most notable symptom in women is a yellow-green or fluorescent green vaginal discharge with a foul odor. - Untreated can cause pelvic inflammatory disease & fallopian tube blockage - Treatment is Metronidazole or tinidazole -- orally, however, this medication is not given during the 1st trimester due to the teratogenic effects on the fetus. - HPV - Causes genital warts and cervical cancer - Do not receive the vaccine during pregnancy - Unlikely to complicate pregnancy **Fetal assessment** - Ultrasound - Need a full bladder\*\* drink 32 oz of water - Transabdominal 1^st^ trimester, transvaginal 2nd and 3^rd^ trimester - Nonstress test - Monitors response of fhr to fetal movement, toco monitors moms contractions - Indications to perform nst - Decreased fetal movement - Intrauterine growth restriction (IUGR) - Postterm fetus - Gestational hypertension (GHTN) - Gestational diabetes mellitus (GDM) - Oligohydramnios (low amniotic fluid) - Multiple gestation - Biophysical profile - Determines fetal well-being by visualizing physical and physiological characteristics of baby - Just a nst with an ultrasound - 4/10 and lower - Chorionic villus sampling - Diagnoses fetal chromosomal, metabolic, and DNA abnormalities - Done in first trimester, catheter goes into cervix - Education prior = EMPTY BLADDER - Education post: spotting or bleeding like a period, clots / tissue passage, cramping, leaking of fluid, temperature of 100.4 - Amniocentesis - Assesses for neural tube defects or chromosomal disorders - Done in second and third trimester, needle inserted in abdomen into amniotic sac using ultrasound - Education prior = EMPTY BLADDER - Education post: spotting or bleeding like a period, clots / tissue passage, cramping, leaking of fluid, temperature of 100.4 - Complications - Amniotic fluid emboli - Maternal or fetal hemorrhage - Maternal or fetal infection - Miscarriage - Premature ROM **Hemorrhagic conditions of early pregnancy** - Spontaneous Abortion - Pregnancy ends from natural causes before 20 weeks - Risk factors - Chromosome abnormalities - Advanced maternal age - Premature cervical dilation - Chronic maternal infections - Maternal malnutrition - Substance use - Trauma or injury - - Expected findings - Vaginal bleeding - Uterine cramping - Expulsion of products of conception (partial or complete) (if cant happen naturally a dnc is done to remove products) - Client edu - Notify provider of heavy, bright red vaginal bleeding, a fever, or foul-smelling vaginal discharge - Take prescribed antibiotics - A small amount of discharge is normal for 1-2 weeks - Refrain from tub baths, sex, tampons, douches for 2 weeks\*\*\* - Ectopic pregnancy - Implantation of ovum outside the uterus - Risk factors - Stis,tubal surgery,iuds, mulitple induced pregnancies - Expected findings - Missed menstrual period, abdominal pain & vaginal bleeding - [RUPTURE: Abrupt unilateral stabbing pain in lower abdomen with or without vaginal bleeding\*\*] - Management - Methotrexate: oral med that stops cell division & embryo enlargement - Surgical: Salpingectomy to remove ectopic pregnancy fallopian tube - Ruptured requires salpingectomy with ligation of bleeding vessels (emergnecy\*\*) - Client edu - Methotrexate - Avoid alcohol: decreases effectiveness - Avoid folic acid: toxic response - Avoid nsaids **Hemorrhagic conditions of late pregnancy** - Placenta previa - Placenta attaches low in the uterus covering the cervix, cannot have a vaginal birth - Risk factors - Advanced maternal age 35+ - Multiparas - Previous c-section / uterine surgeries - Prior placenta previa - Multifetal pregnancy - Smoking - Expected findings - Sudden onset of painless bleeding that is BRIGHT RED after 20 weeks - Diagnosed via ultrasound - Management - Conservation management : at home or hospital to stop bleeding (bed rest with bathroom privileges) - Placenta abruption - Placenta partial or completely seperates from uterine wall, bleeding may or may not occur (concealed). Most likely to happen in third trimester - Risk factors - HYPERTENSION\*\*\* - PROM - Abdominal trauma - Cocaine use - Nicotine use - Multifetal pregnancy - Increased age - Prior placental abruption - Expected findings - Intense localized pain with a board like abdomen \*\*\* - Dark red vaginal bleeding - Fetal distress - Management - Immediate delivery if s/s of fetal compromise or excessive bleeding (hypovolemic shock) - s/s of hypovolemic shock: high hr, low bp, high rr, sweaty, pale **PROM /PPROM & preterm labor** - Preterm Labor - Uterine contractions AND cervical changes that occur between 20 weeks and 36 weeks - Risk factors - Infections: UTI, STIs, HIV, active HSV, chorioamnionitis - Prior preterm birth - Multifetal pregnancy - Smoking & Substance use - Violence or abuse - Lack of prenatal care - Uterine abnormalities - Low pre-pregnancy weight - Assessment findings - Cervical dilation - Regular uterine contractions - Discomfort: dull lower abdominal pain, back pain, pelvic pressure - Nursing care - STOP CONTRACTIONS\*\* (Will try to stop preterm labor if the patient is 32 weeks) - Bedrest with bathroom privileges - Hydrate - Identify and treat infection - Administer tocolytics to delay labor \* - PROM / PPROM - PROM: rupture of membranes before labor any time after 37 weeks - Pprom: rupture of membranes before labor prior to full term - High risk of infection with rupture of membranes - Risk factors - Infection (most common complication of PPROM) - Chorioamnionitis: infection of the membranes - Prior preterm birth - Short cervix - 2nd & 3rd trimester bleeding - Smoking or substance use - Assessment finding - Client reports a gush or leakage of clear fluid from the vagina - Assess for a prolapsed umbilical cord - Abrupt FHR variable or prolonged deceleration - Visible or palpable cord in the vaginal canal - Complications - Placental abruption - Cord compression - Fetal pulmonary hypoplasia - Fetal demise - Lab test - Ferning (tests to see if its amniotic fluid) - Nitrazine paper (blue = positive) - Nursing care - Depends on gestation age, presence of infection, or if mom / baby distress is present - GBS culture - Limit vaginal exams (infection risk) - Hydrate - Daily fetal monitoring - Pt edu - Keep record of daily kick count - Notify nurse of - Contractions - Vaginal bleeding - Decreased fetal movement - Bedrest with bathroom privileges & avoid tubs - Do not insert ANYTHING into the vagina - For complications: - Depending on gestational age treatment is conservative - Hospitalization can prolong pregnancy while monitoring risk factors - Meds - Ampicillin: treat chorioamnionitis - Betamethasone: enhance fetal lung maturity - **Pain management during childbirth** - 3 types of pain - First is muscle contractions as the cervix is dilating - Second is intense pressure as the baby drops lower and pushes against pelvic muscles - Third is burning / stretching of vagina and skin - Factors that influence pain - Increase fear and anxiety = increased muscle tension and pain - Educate pt on procedures and progression of labor \* - Nonpharmacological Pain management - Education during pregnancy (prior to birth) - Breathing techniques (WATCH FOR HYPERVENTILATION) - Effleurage: light gentle circular stroking of the abdomen in rhythm with breathing during a contraction\* - Sacral counterpressure: heal of hand apply consistent pressure to sacrum to counteract low back pain \* - Pharmacological Management - Analgesia provides pain relief while still allowing the client to sense contractions. - Opioids - Anesthesia eliminates pain perceptions by interrupting the nerve impulses to the brain. - Spinal and epidural - General anesthesia - Opioids - Pt can receive opioids via IM or IV during the early part of active labor, but the intravenous route is recommended, because the action is quicker. - Educate to call for help during ambulation\* - Decreases fhr variability, N/V, neonatal respiratory distress - Administer Narcan if pt goes into respiratory distress \* - Epidural block - Can cause maternal hypertension\*, fetal bradycardia - Ephedrine is used if mom has hypotension, also lay mom on left lateral side and give fluids - Pt must be in active labor and dilated 4 cm - Pressure sensations may still be present - Spinal block - Monitor maternal hypotension, fetal bradycardia, bladder / urine atony, headache (spinal headache: treat withsupine, dark room, PO analgesics, caffeine, fluids) - Used in C-sections, sensation lost from nipples down - General anesthesia - Used when there is a complication or pt has a contraindication to nerve block anesthesia - Nursing Actions - Monitor maternal VS & FHR patterns - Ensure client has been NPO - Apply SCDs - Assess client post-delivery for decreased uterine tone, which can lead to hemorrhage **Processes of Birth** - Premonitory signs of labor - Dilates and effacement of the cervix (opening and thinning) - Lightening: baby drops into pelvis, easier to breath but a lot of pressure in pelvis, dependent edema - Increased energy level: burst of energy 24-48 hours prior to birth "nesting" - Bloody show: mucus plug is expelled - Braxton hicks: false contractions bc there is no cervical change, and theyre irregular - Lessened by activity\*\* - If contractions last longer than 30 seconds and are 4-6 minutes apart call OB - Spontaneous rupture of membranes: sudden gush or steady leakage - Assessment - Time it happened - Amount of water - Color - Odor - Risks - Infection is the main risk (after 24 assess, high fhr + mom has fever) - Cord Prolapse: life-threatening to baby\* assess fhr (will DROP) \* **Stages of Birth** - Stage 1 - Longest stage - Cervical dilation 0-10 cm - Latent phase - Dilation 0-3 cm - Irregular mild contractions every 5-10 minutes - Pt is still at home, [Encourage rest,] monitor fhr - Active Phase - Dilation 3-7 cm - More regular contractions with moderate pain every 3-5 minutes: [focus is pain management\* (epidural, narcotic can only be given slowly during PEAK of contractions)] - Increased anxiety and restlessness, mom needs to be able the hosptial - Transition phase (bc they\'re transiting to the next stage) - Dilation 8-10 cm - Intense contractions every 2-3 minutes - [Focus is the urge to push, get mom ready] - Assess amniotic fluid color, look for meconium-stained fluid (baby is in distress) - Stage 2 - Complete dilation to birth - Pushing stage - Mom may feel like she has to have a bm - Primigravida can take 2 hrs compared to a multigravida where it may be much quicker - Stage 3 - Delivery of the placenta - Begins with birth end with placenta delivery - 5-20 minutes after delivery - Should detach naturally - Stage 4 - Recovery stage - Last 1-4 hrs after birth - Uterine Assessment (assessing for hemorrhage) - Fundus should be firm & well contracted - Initially felt midline between umbilicus & symphysis - Slowly rises to level of umbilicus during 1st hour after birth - If boggy, then massage to firm - Lochia (bleeding after birth) is red, mixed with small clots, & moderate flow - Lochia rubra \--\> lochia serosa \--\> lochia alba - Shouldn't smell bad, have large clots, and shouldn't be heavy (ie. Pad shouldnt need to be replaced every 15 minutes) - Pain assessment - Monitor peri pads (shouldnt be fully saturated in less than an hour) **Intrapartum fetal surveillance** - Leopold maneuvers used to palpate the gravid uterus systematically. - Determines position, presentation, and engagement of fetus in utero. - Best place to put doppler is the firmest surface of abdomen, toco goes at the fundus - Baby needs to be cephalic, breach babies best practice is c --section - Continuous external fetal monitoring - Noninvasive monitoring (nurses place and monitor the devices) - Monitors frequently need to be repositioned as mom and baby move - Continuous internal fetal monitoring - Electrode is twisted into the babies\' scalp to monitor babies hr, very accurate - Intrauterine pressure monitor measures the contraction intensity - Advantage: early detection of abnormal fhr, accurate fhr varitability, mom can move around - Disadvantage: risk for infection, done by a physician, - Look at powerpoint for the display of monitor and baseline info\*\*\* - WRITE OUT VEALCHOP AND THOSE YOU NEED THIS ON THE EXAM\*\*\* - Reassuring - Baby looks good and everything is normal - Non reassuring - Some sort of intervention is needed **Nursing care during labor** - Artificially initiate uterine contractions before spontaneous onset of labor - Indications - Post-term - Labor dystocia - IUGR (intrauterine growth restriction) - Prolonged ROM - Maternal medical conditions (diabetes, hypertension) - Fetal demise - Infection - Mom request (39 + weeks) - Methods - Cervical ripening - Pitocin to initiate or maintain contractions - Nipple stimulation (trigger release of oxytocin) - Complications - Abnormal baseline - Loss of variability - Late or prolonged decelerations - Bishop score: score of 8 and higher indicates a successful induction of labor - Cervical ripening - Increases readiness for labor by promoting softening of cervix = dilation & effacement - Indicated if bishop score is less than 8\*\* - Nursing interventions - VOID PRIOR - Side lying postion - Monitor fhr and uterine activity - Complications - Fetal distress - Tachysystole (hypertonic contractions) - Augmentation of labor - Intervention to stimulate hypotonic contractions once labor has started but slow to progress - Pitocin & artificial ROM - Amniotomy: artificial ROM - Risk: Infection and cord compression - Benefit: decrease duration of labor - Assessment: fhr - Amnioinfusion: infusion of saline into amniotic sac - Indication: - Oligohydramnios: low amniotic fluid - Cord compression causing variable decelerations - Operative delivery - Indications: maternal exhaustion with ineffective pushing efforts or fetal distress during second stage of labor - Vacuum-assisted - Risks: scalp lacerations, fetal cephalohematoma, maternal vaginal trauma - Forceps assisted - Risks: maternal vaginal trauma, facial nerve palsy, facial bruising - Episiotomy - Manual cutting of perineum to increase room for delivery - Shortens second stage of delivery - Prevent cerebral hemorrhage in a fragile preterm fetus - Facilitate birth of a large infant - C-section - Abdominal incision in lower uterine segment to deliver baby - Indications - Breech presentation - Non-reassuring fetal heart tones - Placenta previa - Placental abruption - Previous c-section - Umbilical cord prolapse - High-risk pregnancy: HIV+, active genital Herpes, maternal hypertension, maternal diabetes - Multiple gestations - Vaginal Birth after c-section - Client delivers vaginally after previous c-section - Criteria to be able to do - Only 1-2 previous low transverse cesarean births - No other uterine scars - No prior uterine rupture - Adequate pelvic size - Reason for prior cesarean was dysfunctional labor, breech, or abnormal FHR pattern (these are non-recurring events) - No current contraindications: LGA, malpresentation, cephalopelvic disproportion, previous classical vertical uterine incision **Factors Affecting labor** - 5 ps - Passage (birth canal) - Must be adequate size and shape to allow the fetus to pass through & cervix must be dilated and effaced - Passenger (fetus & placenta) - Placenta must go through birth canal - Factors that impact include - Size of fetus head - Fetal presentation - Body part of baby that is presenting at the cervix - Cephalic : head - Breech: feet / sacrum - Shoulder - Fetal lie - Fetal spinal to mother spine - Longitudinal lie: fetal spine parallel with maternal spine - Transverse lie: fetus horizontal to maternal spine - Not deliver vaginally, requires c-section delivery - Fetal attitude - Fetal posture - Flexion / extension of fetal body parts - Complete flexion present smallest part of fetal skull - Fetal position - Presenting part of fetus in relationship to moms pelvis - Look at powerpoint slide 9 to see - Station - Measurement of fetal descent - Determined by comparing the presenting part of the fetus to the level of maternal ischial spines - Ischial spines are used as guides - Positive station is when you start pushing - Done via vaginal examination - Powers (contractions) - Primary (involuntary)  Uterine Contractions - Contractions cause effacement & dilation of the cervix - Secondary (voluntary)  Maternal Pushing Efforts - Measured in frequency (in minutes) , duration (measured in seconds), intensity (measured most accurately using IUCP or mild, moderate, and high) - Cervical changes - Dilation: 0-10 cm openness - Effacement: 0% - 100% thickness (100% effaced is good) - Position (maternal) - Frequent position changes to provide comfort, relieve fatigue, and promote circulation (sata questions it sounded like)\* - Upright or lateral positions are ideal , DO NOT WANT supine or lithotimy\* - Reduce length of labor - Reduce assisted delivery - Reduce episiotomies & perineal tears - Contribute to fewer abnormal FHR patterns - Increase comfort & reduce requests for pain medication - Allow gravity to move fetus downward - Psyche (feelings, fears) - Factors that promote positive birth experience - Clear info about procedures - Support - Sense of mastery (self-confidence) - Trust - Positive reaction to the pregnancy - Personal control over breathing - Preparation for childbirth experience **Labor complications** - Prolapsed umbilical cord - Cord is being suppressed by fetus or cervix and is compromising fetal circulation - Risk factors - Spontaneous ROM - High station (-3) - Breech or transverse lie - SGA - Expected findings - FHR shows prolonged decelerations after ROM - Visual / palpable part of the umbilical cord through vagina - Nursing care - Call for assistance - Trendelenburg - Use STERILE GLOVES, insert two fingers into vagina & apply pressure to elevate fetus off cord - Administer 02 - Emergent c-section - Labor dystocia - Dysfunctional labor is difficult or abnormal labor related to 5 ps - Risk factors - Maternal pelvis size (passage) - Large fetus (passenger) - Cephalopelvic disproportion: fetal head larger than maternal pelvis (passenger) - Abnormal fetal presentation - Ineffective contractions (powers) - Ineffective maternal pushing d/t fatigue, fear (powers) - Expected findings - Lack of progress in dilation, effacement, or fetal descent - Ineffective pushing - Persistent occiput posterior presentation - Hypotonic uterus: weak, inefficient, or absent contractions - Hypertonic uterus: excessively frequent, strong intensity with inadequate uterine relaxation - Nursing interventions - Encourage maternal position changes - Apply counterpressure using heel of hand to sacral area to alleviate discomfort - Prepare for possible forceps, vacuum, or c-section delivery - If hypertonic, administer analgesics - If hypo, administer Pitocin to augment & strengthen uterine contractions - Uterine Rupture - Muscular wall of the uterus tears, rare but life-threatening emergency - Risk factors - Uterine trauma result of prior c-section\*\*\* (or accident) - Overdistention of uterus (LGA or multifetal gestation) - Hypertonic contractions - Forceps assisted birth - Multigravida pt - Expected findings - Sharp abdominal pain with uterine tenderness - Change in uterine shape - Cessation of contractions - Nonreassuring FHR - Bradycardia - Variable or Late decelerations - Absent or Minimal variability - Nursing care - Prepare for emergent c-section - Administer IV fluids - Administer oxygen - Administer blood transfusion if ordered - Other complications - Meconium-stained amniotic fluid - Sign of fetal distress & hypoxia if variable / late decelerations in fhr present - Precipitous labor - Labor that last 3 or less hours from onset of contractions to time of delivery - Related to hypertonic uterine dysfunction, pitocin stimulation, or multiparous pts - Amniotic fluid emboli - Amniotic fluid enters the maternal circulation - Respiratory distress & circulatory collapse - Occurs during labor, birth, or 30 minutes after birth