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OB Final Exam Study Guide
Questions Antepartum and
intrapartum GTPAL
- G (Gravida): the number of pregnancies
- T (Term): number of infants born at ≥ 37
- P (Preterm): born after 20 weeks but before the completion of 37 weeks.
- A (Abortion): pregnancies ending in either spontaneous or therapeutic abortion before
the end of 20 weeks.
- L (Living): number of currently living children.
o Due Date: from the month of their last period add nine months, then add seven
days to the first day of their last period.
o N ägele’s Rule: most common method of determining the EDB, which uses 280
days as the mean length of pregnancy. To use this method, begin with the first
day of LMP, subtract 3 months and add 7 days. For
SIGNS OF PREGNANCY
- Presumptive Changes
Subjective symptoms experienced by the woman. Doesn’t confirm pregnancy.
o Morning sickness
o Excessive fatigue
o Urinary frequency
o Breast changes
o Quickening
- Probable Changes
Objective changes that occur in pregnancy. Doesn’t confirm pregnancy since it could be
due to others things
o Goodell’s - Softening of the cervix
o Chadwick’s - Dark violet coloration of cervix
o Hegar’s - Softening of lower part of uterus
o Progressive uterine enlargement
o Enlargement of the abdomen with amenorrhea (no period)
o Braxton-Hicks contractions
o Fetal outline
Ballottement: passive fetal movement elicited when the examiner inserts two
fingers into the vagina and pushes against the cervix. This action pushes the fetal
body up and as it falls back down, the examiner feels a rebound
o Pregnancy test
- Positive Changes
Diagnostic test that confirm pregnancy
o Fetal heartbeat: detectable by doppler ultrasound
o Fetal movement: detected by echocardiography or transvaginal sonography
o Fetal soufflé: blowing murmur, synchronous with the fetal heartbeat
TRUE VS FALSE LABOR: Many times the only way to tell between true or false is
to asses effacement and dilation.
TRUE LABOR:
- Contractions of TRUE LABOR produce progressive DILATION and EFFACEMENT of
the Cervix, occur regularly with increase in frequency, duration and intensity.
- The discomfort of true labor contractions usually starts in the back and radiates
STAGES OF LABOR AND BIRTH
- First stage begins with the onset of true labor and ends when the cervix is
completely dilated to 10 cm, divided into the latent, active, and transition
phases.
1. Latent (early) Phase:
o beginning of regular contractions, usually mild , woman able to cope with the
discomfort, may feel anxious, and able to recognize and express feelings. Woman is
often talkative and is eager to talk about herself and answer questions, her partner
or other support person is often as elated as she is
o They may start as lasting 30 seconds with frequency of 10 to 30 minutes and
progress to moderate ones lasting 30-40 seconds with frequency of 5 to 7 minutes.
As the cervix begins to dilate and effaces (little or no fetal descent is evident).
o For a primipara, latent phase of labor averages 8.6 hours but should not exceed
20 hours, in multipara averages 5.3 hours but should not exceed 14 hours.
o Spontaneous Rupture of membranes (SROM) occurs at the height of an
intense contraction with a gush of fluid out of the vagina. In many instances
ruptured by the certified nurse-midwife (CNM) or physician, using an amnihook,
procedure is called an amniotomy, or artificial rupture of membranes (AROM).
2. Active Phase:
o Anxiety increases as the contractions and pain increases. Shows decreased ability to
cope and a sense of helplessness. Women who have support may feel greater
satisfaction and less anxiety than those without support.
o Cervix dilates from about 4 cm to 7 cm. Fetal descent is progressive.
o Cervical/dilation averages 1.2cm/her in primiparas and 1.5cm/hr in multiparas
3. Transition Phase
o Last part of the first stage of labor, woman shows significant anxiety. Becomes
acutely aware of the increasing force and intensity of contractions, may become
restless, and changes position frequently.
o Often already tired. Fears to be left alone, the nurse should reassure her that she will
not be left alone.
o Contractions have a frequency of 1.5 to 2 minutes, a duration of 60-90 seconds, and
strong in intensity.
o Cervical dilation slows down and progresses from 8 to 10 cm and the rate of fetal
descent dramatically increases.
o This phase does not last > 3 hours for primiparas or > 1 hour for multiparas.
o Other characteristics of this phase may include: Increasing bloody show –
Hyperventilation - Generalized discomfort, low backache, shaking, cramping in legs
- Increased need for partners’ or nurse’s support – Restlessness - Increased
apprehension and irritability - A sense of bewilderment, frustration, and anger at
the contraction - Request for medication - Hiccupping, belching, N/V - Beads of
perspiration on the upper lip or brow - Increasing rectal pressure and an urge to
bear down.
- Second stage begins with complete dilation and ends with the birth of the baby, usually
completed within 3 hours after fully dilation
for primiparas; the stage averages 15 minutes for multiparas.
o Contractions frequency 1
1 / 2 to 2 minutes, duration 60-90 seconds and strong
intensity. Descent of fetal presenting part continues until it reaches the
perineal floor.
o During this time, the “first phase”, passive fetal descent occurs in response to
uterine contractions. Nursing tasks during this phase include:
- Assessing the woman’s perception of the need or urge to push
shoulder, the body follows quickly.
- Third stage begins with the birth of the baby and ends with expulsion of the placenta.
o After birth the uterus contracts firmly, decreasing the surface area of the placental
attachment. The placenta begins to separate due to this
o When the signs of placental separation appear, the woman may bear down to aid in
expulsion. A placenta is considered retained if 30 minutes have elapsed from
completion of the second stage of labor.
- Fourth stage , last 1 to 4 hours after expulsion of the placenta, the uterus contracts to
control bleeding at the placental site. With the
birth, hemodynamic changes occur. Blood loss ranges from 250 to 500 mL, results in a
drop in BP, increased pulse pressure, and moderate tachycardia.
o Woman may feel thirsty or hungry. She may experience shaking chill.
o Bladder is often hypotonic due to anesthetics that decrease sensations. Hyptonic
bladder can lead to urinary retention.
o women should be assisted during their initial attempt to ambulate since dizziness
and syncope can lead to falls.
FETAL POSITION AND ENGAGEMENT
- Bones are not fused, head can adjust in shape as it passes through the narrow portions
of the pelvis.
- The cranial bones overlap under pressure, called molding, sutures allow for molding,
allows clinician to identify position of the head
- Fetal attitude: relationship of baby’s limbs to body, normal attitude: moderate
flexion of head, flexion of the arms to chest, and flexion of the legs onto the
abdomen.
- Fetal lie: fetal spine as it relates to the mother’s spine (oblique, longitudinal,
transverse )
- Fetal presentation : determined by fetal lie and presenting part in the pelvic passage
(cephalic, breech (buttocks), or shoulder)
- Engagement: occurs when the largest diameter of the presenting part reaches or
passes through the pelvic inlet, at the ischial spines.
- Station: relationship of presenting part to the ischial spines and the maternal
pelvis. if the presenting part fails to descend with contractions there may be
disproportion between maternal pelvis and presenting part.
➢ Ischial spines : 0 station; when engagement occurs
➢ Above ischial spines : (–) minus station; presenting part at
pelvic inlet
➢ Below ischial spines : (+) plus station; presenting part
descended past ischial spines
- Fetal Position: refers to a designated landmark on the presenting fetal part to the
front, sides, or back of the maternal pelvis.
o vertex presentation is the occiput
o face presentation is the mentum
o breech presentation the sacrum
o Should presentations the acromion process
DECELERATIONS
- Early Deceleration: before onset of uterine contraction , is uniform shape,
usually considered benign, and does not require intervention.
- Late Deceleration: onset after the onset of a uterine contraction caused by
uteroplacental insufficiency results from decreased blood flow and O2 to the fetus
through the intervillous spaces during uterine contractions; most common cause:
maternal
hypotension resulting from epidural anesthesia and uterine hyperstimulation associated
with oxytocin infusion. Considered a non- reasseuring sign but does not necessarily
require immediate childbirth. However id they continue caesarean birth may be
indicated.
- Variable Deceleration: onset varies in timing with the onset of the contraction.
Occurs if umbilical cord becomes compressed,
reducing blood flow between the placenta and fetus. This pattern requires further
assessment.
Variable
deceleration
s
Cord compression
Early
decelerations
Head compression
Accelerations Oxygenation and perfusion is good!
Late
decelerations
Poor oxygenation, uteroplacental
insufficiency, NEVER REASSURING
Managing Decelerations:
- Early decelerations: No intervention necessary; however, the nurse may choose to
reposition the patient
- Late and variable decelerations:
o Reposition to left lateral
o Administer oxygen via face mask
o Give IV fluids (bolus)
o Turn off Pitocin, if applicable
o Notify physician as needed
DRUGS DURING LABOR
- Opioid analgesics
o Morphine sulfate
o Demerol (Meperidine); can be given up to the second phase of first stage.
Fetal Effects: Liver/kidney clears drug slowly (immature liver); Respiratory
depression @ birth Reversal agent (Narcan)
o Sublimaze (fentanyl); Narcotic angonist-anatagonist compound: Stadol; Nubain
✓ FHR needs to be between 120-160 , SVT needs to be present and LTV is
average, accels are noted with normal fetal movement
✓ Contraction pattern needs to be well established, cervix is dilate 4 cm (varies a
little in first time versus multiparas)
✓ Never given within 1 hour of birth - minimal use to the mother at this point
and can cause fetal respiratory depression
✓ IF MOTHER GETS DEMEROL TOO LATE BABY CAN COME OUT W/
RESPIRATORY DEPRESSION.
✓ STEROIDS ARE USED TO MATURE LUNGS OF PRETERM BABIES GIVEN
BEFORE THE DELIVERY. (DEXAMETHASONE)
for approx. one hour. Provides anesthesia for vaginal births, forceps or vacuum
extraction, perineal repair
o Monitoring: Assess maternal FHR and maternal BP
o Advantage: easy to administer, no risk of maternal hypotension, doesn’t affect
maternal HR or FHR
o Disadvantages - include risk for ligament hematoma , perforation of rectum and
trauma to sciatic nerve
• SPINAL ANESTHESIA:
o Advantages: Immediate onset ; Ease of administration ; Smaller dose ; Excellent
muscle relaxant ; Does not pass through placenta
o Disadvantages; Cannot sense urge to push, might need forceps or vacuum
extraction ; Bladder and uterine atony ; Spinal headaches , Headache is normal
a few days after
o NURSING MANAGEMENT: pt. must lie flat 6-12 hours after injection ; monitor
for adverse reactions and complications , Postdural spinal headache ; Epidural
blood patch
20 Questions: Assessment of the
Postpartum (woman (6 WKS)
MATERNAL AND PATERNAL
ADJUSTMENT
Taking-in
- First PP day or 2, mother preoccupied with own needs
- Tells her story
- Passive, independent
- Touches and explores infant
Taking-hold
- Second or third PP day ready to resume control
POSTPARTUM HEMORRHAGE
Early (Primary) postpartal hemorrhage occurs in the first 24 hours after childbirth.
o Contributing factors: Over distension caused by multigravida; hydramnios; or
large infant (Macrosomia); Twins; Dysfunctional or prolonged labor. Oxytocin
augmentation or induction of labor. Use of anesthesia, magnesium sulfate,
CCBs, or tocolytics; use vacuums or forceps. Retained placental fragments.
Preeclampsia. Asian and Hispanic heritage. Placenta Previa.
o If not contracted after birth, fundal massage performed until fundus contracts,
fundal massage is painful. If bleeding persist, HCP may order IV oxytocin. IV fluids
may be required as well as blood transfusions; depends on the H&H and
coagulation
studies. Surgical interventions may be required if bleeding does not stop. Manual
compressions (Putting pressure on the uterus internally). Uterine balloon
tamponade is a successful technique to stop bleeding.
- Lacerations of the genital tract; Retained placental fragments; Vulvar, vaginal, and pelvic
hematomas- result from injury to a blood
vessel from birth trauma.
- Uterine inversion- Prolapse of the fundus to or through the cervix so that the uterus is,
in effect, turned inside out after birth. Late (Secondary) postpartal hemorrhage
occurs from 24 hours to 6 weeks after birth. Usually caused by subinvolution
(failure to return to normal size). Subinvolution commonly diagnose during the routine
postpartal examination at 4 to 6 weeks.
POSTPARTUM BLUES
- Usually resolves in 10-14 days but can last up to 6 weeks.
- Precipitated by decrese in estrogen and progesterone level
- Adjustment reaction with depressed mood is known as the postpartum blues
- Postpartum mood episodes with psychotic features is worse
- Contributing factors: emotional letdown (failure to be the “perfect mother”), physical
discomfort, and fatigue, anxiety to care for newborn, severe pms, depression during
pregnancy or hx of depression.
- S/S: tearfullness, anorexia, difficulty sleeping.
BREASTFEEDING AND CARE
Engorgement:
- Nipples are hard and distended with congestion and accumulation of milk
- Causes can be not fully emptying
- Mastitis-infection of the breast tissue causative organisms=staph, e-coli, or strep
- Can cause difficulty in latching on, bc nipple becomes less pliable
- Cold compress if mother doesn’t want to breastfeed, and tight bra.
- If breastfeeding can put warm compresses
- Encourage feeding every 2 -3 hrs.
- Express small amount of breast to help soften breast and to latch successfully.
- Assess symmetry, redness, drainage, bruising, consistency, lumps , cracked nipples
Milk production:
- Colostrum- secreted mid pregnancy, 1
st milk baby receives, lasts 3 days
(immunoglobulins, antibodies, bacteria for babys gut-helps prevent hyperbilli,
antioxidants, laxative effects to help release meconium) does not contain high fat,
takes place after day 3. Yellowish and is a creamy fluid, thicker than milk
- Transition milk- intermediate colostrum and mature milk, contains more fat
- Mature milk - white or blue tinged (starts in 2 weeks)
- Let down reflex = release of oxytocin and prolactin. Oxytocin Contracts and ejects milk.
AFTERPAINS
- Intermittent uterine contractions
- Common in multiparas than primiparas
- May cause the mother severe discomfort for 2-3 days after birth
- Breastfeeding also increases the frequency and severity of afterpains
20 Questions Newborn Care
and Assessment APGAR
SCORE
Sign 0 1 2
A Appearance/Color Blue/pale Pink body with
blue
extremities
Pink
P Pulse Absent <100/min >100/min
G Grimace/reaction Absent Grimace/
whimper
Cough/sneeze/cry
A Activity/Muscle
tone
Limp Some flexion Active/
spontaneous
R Respiratory effort Absent Slow, weak cry Regular, good cry
✓ Apgar Score is recorded at 1 minute and at 5 minutes after birth, and at 10
minutes if needed
- Heart Rate = Absent (0) - < 100 (1) - >100 (2)
- Respiratory effort = Absent (0) - Slow Irregular (1) - Good crying (2)
- Muscle tone = Flaccid (0) - Some flexion of extremities (1) - Active motion (2)
- Reflex Irritability = None (0) – Grimace (1) - Vigorous cry (2)
- Skin Color = Pale Blue (0) - Body pink, blue extremities (1) - Completely Pink (2)
Interventions:
- 8-10: no intervention except to support newborns spontaneous efforts, nasopharyngeal
suctioning
- 4-7: Stimulate; rub newborn’s back; administer oxygen to newborn; rescore at specific
intervals
- 0-3: Newborn requires full resuscitation; score at specific intervals - Apgar scores of less than 3 at 5 minutes postbirth may correlate with neonatal
mortality.
- Establish airway suction mouth first then nose
Vital sign – normal findings
- Respirations = Rate 30-60 (nares shouldnt flare, indicator of respiratory distress)
- Apical Pulse = Rate 120-160 (80-100 asleep – up to 180 crying)
- Temperature = Skin Temp above 36.5C – 37C (96.8-99F)
- Skin Color = Body pink with bluish extremities
- Umbilical Cord = 2 Arteries and 1 Vein
- Gestational Age = Should be 38-42 wks to remain with parents for extended time.
- Sole creases= Sole creases that involve the heel.
• BP: 80/
Basic Measurements
o Weight: Average 2500-4000g (7lb 8oz)
o Length: 45-55 cm (18-22 in)
o Head: 32-37 cm (12.5-14.5 in)
o Chest: 30-33cm (12.5 in)
o Abdomen: 30-33cm
Fetal Development
4 wks: heart begins to beat
