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OB Final Review

Concepts Of Maternal-Child Nursing And Families (Nova Southeastern University)

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1. Placenta Previa
The two most clinically significant causes of bleeding in the second half of CAUSE OF PLACENTA PREVIA IS UNKNOWN
pregnancy are: placenta previa and placentae Women at higher risk are:
In placenta previa, the placenta is implanted in the lower uterine segment rather Women of African descent
than the upper portion of the uterus Women who have undergone prior C-section
The placenta is implanted in the lower segment of the uterus or over the internal Other risk factors:
cervical os. High gravidity
Bleeding begins – may be either scanty or perfused High parity
Placenta previa is categorized as being: Advanced maternal age
o Low lying – placenta is in the lower uterine segment but DOES NOT COVER Previous miscarriage
THE OS Previous induced abortion
o Partial – internal os is partially covered Cigarette smoking
o Marginal – edge of placenta is covered Male fetus
o Complete – internal os is covered
Fetal/Neonatal Implications
o Prognosis for fetus depends on the extent of placenta previa
o Woman may be allowed to labor with: marginal and low-lying placenta previa
o Fetus may have changes in: FHR and meconium staining of the aminotic fluid -
FHR monitoring is imperative
o Porfuse bleeding: fetus is compromised and suffers some hypoxia
o If nonreassuring fetal status occurs  C-section is indicated
o Woman with complete or partial previa  C-section because of high risk for
hemmoraging!!!
o Postpartum: blood sampling to check for anemia in the newborn

Clinical Therapy Expectant Management

Goal of medical care is to identify the cause of bleeding and to • Bed rest
provide treatment that will ensure birth of a mature newborn • Bathroom privileges as long as woman is not bleeding
• Transabdominal ultrasound scan to localized placenta • Performing no vaginal exams
• Until placenta previa is ruled out: VAGINAL • Monitoring blood loss, pain, and uterine contractility
EXAMINATIONS ARE NEVER DONE WITH WOMAN WITH • Evaluating FHR with an external fetal monitor
BLEEDING • Monitoring maternal v/s
o Examiners fingers can perforate placenta if • Labs: H&H, Rh factor and urinalysis
cervical dilation has occurred • IV (LR solution)
o Once r/o then examiner can perform vaginal • 2 units of cross-matched blood available for transfusion
exam with speculum to determine cause of • If frequent, recurrent or profuse bleeding persists or if fetal well-
bleed being appears threatened a C-section is needed
• Differential diagnosis of placental or cervical bleeding takes Clinical Signs
careful consideration • Most accurate diagnostic sign of placenta previa: PAINLESS,
• Partial separation: painless bleeding BRIGHT-RED VAGINAL BLEEDING
• True placenta previa: may not demonstrate overt bleeding • First bleeding episode is generally light, scanty
until labor begins • If no vaginal examinations are performed it often subsides
• Confusion between partial and true placental is an issue spontaneously, however each subsequent hemorrhage is more
when diagnosis perfuse
• Care of woman with painless late-gestational bleeding • Uterus remains soft
depends on: • If labor begins, the uterus relaxes during contractions
1. week of gestation during which the 1st bleeding • FHR remains stable unless profuse hemorrhage and maternal
episode occurs shock occur
2. The amount of bleeding • Fetal presenting part is often unengaged and transverse lie is
• If pregnancy is less than 37 weeks’, expectant management common
is used to delay birth until about 37 weeks’ to allow the
fetus time to mature
Nursing Prevent or treat complications
Management • Nurse should assess blood loss, pain and uterine contractility (subjective and objective)
• Maternal V/S and the result of blood loss and urine test
• Monitor maternal vital signs every 15 min in the absence of hemorrhage and every 5 mins with active
hemorrhage
• Evaluate the FHR w/continuous external fetal monitoring
• Observe and verify family’s ability to cope with the anxiety associated with an unknown outcome
• Record, I&O’s, V/S, prepare whole-blood setup to be ready for IV infusion, establish IV site,
• Fluid volume deficit due to excessive blood loss
• Impaired gas exchange of fetus r/t decreased blood volume and maternal hypotension
• Anxiety related to concern for own personal status and baby’s safety
• Check newborns Hgb, cell volume and erythrocyte count STAT and monitor it loosely, baby may require O2 and O
2. Abruptio Placentae
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• Abruptio placentae - is the premature separation of a normally implanted placenta from the uterine wall
• Leading cause of perinatal mortality
• Catastrophic event because of the severity of resulting hemorrhage
• CAUSE IS LARGELY UNKNOWN
• Risk factors:
o Maternal age over 35 or under 20 years old
o Increased parity
o Cigarette smoking
o Alcohol use
o Cocaine abuse
o Trauma
o Maternal HTN and many more
• Abruptio placentae is subdivided into 3 types:
o Marginal – placenta separates at its edges, blood escapes through the vagina
o Central – placenta separates centrally, blood is trapped between placenta and uterine wall
o Complete – massive vaginal bleeding seen in the presence of total separation
Abruptio placentae grading: Maternal Implications
1. Grade 1 (mild) Risk for DIC – serious and can cause death!!!
 Mild separation with slight vaginal bleeding • Because of damage to uterine wall and clotting, large thromboplastin
 FHR pattern and maternal BP unaffected are released into the maternal blood.
 Accounts for 40% of abruptions • Thromboplastin trigger DIC
2. Grade 2 (moderate) • Fibrogen levels decrease (which are normally elevated during
 Partial abruption with moderate bleeding pregnancy)
 Significant uterine irritability is present • Fibrogen levels drop to the point at which blood will no longer
(irritability in uterine is due to the blood that coagulate
invades the tissues between the muscle fibers) • Hypofibrogenemia - an acute hemorrhagic state brought about by
 Maternal pulse may be elevated inability of the blood to clot, with massive hemorrhages
 Blood pressure of mother is stable • Can result in hemorrhagic shock
 FHR – signs of fetal compromise • Fatal to mother if not treated STAT
 Accounts for 45% of abruptions • Postpartum:
3. Grade 3 (severe) o Risk for hemorrhage and renal failure due to shock
 Large or complete separation with moderate o Vascular spasm
to o Intravascular clotting
severe bleeding Fetal/Neonatal Implications
 Maternal shock and painful uterine • When placenta has separated the infant mortality rate is near 100%
contractions present • In less severe separation, fetal outcome depends on level of maturity
 Fetal death common and length of time to birth
 Accounts for about 15% of abruptions • Most serious complications:
o Preterm labor
• If hemorrhaging continues eventually the uterus turns o Anemia
entirely blue because muscle fibers are filled with blood o Hypoxia – if fetal hypoxia is unchecked it can lead to
• Couvelaire uterus is a condition that occurs after birth irreversible brain damage or fetal demise
when
the uterus contracts poorly 
Clinical Therapy Mild Placental Separation
• DIC - there is abnormal coagulation and abnormal bleeding • Vaginal labor may be induced if baby is late preterm
in o If induced labor or oxytocin don’t work  C-section is required
the skin, GI and respiratory system o The longer they delay birth the more risk for increased
• The DIC cascade leads to microclots that disrupt normal hemorrhage
blood flow to major organs and can lead to organ failure Moderate to Severe placental Separation
• Coagulation test results are imperative!!! • Treat hypofibrinogemia 1st by IV cryoprecipitate or fresh frozen
• fibrinogen levels and platelet counts are decreased plasma
• PT and PTT are prolonged (longer to clot) • Then after treatment of hypofibrinogemia then C-Section is done
• Maintain cardiovascular status of mother and baby • Vaginal birth is IMPOSSIBLE
• C-section is the safest option Nursing Management
• Type and cross-match for blood transfusion (at least 3 units) • Electronic monitoring of uterine contractions
• IV fluids • Resting tone btwn contractions
• Evaluate clotting mechanism • Evaluate uterine resting tone for increased tone (frequently
• CVP is monitored hourly to evaluate IV fluid replacement. increased tone with abruptio placentae)
• High CVP may indicate fluid overload and pulmonary edema • Abdominal girth measurement hourly (at level of umbilicus)
• Lab exams: H&H and coagulation status • Uterine size increases with bleeding
• HYPOVOLEMIA – with severe placentae abruptio is life • To measure uterine size from top of fundus to symphysis pubis
threatening and is combated with whole blood • Over distension of uterus can lead to a ruptured uterus (life
• If fetus is under stress C-section is done! threatening)
• With still birth fetus, vaginal birth is preferred if bleeding has
been stabilized
3. Oxytocin (Pitocin)
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Administering oxytocin is effective for initiating uterine • Has effects on the cardiovascular system:
contractions to induce labor and may also use to enhance o BP may decrease
ineffective contractions o Prolonged administration causes an increase above baseline (by
• It has a stimulatory effect on the smooth muscle of the 30%)
uterus and blood vessels o CO and SV increase
• Increases the strength of contractions and o 20 milliunits/min or more makes it a diuretic effect (decrease in
propagations of contractions UO)
• Effects on uterus depends on the dosage used • Oxytocin is used to induce labor at term
• Has a half-life of 3-5 mins • Oxytocin is also used to augment uterine contractions in the 1st and 2nd
• 40 mins to take effect in plasma stages of labor
• Oxytocin can also be given after birth to stimulate uterine contraction and
thereby control uterine atony
Route, Dosage and Frequency Maternal Contraindications
• Start with primary IV tubing and piggyback secondary • Severe preeclampsia/eclampsia
IV • Predisposition to uterine rupture
• Oxytocin is infused in IV infusion pump • Cephalopelvic disproportion
• Start with 0.5-1 milliunit/min and increase by 1-2 • Malpresentation or malposition of fetus
milliunit/min every 40-60 minutes until mom reaches • Cord prolapse
adequate contraction pattern of contractions every • More than one previous C-section birth
2-3 mins and lasting 40-60 seconds • Preterm infant
• Provide continuous monitoring of fetus and uterine • Rigid, unripe cervix; total placenta previa
contractions • Nonreassuring fetal status
• Ensure that V/S: BP, heart rate and O2 saturation are
good Maternal S/E
Administration of Oxytocin After Expulsion of • Hyperstimulation can lead to too many contractions which can cause:
Placenta o Abruptio placentae
• 10 units of oxytocin are given IM or added to the IV o Impaired uterine blood flow  fetal hypoxia
fluids for continuous infusion o Rapid labor and birth
• Assess BP, pulse, and uterine resting tone before o Lacerations
each increase in dose o Uterine atony
• Record all patient activity and procedures o Uterine rupture
• If bleeding is well controlled, the oxytocin is o Water intoxication (n/v, hypotension, tachy) if too much is given
discontinued after the initial postpartum infusion 20mu/min
o Hypotension with rapid IV bolus
4. Episiotomy
Surgical incision of the perineal body to enlarge the Factors that Predispose to Episiotomy
outlet • PRIMIGRAVIDAS
• Minimize the risk of laceration of the perineum • Large Macrosomic fetus
and the overstretching of perineal tissues • Occiput-posterior positions
• There is however an increased risk for 4rth • Forceps and vacuum
degree perineal laceration • Shoulder dystocia
• Complications with episiotomy: Other causes:
o Blood loss • Lithotomy position and recumbent position
o Infection, pain • Sustained breath holding can cause stretching or perineal area and affects
o Perineal discomfort blood flow to fetus and mom
o Painful intercourse • Arbitrary time placed by MD/CNM on the length of the 2 nd stage of labor
Preventative Measures Procedure
• Perineal massage during pregnancy in nulliparous mom • Midline and mediolateral cut
• Natural pushing in labor (avoid lithotomy position or pulling • Mediolateral is done in emergent situation such as in a
back on legs) prolapsed cord or breech birth
• Side-lying to push • When 3-4 com of fetal head is seen in contraction  episiotomy
• Warm /hot compresses on perineum, firm counter pressure is performed with scissors
• Push and take a breath, push and take a breath • Performed with regional or local anesthesia
• Avoid immediate pushing after epidural • May be done w/o anesthesia in emergencies
• Episiorrhapy – repair of episiotomy with anesthesia
Nursing Management • Assess the area to prevent injury from ice
• May feel some pressure or pulling or tugging, may feel pain if • Inspect site every 15 mins for redness, swelling, tenderness,
anesthesia is no adequate brusing and hematoma
• Place hand on women’s shoulder, talk to her for comfort and • Inspect site by having mom roll to side with HOB in low
distraction position
• After birth to provide comfort apply ice on perineum area (apply 20-30 • Women with pain can become depressed and have issues
min/removed at least 20 mins before reapplying) breastfeeding and are scared to have intercourse

5. Presentations:
 Fetal attitude refers to the relation of the fetal parts to one another

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Normal attitude of the fetus: is one moderate flexion of the head, flexion of the arms onto the chest and flexion of the legs into
the abdomen
 Fetal lie – refers to the relationship of the spinal column of the fetus to the spinal cord or the woman

 Fetal Presentation (to know do an ultrasound) is determined by fetal lie and by the body part of the fetus that enters the
pelvic passage first. which can be cephalic, breech or shoulder
o When cephalic presentation occurs labor and delivery are likely to proceed normally

o Breech birth in which the butt or feet are first out, the sacrum is the landmark to be noted. Breech and shoulder are
associated with more difficulties in labor (known as malpresentations)

Butt firs - Butt first: feet can be flexed or extended upward

Ultrasound is done to confirm
Leopold's maneuver can be done too
-Shoulder:
External ECV, trying to move the baby, has its risks

6. Contractions: it is the primary force which causes complete

effacement and dilation of the cervix, and causes baby to move down the birth canal (descend).

 The cervix dilates or opens from 0-10 cm during the 1st stage of labor in response to uterine contractions
 They are rhythmic but intermittent. There is a period of relaxation between them. This allows the muscles to rest and
provides relief for the laboring mother. It also restores uteroplacental circulation, which is important to fetal oxygenation
and adequate circulation in the uterine blood vessels.
 Each contraction has three phases: increment(build up, longest phase), acme(peak) and decrement (letting up)
 Frequency: time b/w the beginning of one
contraction and the beginning of the next
one.
 Duration: from the beginning of a
contraction to the completion of the same
one.
 Intensity: strength of contraction during
acme. Determined by palpating the fundus or intrauterine catheter.

 If when palpating the uterus during the acme, it feels hard that means the contraction is strong
 If when palpating the uterus during the acme, it indents easily that means the contraction is mild
 Strong intensity exists when the uterine wall cannot be indented
 When measuring the intensity with the intrauterine catheter – the pressure increases as the woman pushes
 As labor progresses, the duration, frequency or intensity of contraction increases
TRUE vs FALSE LABOR
1. True labor – produces effacement and dilation
 Discomfort starts in the back and radiates around the abdomen
 Contractions are REGULAR and increase in FREQUENCY, DURATION and INTENSITY
 pain is not relieved by ambulation
 Walking intensifies the pain
2. False labor–do not produce progressive cervical effacement or dilation
 IRREGULAR and do not increase in FREQ., DURA., AND INTENSITY
 Sometimes there is no discomfort
 If there is discomfort its more in the lower abdomen and groin
 Relived by ambulation, change in position, drinking large amount of water or warm shower

7. STAGES OF LABOR AND BIRTH

First stage- begins with onset of true labor and ends when the cervix is completely dilated to 10 cm.
Second stage – complete dilation and ends with the birth of the baby
Third stage – begins with birth of the baby and ends with the expulsion of the placenta
Fourth stage – last from 1-4 hrs after expulsion of the placenta, the uterus contracts to control bleeding at placenta site
1st LATENT PHASE ACTIVE PHASE
• Starts with the beginning of regular • Anxiety increases due to contractions and pain
Stage contractions which are mild at this • Decreased ability of coping and sense of helplessness
time • In this phase the cervix dilates from 4cm to 7 cm
• Excitement is high, and her partner is • Fetal decent is progressive

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elated as she is for the baby • Cervical dilation averages 1.2 cm/hr in nulliparas and 1.5 cm/hr in
• Contractions may start as mild lasting multiparas
30 seconds with frequency of 10 to TRANSITIONAL PHASE
30 mins and progress to moderate • Woman is often tired, and severely anxious
• As the cervix begins to dilate, it also • Contractions become more frequent and longer in duration and increase
effaces (very little fetal descent) in intensity
• Nullipara women – latent phase • Contractions occur every 1 to 2 mins, duration of 60-90 secs and strong
averages 8.6 hrs but should not intensity
exceed 20 hrs • Cervical dilation slows as in progresses from 8 to 10 cm
• Multipara women – latent phase • Rate of fetal descent increases dramatically
averages 5.3 hrs but should not • As dilation increases to 10cm the woman may feel pressure in the rectum
exceed 40 hours • Bloody show may increase
• Fluid out of the vagina due to rupture • Sensation of pressure SO great that she may feel like abdomen is going to
of membranes burst open! Urge to bear down, increasing rectal pressure
• Amniotomy – artificial rupture of • Hyperventilation, restlessness, irritability, and frustration(get it over with)
membrane • Request medication. hiccupping, belching, n&v.
2nd BEGINS WITH COMPLETE CERVICAL DILATION AND ENDS WITH BIRTH OF INFANT
• This stage is completed in 3 hours after the cervix becomes fully dilated for Primigravidas
Phase • This stage is about 15 minutes for multiparas
• Contractions are more frequent of about 1 ½ to 2 mins, duration of 60-90 sec’s and strong intensity
• The nurse should assess the woman’s perception of the need to urge to push
• Nurse should evaluate maternal-fetal O2 status during contractions
ACTIVE PHASE OF PUSHING
• Assess the effectiveness of the pushing efforts
• Provide encouragement and direction
• Asses fetal response that occurs as mom pushes
• Some moms won’t want to push and rather wait and allow for passive fetal descent known as “laboring down”.
• As the fetal head descend mom has urge to push
• The amount of bloody show may increase with each contraction
• Crowning – occurs when the fetal head is encircled by the external opening of the vagina (means birth is imminent)
• Spontaneous Birth (Vertex Presentation) –head first birth
CARDINAL MOVEMENTS OF LABOR*
• sequence of positions assumed by the fetus as it descends through the pelvis during labor and delivery
rd 8. PLACENTAL SEPARATION PLACENTAL DELIVERY
3
• after baby born, uterus contracts firmly, decreasing its • woman bears down to aid in placental expulsion
Phase capacity and the surface area of placental attachment • if bearing down doesn’t expulse placenta, MD or
• placenta begins to separate midwife may apply traction to remove while
• hematoma forms due to bleeding present down on the fundus
• placenta starts to descend into the vagina • placenta may be retained inside the uterus if 30
• signs of placental separation about 5 mins after birth mins pass (if it stays inside it can cause further
• signs of placenta separation: globular-shaped uterus, rise in bleeding and infection)
the fundus in abdomen, sudden gush or trickle of blood and • After the placenta is expulsed the cervix is
further protrusion of the umbilical cord out of the vagina widely spread and thick
4th • 1 to 4 hrs after birth with physiologic revision of mother’s body begins
• Hemodynamic issues due to blood loss (250 – 500 mL)
stage • Drop in blood pressure, increased pulse pressure and tachycardia
• Uterus remains contracted to constrict vessels
• N/V cease and woman may feel thirsty and hungry, and shaking chills
• Bladder is hypotonic due to trauma during labor (leads to urinary
retention)

9. Fetal Descent

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10. Cardinal Movements of labor

For the fetus to pass though the birth canal, the fetal head and body must
adjust to the passage by certain position changes:
b. Descent: occurs because of four forces (1) pressure of the amniotic
fluid, (2) direct pressure of the uterine fundus on the breech, (3)
contraction of the abdominal muscles, and (4) extension and straightening
of the fetal body. The head enters the inlet in the occiput transverse or
oblique position because the pelvic inlet is widest from side to side. The
sagittal suture is an equal distance from the maternal symphysis pubis and
sacral promontory.
c. Flexion: occurs as the fetal head descends and meets resistance from
the soft tissues of the pelvis, the muscles of the pelvic floor and the cervix.
As a result of the resistance, the fetal chin flexes downward onto the
chest.
d. Internal rotation: the fetal had must rotate to fit the diameter of the
pelvic cavity, which is widest in the anteroposterior diameter. As the
occiput of the fetal head meets resistance from the levator ani muscles
and their fascia, the occiput rotates (usually from left to right_ and the
sagittal suture aligns in the anteroposterior pelvic diameter.
e. Extension: the resistance of the pelvic floor, and the mechanical
movement of the vulva opening anteriorly and forward, assist with
extension of the fetal head as it passes under the symphysis pubis. With
this positional change, the occiput, then brow and face, emerge from
vagina.
f. Restitution: the shoulder of the fetus enter the pelvic inlet obliquely
and remain oblique when the head rotates to the anteroposterior
diameter through internal rotation. Because of this rotation, the neck
becomes twisted. Once the head is born and is free of pelvic resistance, the neck untwists, turning the head to one side (restitution), and aligns
the position of the back in the birth canal.
g. External rotation: as the shoulder rotate to the anteroposterior position in the pelvis, the head turns farther to one side (external rotation).
h. Expulsion: after the external rotation, and through the pushing efforts of the laboring woman, the anterior shoulder meets the
undersurface of the symphysis pubis and slips under it. As lateral flexion of the shoulder and head occurs, the anterior shoulder is born before
the posterior shoulder. The body follows quickly.

11. Electronic Monitoring

ELECTRONIC MONITORING OF CONTRACTIONS

• Provides continuous data

• Electronic monitoring can be done eternally with a device placed on the maternal
abdomen
o Tocodyamometer – placed in the fundus, responds to pressure. When uterus contracts the change in pressure is amplified and
transmitted to the monitor
o It does not accurately record the intensity of contraction
o It is difficult to obtain accurate FHR in women who are obese, abnormal amount of amniotic fluid, active fetus and premature
cases of fetus
• Electronic monitoring can be done internally with an intrauterine pressure catheter
o Accurate measurement of contraction intensity (the strength of contraction and
the pressure within the uterus

Catheter is only placed with the membrane has ruptured

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Electronic • Electronic fetal monitoring – produces continuous tracing of the • Internal monitoring requires an internal electrode
Monitoring FHR which allows visual assessment of many FHR characteristics thru the vagina.
Of FHR • When to monitor electronic FHR – previous Hx of stillbirth, o In order to get the monitor the amniotic
presence of complication of pregnancy (preeclampsia, placenta membranes must have ruptured, the cervix
previa, abruptio placentae), induction of labor, premature must be dilated at least 2 cm and presenting
gestation, decreased fetal movement, nonreassuring fetal status part should be known
• External monitoring- fetus is accompanied by a ultrasound o The electrode is attached to a fetal monitor
• telemetry systems that can be placed in the woman o Provides more accurate data than external
monitoring

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Variability Strip’s

Fetal Heart • Baseline rate – normal FHR 110-160 beats/min, during at • Baseline variability - interchange between sympathetic
Rate 10 min duration, baseline should no less than 2 mins and parasympathetic system over 10 mins. It reflects
• Variability – change in the FHR over a few seconds to a few baseline fluctuations that are irregular in frequency and
mins amplitude.
• Fetal tachycardia– sustained rate of 161 beats/min or • If an fetus has absent or minimal variability they are at
above high risk of acidosis and subsequent hypoxia
• Marked tachycardia is 180 bpm or above • Causes of reduced variability: hypoxia and acidosis,
• Causes of tachy: fetal hypoxia, maternal fever, maternal drugs that depress the CNS, fetal sleep cycle
dehydration, sympathetic drugs, intrauterine infections, • Causes of marked variability: early mild hypoxia, fetal
maternal hyperthyroidism, and fetal anemia stimulation, fetal breathing movements, stimulant
• Fetal bradycardia– rate less than 110 bpm during a 10 min meds
period or longer • Absent variability that does not appear to be
• Causes of brady: late fetal hypoxia, maternal hypotension associated with a fetal sleep cycle or meds is a
(less blood to fetus), umbilical cord compression, fetal warning sign!
arrhythmia, abruptio placentae, uterine rupture, vagal • External fetal monitoring is not adequate way to assess
stimulation, heart block and maternal hypothermia variability, internal monitor is more accurate

Accelerations – the transient increases in the FHR (normally caused by fetal Types of decelerations
movement) • Early– occurs before the onset of uterine contractions
• When fetus move heart rate increases (considered benign and doesn’t require intervention)
• Accelerations may accompany uterine contractions (due to fetal • Late– caused by uteroplacental insufficiency resulting
movements) from decreased blood flow and O2. Late deceleration
• Accelerations during contractions are a sign of fetal well-being occurs after the onset of contraction. Late decelerations
Decelerations – decreases in FHR from normal baseline are considered a nonreassuring sign. If late decelerations
• Wh continue and birth is not forthcoming, a C-section may be
en needed 
the • Variable – occurs when the umbilical cord is compressed,
thus reduces blood flow between the placenta and the
fetus. The resulting increase in peripheral resistance in
the fetal circulation causes fetal HTN. The fetal HTN
fetal head is compressed, cerebral blood flow is decreased, which leads to stimulates the
central vagal stimulation and results in early deceleration • baroreceptors which lowers the FHR

Nursing Management
• It is crucial that nurses balance technology with holistic nursing practice
• Before the nurse uses the electronic fetal monitoring, explain the reason for its use and the information it can provide
• Record basic information on the strip
• As the monitor strip runs should note down occurrences during labor such as: dilation, effacement, station, position, color and amount of
amniotic fluid and odor, maternal vital signs, maternal position, O2 administration, emesis, cough, hiccups, pushing and administration of
anesthesia blocks
• If monitor doesn’t automatically add the time on the strip at specific intervals, include the time on the strip
• If more than one nurse is adding info on the strip, make sure to initial each note on the strip
• Fetal monitor strip should be reviewed regularly (at least every 30 mins in the first stage and every 15 min in the 2 nd stage of labor)
• Evaluating the electronic monitor tracing by looking at the uterine contraction patterns:
o The nurse should determine the uterine resting tone and should assess the contractions frequency, duration and intensity
• Share information with mother to reassure that everything is ok
11. Demerol Common s/e:
• Aka Meperidine  Sedation
• CNS analgesic  Dizziness, Pruritus
• Narcotic antagonist  Nausea and Constipation
12. Epidural Block
 Involves injection of an anesthethic agent into the epidural space to provide pain relief Administration
throughout labor  Given in the active phase of the first

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 Most frequently used as a continuous block to provide analgesia and anesthesia from active stage of labor; cervical dilation 4-5 cm
labor through episiotomy repair  Fetal head engaged at zero station
 Most common method currently used in the United States  Reassuring FHR pattern
 Controversial
 Most effective and flexible method of pain management
 Vaginal births
Advantages Disadvantages Contraindications
 Relieves discomfort during labor and birth  Hypotension—most common complication!  Client refusal
 Woman is fully awake & a part of the birth process o Prevented by: giving IV fluids before,  Infection at the site
 Results in less adverse fetal effects left uterine displacement, maternal  Maternal problems
 Allows woman to rest and regain strength before the positioning on her side w/ blood coagulation
woman needs to push  Labor progress and fetal descent may be slowed  Raised intracranial
 Airway reflexes remain intact  Pushing efforts may be less effective in the pressure
 Gastric emptying not delayed second stage of labor b/c of decreased sensation  Specific med allergy
 Minimal blood loss  Delay in return of bladder sensation  Hypovolemic shock
 Epidurals that combine anesthesia and opiod provide  Low back pain may occur
post op pain relief for longer periods of time

Nursing Management
 Assess woman’s knowledge level
 Assess the woman’s pain level, maternal vital signs, and FHR to establish a baseline!
 Encourage the woman to empty the bladder before
 Monitor maternal BP and pulse for HYPOTENSION!
 Monitor O2 sats; Patient is NPO
 Woman should have continuous fetal monitoring
 A bolus of 500 to 1000mL is given before the epidural to decrease incidence of hypotension over 15-30mins
 Patient is placed in a side-lying or sitting position
 Side-lying:
o Woman’s back needs to remain straight, with shoulders square
o Legs are bent and her knees kept together
 Sitting:
o Woman’s back is flexed; instruct woman to stick back out towards the
analgesia provider
o Nurses stands in front of the woman with hands on shoulders for support
 VS are assessed per protocol until the block wears off
 Encourage the woman to maintain side-lying position to maximize uteroplacental
blood flow and change positions from side to side to increase circulation and
promote comfort
 Assess the woman’s ability to lift her legs and her level of sensation EVERY 30 MIN to
monitor the effects of the nerve block
 Assess the woman’s bladder for distention at frequent intervals
 Woman may need assistance with pushing
 Woman’s legs need to be protected from pressure applied to them while sensation is diminished
 If hypotension occur, the nurse increases the IV flow rate , ensures or verifies left uterine displacement, and administers oxygen
o If BP is not restored in 1 to 2 min, ephedrine 5 to 10mg IV is given
 The epidural can cause elevation in temperature; may be confused with maternal infection
 Motor control of the legs is weak but not totally absent after birth
 To assess sensation, touch various parts of the woman’s legs and abdomen bilat
 Evaluate motor control by asking the woman to raise her knees, to life her feet one at a time, or to dorsiflex her foot
 BP ASSESSMENT HELP THE NURSE DETERMINE THE SAFETY OF AMBULATION
Continuous Epidural Infusion
 Epidural anesthesia is given with a continuous infusion pump Side Effects
 Benefits include:  Hot spots-- (areas of imcomplete anesthesia coverage)
o Good to excellent analgesia o NI: change positions
o Infrequent nausea  Respiratory depression—RR should be assessed q15-
o Minimal sedation 30min
o Decreased anxiety o If RR decreased below 14, Narcan may be given
o Earlier mobilization  N/V—give antiemetic or decrease infusion rate
o Retained cough reflux  Pruritus (itching and rash)—appears first in the face, neck,

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o Decreased risk for DVT or torso; give benadryl

o Decreased myocardial oxygen demand  Hypotension—may occur from hypovolemia or from
o Ease of adminsitration epidural
 PATIENT STILL NEEDS TO BE CONTINOUSLY MONITORED o Give crystalloid fluids, give O2, notify analgsia
 Potential problems: breakthrough pain, sedation, N/V, pruritus and provider
hypotension o Woman may be placed in Trendelenburg position
o If breakthrough pain occurs, check the pump itself and notify the
analgesia provider
Combined Spinal-Epidural Block Local Infiltration Anesthesia
 Can be used for labor analgesia and for cesarean birth  Used at the time of birth, both in
 Administered in the subarachnoid space preperation for an episiotomy if
 Has a faster onset of pain relief than epidural anesthesia needed
 Use in the second stage of labor  Practically free of complications
 Spinal analgesia may be given early in labor; epidural is  A disadvatange is the large amounts used to infuse tissues
activated when active labor begins  No affect on VS or FHR
 Woman can abulate after CSE is placed
 Usually used for cesarean births
 Duramorph protocol

13. Betamethasone
Maternal-Fetal action: Maternal SE NI
Is capable of inducing pulmonary maturation and decreasing the incidence of Some infection Assess for contraindications
RDS in preterm infants. It stimulates enzyme activity Hyperglycemia Provide education about SE
Shouldn’t be used frequently Fetus/newborn Administer deep into gluteal
Contraindication: Low cortisol levels, rebound muscle
Inability to delay birth occurs by 2 hours of age Monitor BP, HR, weight, and
Adequate L/S ratio Hypoglycemia edema
Presence of a condition that necessitates immediate birth Increased risk of neonatal Assess lab for electrolytes and BG
Presence of maternal infection, DM, sepsis Monitor for pulmonary edema.
Gestational age greater than 34 completed weeks
14. Premature ROM
Some complications can occur before the onset of labor that significantly impact the
outcome of pregnancy
• Premature rupture of membranes is a spontaneous rupture of the membranes
before the onset of labor
• Occurring before 37 weeks gestation
• The exact cause is unknown but thought to be due to infection, trauma,
amniocentesis, placenta issues, incompetent cervix, bleeding and multiple
pregnancy etc.
• Fetal/neonatal: risk for respiratory distress syndrome, fetal sepsis ,
malpresentations, prolapse of umbilical cord, nonreassuring FHR, compression
of the umbilical cord, premature birth
• The greater the gestational age, the greater the chances of infant complications
Clinical Therapy • After birth, newborn is assessed for sepsis and placed on
• Sterile speculum examination is done to detect the presence of antibiotics
amniotic fluid in the vagina • Continues electronic fetal monitoring
• Nitrazine paper – other test done, turns deep blue when • Regular NST or BPP
amniotic fluid is present. • Maternal BP, HR, temp, and FHR every 4hr
o Bacterial pathogens may cause a positive Nitrazine • If woman has a preterm PROM, she is assessed and exams
test such as: CBC, NST, BPP are done
• Ferning test – microscopic test done to determine rupture of • Vaginal exams are avoided to decrease chance of infections
membranes • Maternal corticosteroid administration promotes fetal lung
• Digital examination increases the risk for infection (not maturity and prevent respiratory distress syndrome
recommended)
• If maternal s/s of infection are evident, antibiotic therapy is done o BETAMETHASONE
STAT and fetus is born vaginal or by C-section regardless of
gestational age
• Prophylactic antibiotics administered for the 1 st 48 hours while
waiting for culture results

Nursing Management • Monitor for s/s of infection

• Evaluate uterine activity and fetal responses to labor NO
• Nurse should ask and determine when rupture occurred,
VAGINAL EXAMS ARE DONE (risk for infection)
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determine gestational age to prepare for possible birth, observe • Encourage woman to rest on her side to promote perfusion to
for s/s of infections, assess fever of mother and hydration status fetus
• Risk for infection related to premature rupture of membranes • Ensure hydration (especially If fever present)
• Impaired gas exchange in fetus related to compression of • Mother and father need to understand that although the
umbilical cord membranes have rupture, amniotic fluid Is still done

15. Brethine
Brethine is used to attempt labor (preterm labor)
• It suppresses uterine contractions and allow pregnancy to continue
• Can cause maternal side effect of PULMONARY EDEMA
• Was once used to stop labor but are now being replaced by other meds
• Long term use of Brethine is no longer considered standard of care – because of risk of maternal morbidity r/t pulmonary edema
16. Prolonged Labor
Posterm pregnancy is one that extends more than 294 days or 42 weeks • Fetal risks:
past the first day of the LMP o Decreased perfusion from the placenta
• Gone beyond EDB o Oligohydramnios – decreased amount of amniotic fluid
• Cause of postdate pregnancy is unknown (increases risk for cord compression)
• Occurs more frequently in Primigravidas and women with hx of o Meconium aspiration (more likely if Oligohydramnios and
prolonged pregnancy thick meconium are present)
• Women who have a previous posterm pregnancy are at risk for o Low 5 minute Apgar score
posterm pregnancy in subsequent pregnancies • Some fetus grow beyond 42 weeks and can be excessively large at
• Maternal Risks: birth (Macrosomia)
o Probable labor induction • Intrauterine environment becomes unfavorable for growth,
o Increased risk for large-for-gestational age (LGA) infant and uteroplacental insufficiency occurs and at birth the infant has lost
resultant perineal trauma muscle mass and fat known as dysmaturity syndrome
o Increased incidence for forceps-assisted, vacuum assisted or • Macrosomic fetus is at risk for birth trauma
C-section birth and risk for infection
Concerns of posterm pregnancy Clinical Therapy
1. Increase in fetal mortality rate after 40 weeks • Some HCP prefer induction at 41 weekOther HCP do NST and
2. Mortality rate doubles by 42 weeks BPP (especially the amniotic fluid volume portion of the BPP) 2
3. Post 40 weeks and GD increases morbidity to 3 times a week to see fetal well-being
4. Post 38 weeks the placenta begins to deteriorate • If fetus has problems interventions are begun to accomplish
5. Meconium staining increases with prolonged pregnancies birth
6. Anxiety
Nursing Management • Variable decelerations are often associated with oligohydramnios
• Reassuring FHR and evaluate nonreassuring patterns (such as because the decreased amount of fluid may allow compression
nonperiodic variable decelerations – which indicate cord of the umbilical cord
compression or Oligohydramnios) • If fetus is Macrosomic, carefully assess labor progress
• When amniotic membranes rupture assess fluid for meconium o contraction characteristics
• Teach mother about assessing fetal movement every day in the o progressive cervical dilation
community o fetal descent
• If Oligohydramnios exists, obtain continuous FHR tracing • Emotional support
17. Prolapsed Umbilical Cord
• The umbilical cord falls in front of, lies beside, or hangs below the • Prolapsed umbilical cord results when the umbilical cord
fetal presenting part precedes the fetal presenting part
• Related to a long umbilical cord • Pressure is placed in the umbilical cord as it is trapped
• Malpresentation between the presenting part and the maternal pelvis the
• Contributing factors - Transverse lie and breech presentations vessels carrying blood to and from fetus are compressed
Risks of Prolapsed Cord Clinical Therapy for Prolapsed Cord
• Maternal Risks: Preventing prolapse of the cord is the preferred medical approach
o Does not directly precipitate physical alterations in • In bed, until fetal head is well engaged to prevent risks of prolapse of
women cord
o Enormous stress on mother due to concern of fetus • Relieving pressure on the prolapse cord is critical for fetus
o C section may be needed • Medical team work together to facilitate birth
o Sometimes death of baby can occur • Bed rest – for women with Hx of ROM, until engagement with no cord
• Fetal Risks: prolapse has been documented
o Decreased blood flow • Auscultate FHR for at least a min full (at beginning and end of
o Leading to nonreassuring fetal status contractions)
o Cord compression is further in each contraction • If fetal bradycardia  perform vaginal examination to r/o cord prolapse
o Fetus can die if pressure on cord isn’t relived • Cord prolapse Monitoring findings:
• Risk factors o severe, moderate or prolonged variable decelerations with
o Preterm labor baseline bradycardia
o fetal abnormalities,Polyhydramnious • examiners gloved fingers must remain in vagina to provide firm
o pROM, placenta previa, pelvic tumors, ECV pressure on fetal head (to relieve compression)
o LIFE SAVING MEASURE
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• Vaginal birth is possible with prolapsed cord if the cervix is • Give mommy O2 via face mask
completely dilated and pelvic measurements are adequate • Force of gravity to relive compression of cord
• If not then C-section is needed! • Mom should be in knee-to chest or trendelenburg
• Hard to determine if fetus is alive on palpation
Nursing Management • Perform sterile vaginal exam to determine if there is danger
• Care of patient with prolapsed cord of cord prolapse
• Keep pressure off cord until delivery • O2 via mask
• Place woman in knee-chest position, trendelenburg, sims lateral • IV Fluids
position • Notify HCP
• Manually elevate the presenting part • Ultrasound as needed
• Assess FHR • Provide emotional support
• Keep exposed cord moist with warmed NS (do not reinsert) and • Document all care
assess for pulsation and color • Prepare for emergency cesarean birth
18. Forceps Assisted Birth
• Instruments designed to assist in the Before use of forceps these conditions must
birth of a fetus by providing be met:
• Either traction or rotate the fetal head to • Cervix must be completely dilated • Type of pelvis must be known
occiput anterior position • Exact position and station must be known • Moms bladder should be empty
• Indicated in the presence of any • ROM had to occur • Anesthesia should be adequate
condition that threatens mother and • Engagement in vertex or face • No cephalopelvic disproportion
baby and that can be relieved by birth presentation present
• Used to shorten the second half of labor • Maternal consent!!!
and assist mommy’s pushing efforts
Neonatal Risks Maternal Risks
• Conditions that put woman at risk:
• Ecchymosis • Lacerations of birth canal
o Heart disease
o Pulmonary edema
• Edema alongside of face • Extensions of midline
• Facial lacerations episiotomy into the anus
o Infection
o Exhaustion • Brachial plexus • Increased bleeding
• Conditions that put fetus at risk: • Caput head • Perineal edema
o Premature placental separation • Cephalohematoma • Anal incontinence
o Nonreassuring fetal status • Transient facial paralysis
• Rare: cerebral Hemorrhage, fractures, brain damage
and fetal death
Nursing Management
• Note variables
• FHR rate issues – position change, increase fluid intake and O2 via mask
• Ensure the woman gets adequate anesthesia use
• Encourage breathing techniques that help prevent her from pushing during
application of forceps
• Monitor contractions
• Advise MD when contractions are present
• Reinforce that woman needs to push while traction is being applied
• Not uncommon to see mild fetal bradycardia as traction is being applied to the
forceps
o Bradycardia results from head compression and its transient

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