OB Final Exam Study Guide: Antepartum, Intrapartum, Postpartum, and Newborn Care | Study Guides, Projects, Research Obstetrics

OB Final Exam Study Guide

23 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.

oDue Date: from the month of their last period add nine months, then add seven days to the first day of their last period.

oNägele’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.

oMorning sickness

oExcessive fatigue

oUrinary frequency

oBreast changes

oQuickening

•Probable Changes

Objective changes that occur in pregnancy. Doesn’t confirm pregnancy since it could be due to others things

oGoodell’s - Softening of the cervix

oChadwick’s - Dark violet coloration of cervix

oHegar’s - Softening of lower part of uterus

oProgressive uterine enlargement

oEnlargement of the abdomen with amenorrhea (no period)

oBraxton-Hicks contractions

oFetal 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

oPregnancy test

•Positive Changes

Diagnostic test that confirm pregnancy

oFetal heartbeat: detectable by doppler ultrasound

oFetal movement: detected by echocardiography or transvaginal sonography

oFetal souflé: 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 around the abdomen. pain is not relieved

by ambulation (walking may actually intensify pain)

FALSE LABOR:

•The contractions of FALSE LABOR DO NOT produce cervical effacement and dilation. They are irregular, and do not increase in

frequency, duration, and intensity, perceived as a hardening or “balling up” without discomfort, or discomfort may occur in the

lower abd. or groin.

•Discomfort may be relieved by ambulation, change position.

SIGNS OF ONSET OF LABOR

•S/S of impending labor

•Lightening (when the fetus begins to settle into the pelvic inlet (engagement).

•Braxton Hicks Contractions

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23 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 souflé: 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 around the abdomen. pain is not relieved by ambulation (walking may actually intensify pain) FALSE LABOR:
The contractions of FALSE LABOR DO NOT produce cervical effacement and dilation. They are irregular, and do not increase in frequency, duration, and intensity, perceived as a hardening or “balling up” without discomfort, or discomfort may occur in the lower abd. or groin.
Discomfort may be relieved by ambulation, change position. SIGNS OF ONSET OF LABOR
S/S of impending labor
Lightening (when the fetus begins to settle into the pelvic inlet (engagement).
Braxton Hicks Contractions

Cervical Changes: softening of the cervix is called ripening
Bloody Show: with softening and effacement of the cervix the mucous plug is often expelled.
Rupture of Membranes (ROM)
Sudden Burst of energy (nesting)
Other signs: weight loss of 1-3 lb resulting from fluid loss, diarrhea, indigestion, or N/V just before the onset of labor. 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.

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- 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).
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 11 / 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
Evaluating the maternal-fetal oxygenation status
Assessing fetal status through recommended monitoring protocols. o Second phase is known as the pushing phase, occur with the urge to push, and the woman starts to push with her contractions.
1. Assessing the effectiveness of the maternal pushing efforts
2. Providing encouragement and direction to obtain a more adequate pushing effort
3. Assessing fetal response that occurs as maternal pushing is performed including continued fetal assessment measures. o Crowning: fetal head is encircled by the external opening of the vagina (inroitus) MECHANISM OF LABOR/ CARDINAL MOVEMENTS OF LABOR
  1. Descent: 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.
  2. Flexion: fetal head descend and meets resistance. As a result of the resistance the fetal chin flexes downward onto the chest.
  3. Internal rotation: fetal head must rotate to fit the diameter of the pelvic cavity.

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 decelerations 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)
Prepidil : softens the cervix, rippening (also used Cervidil, Cytotec)
Terbutaline: tocolitic for version
Oxytocin (petocin): used for augmentation or induction of labor. Produces contractions; if contractions are 1-2 minutes lasting

90 sec discontinue. If uterus tone >20 at rest stop petocin. Normal Tone 5-15 mmHg at rest. - EPIDURAL BLOCK: o Most commonly used and controversial in the United States, most effective and flexible method of pain management o Used for vaginal births; Given in the active phase of the first stage of labor; cervical dilation 4-5 cm between L2 and L o Fetal head engaged at zero station; Reassuring FHR pattern o Advantages: Fully awake; good relaxation; Airway reflexes remain intact; Gastric emptying not delayed; Minimal blood loss o Disadvantage: Hypotension; N/V; Pruritis; Urinary Retention; Temperature o NURSING MANAGEMENT: Epidural anesthesia ✓ Monitoring maternal and FHR ✓ NPO ✓ Insertion of foley catheter ✓ IV access established; Loading dose (500ml-1000ml) to prevent HYPOTENSION (most common side effect) EPHEDRINE used when BP is still low after fluids. ✓ Monitor VS (specially BP) according to agency policy, Adverse reactions and complications ✓ Positioning - PUDENDAL ANESTHESIA: o Administered during the second stage of labor transvaginally into the pudendal nerve provides pain relief within 2-10 min, last for approx. one hour. Provides anesthesia for vaginal births, forceps or vacuum extraction, perineal repair o Monitoring: Assess maternal FHR and maternal BP

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
1. 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.
Successdul lactation depends on infant sucking production and delivery of milk LOCHIA
Assess character, amount, odor, and the presence of clots. Wear gloves to assess fundus or to assess perineum. Has fleshy odor but not foul. Consist of blood from vessels at the placental and decidual debris. Suggests the stage of healing. Pooling of blood in vagina may cause a gush of blood upon standing. Clots should not be larger than quarter size. The pads should never be fully saturated. If having a hard time assessing volume, instruct patient to put on clean pad and recheck in one hour, weigh pad, 1g = 1 mL.
Rubra - Red and lasts 3 days.
Serosa - brownish, contains WBCs from 3-10 days.
Alba - Whitish, from day 10 up to 6 weeks
OVULATION: precedes menstruation; non-nursing mothers will resume menstruation by 12 wks; nursing mothers by 6 months EPISIOTOMY CARE
Ice packs generally applied to the perineum to reduce edema and provide numbing of the tissues, which promotes comfort. To attain maximum effect of this cold treatment, a pattern of applying the ice pack for approximately 20 minutes and then removing it for about 10 minutes should be followed during the first 2 hours to reduce edema. Usually ice packs are needed for the first 24 hours to reduce pain.
Sitz baths provide comfort, decrease pain, promote circulation, and reduces the incidence of infection.
Topical agents
Tighten buttocks before sitting.
Signs of infection are: redness, edema, drainage, incomplete approximation of the edges. 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 8 wks: body organs are formed 8-12 wks: heart can be heard 16 wks: you can know the sex of the baby 20 wks: heart can be heard with a fetoscope, feels movemnt Phytonadine (vit K) THERMOREGULATION
Maintenance of thermal balance by the loss of heat to the environment at a rate equal to the production of heat; the newborn responds with increased oxygen consumption and metabolism. Prolonged exposure to the cold may result in depleted glycogen stores and acidosis.
Convection - loss of heat from warm body surface to the cooler air currents. (Having a cooler environment than that of the babies temperature)
Radiation (Indirect) - loss of heat transfer from the heated body surface to cooler surfaces and objects not in direct contact with the

bone and the periosteal membrane. May be unilateral or bilateral without crossing suture lines. Relatively common in vertex birth, may disappear within 2 wks to 3 months. May be associated with physiologic jaundice, extra RBC being destroyed within the Cephalohematoma.

Moro - involuntary response to stimulation seen at birth. Disappears after 3-4 months. Absence on both sides suggests damage to the brain or spinal cord. Absence on one side suggests either broken shoulder bone or injury to the group of nerves
Babinski reflex - Toes fan outward when sole of foot is stroked.
Palmar grasp - Infant closes hand and "grips" your finger.
Plantar grasp - Infant flexes the toes and forefoot.
Placing - Leg extends when sole of foot is touched.
Glabellar - blinking response due to a tap on the bridge of the nose.
Stepping - Takes brisk steps when both feet are placed on a surface, with body supported.
Tonic Neck - Left arm extends when infant gazes to the left, while right arm and leg flex inward, and vice versa.
Magnet – apply pressure to feet with fingers when the lower limbs are semiflexed, legs extend against examiners pressure
Cremastric – testes retract when infant is chill
Galant (truncal incurvation) – place infant prone on flat surface, run finger down side of back first on one side then down the other 4 to 5 cm lateral to spine, body flexes and pelvis swings towards stimulated side
Wink Reflex – anal sphincter responds to touch, open and close
Extrusion – touch or depress tip of tongue, tongue is forced outward
Rooting – touch infant’s lip, cheek, or corner of mouth with nipple, turns head towards stimulus, opens mouth.

OB Final Exam Study Guide: Antepartum, Intrapartum, Postpartum, and Newborn Care, Study Guides, Projects, Research of Obstetrics

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OB Final Exam Study Guide

DECELERATIONS