OB - NUS111

Average heart rate rounded of fetus

Rounded to 5 bpm

Measured over 2 minutes of clear tracing (uterus must be at rest these 2 min) within a 10 minute window

110-160 bpm for a term baby with premies ranging on the higher end

• If baby is at these rates persistently for 10 minutes...
• below 110 (bradycardia)
• above 160 (tachycardia)

Fluctuations in the baseline FHR that cause the wave like appearances on fetal monitor strips

Line looks more straight then with curves

• Possible Factors
• Fetus is sleeping
• Fetal Acidemia
• Fetal anomalies affecting CNS heart, or both
• Gestation younger than 28 weeks
• Mother is on narcotics or sedatives Magnesium sulfate was given to mother
• Alcohol, illicit drug use by mother
• Maternal hypoxia
• Maternal acidemia

• Absent – Undetectable
• Minimal – Undetectable to ≤ 5bpm
• Moderate – 6 to 25 bpm
• Marked – Greater than 25 bpm

Temporary increase in FHR that peaks at least

• Term Babies
• 15 bpm above the baseline for 15 seconds

• Premature Babies
• 10 bpm above the baseline for 10 seconds

• Indications
• Fetal movement
• Vaginal exams
• Uterine contraction
• Mild cord conpression

• Reassuring Sign
• 
  

Decreases in FHR

Early & Late Decelerations

• Decrease in FHR taking place during contractions as fetal head is pressed
• against pelvis or tissue

Compression affects the vagus nerve, lowering the FHR

• Consistent in appearance, uniform
• Mirror the contractions
  The Nadir occurs at same time contraction peaks
• Nadir rate no lower than 30-40 bps from baseline

This is an ok sign

Decrease in FHR occurring after contraction

Look like early decelerations but shifted to the right in relation to contraction

This is a non-reassuring sign

• Indications
• Impaired exchange of waste or oxygen with placenta
• Chronic conditions of mother (maternal hypertension or diabetes)
• Over time will cause decreased heart function & acidemia in baby
• Associated with Uterine Placental Insufficiency (UPI)

• No uniform appearance
• Fall & rise abruptly (within 30 seconds)
• Can occur without a contraction
• This is a non-reassuring sign

• Conditions that reduce flow thru umbilical cord
• Associated with cord compression
• Oxygen to fetus is being reduced
• Get mother on her side & watch her

• Intrapartum
• 7.25 – 7.35
• 7.20
• ASAP via vacuum or section  

Note: Acidosis is more common than alkaline

Assess infant’s acid base balance immediately after birth

• Procedure must be done immediately after birth
• Cord is double clamped & a 10-30 cm segment isolated

• Collect arterial (blood leaving fetus on way to
• placenta) & venous cord blood

• Use a heparinized syringe & put on ice
• Needs to be tested within 60 minutes of collection

Amnihook (disposable plastic hook) is used to perforate amniotic sac my physician or nurse mid-wife

Hooks passed thru cervix & membranes snagged

• Often done in conjunction with induction or stimulation of
• labor

Can be performed to permit internal electronic fetal monitoring

Implies the commitment to delivery

Aka Artificial Rupture of Membranes (ROM)

Document a baseline for FHR before ROM (for baseline)

Place under-pads / towels under woman’s buttocks to absorb fluid

After ROM, assess FHR for 1 full minute

• Keep documenting mom’s temperature
•  
• Inspect the color, quality, quantity, and odor of the fluid
• Anything foul smelling (infection)
• Tinged with green (meconium) means baby is stressed

• Helpful Hint from L&D experience
• Baby’s HR starts increasing into 140s-160s
• This is a pre-indicator that mom is having an infection
• Her temp will start going up
• But the FHR is the 1st sign

• Prolapse Umbilical Cord
• Umbilical cord slips down in gush of fluid
• Obstructs blood flow to & from placenta, & reduces gas exchange

• Suspected if occurs after procedure
• Deep or prolonged variable decelerations occur during contractions

Persistent bradycardia is present after contractions

• Chorioamnioitis
• Infection of the amniotic sac
• Vaginal organisms have free access to uterine cavity
• Risk increases as time between rupture & birth increases
• Birth within 24 hours of amniotomy desired

• Placenta Previa
• Fetus is high up
• Fetus is not in cephalic presentation

• Induction
• Deliberate starting of labor artificially

• Augmentation
• Stimulating a stalled labor (with oxytocin)
• When ending pregnancy benefits woman or fetus
• Labor & vaginal birth are considered safe

• Post-term pregnancy
• Fetal Death
• Fetal Compromise
• Chorioamnionitis
• Placenta Abruption
•        
• PROM (Premature Rupture of the Membranes)
• Spontaneous rupture of membranes at or near term without onset of labor

Within 24 hours

• Maternal Medical Conditions
• Diabetes, hypertension, renal disease, pulmonary disease, chronic illness
•                       
• Elective Inductions

History of rapid labors (no time to get to hospital)

Living in a rural area (far away from any hospital)

Prenatal tests show fetal anomaly (Need a special hospital and or specific equipment ready)

Labor has begun but progress has slowed or stopped due to poor contractions

Progress is slower than expected (even with adequate contractions)

Placenta Previa

Vasa Previa

Any contraindication to labor or vaginal birth is a contraindication to augmentation or induction

• Placenta Previa
• Vasa Previa
• Umbilical Cord Prolapse (immediate cesarean indicated)
• Previous uterine surgery (classic vertical incision cesarean, uterine fibroids surgery)

• Abnormal fetal presentation
• Active genital herpes                
• Mother has severe heart disease           
• High fetal presenting part (above the pelvic outlet)

Contractions are too close together

Less than 2 minutes apart

Relaxation is less than 30 seconds between

• Uterine tachysystole (hyper-stimulation)
• Uterine rupture (if uterus is distended)
• Greater risk of chorioamniontis & cesarean birth
• Maternal water intoxication (due to oxytocin’s antidiuretic effects)                              
• Hypertonic Uterine Activity

Cervical Ripening

• Administering Prostaglandin
• Intravaginally or via intracervical gel

• Administering Misoprostol (Cytotec)
• Route: PO
  Synthetic prostaglandin tablet
• Popular due to low cost & ease of use
• For cervical ripening & labor induction

• Transcervical Catheter
• Balloon tipped Foley catheter in cervix with possible saline infusion

• Hydrophilic (moisture loving) inserts into cervical canal
• Gradually dilates cervix by absorbing water and expanding

• Maternal Indications
• Exhaustion / inability to push effectively
• Cardiac or pulmonary disease
• Intrapartum infection

• Fetal Indications
• Cord compression
• Placenta previa
• Non-reassuring FHR patterns when the delivery is close

• Contraindicated if C-Section
• is preferable because a more rapid is birth required

• Examples
• High fetal station
• Maternal pulmonary edema
• Severe fetal compromise
• Fetal head won’t fit thru pelvis

Chignon

Risks for Vacuum / Forceps

• Laceration or hematoma of vagina, perineum, or peri-urethral
• area

Need of a very large episiotomy

Infant has Ecchymosis, facial and scalp lacerations

Facial nerve injury to infant

Intracranial hemorrhage to infant

• Gradual stretching perineum
• Use of open-glottis pushing rather than prolonged breath-holding
• Push in upright position
• Using warm compresses to perineal area

Perineal massage 10 minutes a day starting at 36 weeks

Observe for hematoma or edema

Apply cold compress to application for first 12 hours (Prevent the swelling)

Then intermittent heat applications in between when too cold

Dystocia

• Dystocia
• Cephalopelvic (fetopelvic) disproportion 
• Hypertension
• Active genital herpes at time of birth
• Fetal malpresentations (breech, transverse)
  Persistent non-reassuring FHR patterns
• Prolapsed umbilical cord
• Previous classic vertical cesarean incision

• Hemorrhagic Conditions
• Abuptio placentae
• Placenta previa

• Maternal Diseases (Labor is not advised)
• Diabetes
• Heart disease
• Cervical cancer

When risk to mother is too great compared to benefit to fetus

• Fetal death
• Fetus is too immature to survive
• Maternal coagulation defects (mother would have issues with bleeding post-op)

• Transient = short-lived (less than 24 hours)
• Tachypnea = rapid breathing

• Usually seen shortly after delivery
• Most common in c-section babies

• Due to delayed absorption of lung fluid
• Vaginal birth allows for that last squeeze of the lungs

• Maternal Risks
• This is major abdominal surgery
• Infection, hemorrhage, transfusion
• Urinary tract trauma / infection
• Possibility that a ureter could be nicked
• Thrombophlebitis, thromboembolism
• Paralytic ileus
• Atelectasis
• Anesthesia complications

• Infant Risks
• Transient Tachypnea of the Newborn (TTN)
• Persistent pulmonary hypertension
• Injury (laceration, bruising, fractures, or other trauma)

Documentation of fetal heart sounds for 20 weeks via non-electronic means

Documentation of fetal heart sounds for 30 weeks by Doppler ultrasound

Interval of 36 weeks since positive results of pregnancy test (by reliable lab)

Ultrasound at 6-11 weeks of pregnancy supporting 39 weeks or more

• Women with questionable due dates
• Amniocentesis to establish lung maturity

Await spontaneous onset of labor to do cesarean if VBAC is now planned

Routine lab work (CBC, clotting studies, blood typing & screening)

Check fetal lung maturity

Epidural or combined spine epidural (CSE) block given

Mother is NPO except for medication to lower gastric acid

• Fetal surveillance continues until just before sterile skin
• prep

Wedge placed under 1 hip prevents promotes placental blood flow

Indwelling catheter is inserted after regional block

Keeps bladder out of way during surgery

Observation of urine output, helps evaluate circulatory status

Grounding pad applied (thigh)

Sterile abdominal skin prep done just before draping

Remember that this is major abdominal surgery, treat it as so

Change positions every hour & ambulate ASAP

Deep breathing

• Check the Following
• Vital signs, cardiac monitor, pulse-ox
• Incisions & dressings
• Perineal area for discharge
• Fundus
• Look for hemorrhoids

• Monitor the Following
• I/O
• Pain
• Return of feeling to lower extremities

2:1

3:1 (if mother is diabetic)

Famotidine (Pepcid)

Sodium citrate (Bicitra)

Contractions are coordinated but too weak to be effective

Occurs during active phase of labor (after 4 cm dilated)

Associated with uterine distension (stretched muscles contract poorly)

Fetal hypoxia is NOT usually seen

• Woman is comfortable because contractions are weak (cramp
• like)

But persistent hypotonic dysfunction is fatiguing & frustrating

It will depend on the cause

Put mother in upright position to promote effective contractions (walking, shower)         

Promote activity and causes better labor progress than being in one position

• Pain management
• May reduce contraction effectiveness
• May improve progress of labor by removing pain

Help mother get her anxieties out in the open to improve stress response

Amniotomy or oxytocin may be used to stimulate a slowed labor

If not work, mother needs a section

Less common than hypotonic

Usually during latent phase of labor (before 4cm dilation)

• Contractions
• Uncoordinated and erratic in frequency, duration, & intensity
• Painful & ineffective
• No or little dilation
• 90-120 seconds long
• Less than 2 minutes apart
• Less than 30 seconds of relaxation between

Mother becomes tired, dehydrated, frustrated, anxious which further lowers pain tolerance

Relief of pain (warm bathing, systemic analgesics, epidural, spinal block)

• IV fluids (maintain hydration)
• Lay mom on her side
• Promote normal labor pattern
• Tocolytic Drugs

Tocolytic Drugs

Uterine over distension & Uterine atony (due to overstretching)

• Postpartum hemorrhage
• C-Section                                            
• Fetal hypoxia

• Intra-Amniotic Infection (IAI)
• Chorioamnionitis

Premature Rupture of Membranes (PROM)

Preterm Premature Rupture of Membranes

Membranes rupture earlier than end of 37th week of gestation with or without contractions

Check temperature 4x a day, alert provider if 100° or higher

No inserting anything into vagina (this includes sex)

• Some activity restrictions
• Observe for contractions

• Infection of vaginal or cervix (from STDs)
• Amniotic sac with weak structure
• Chorioamnionitis
• Fetal abnormalities
• Maternal stress

Recent intercourse (especially late in pregnancy)

Correlations seen with low nutrition & social economics

20-36

34-36

• Short cervical length
• Infection
• Previous pre-term births
• Postive for fFN (Fetal Fibronectin)

• Underweight or obese
• Uterine fibroids
• DES exposure as a fetus
• Chronic illness (cardiac, renal, etc)
• Uterine distension
• Anemia
• Incompetent Cervix
• Preeclampsia
• pPROM
• No prenatal care
• Poor nutrition
• Smoking & substance abuse
• Domestic violence
• Employment requires long hours standing

• Persistent uterine contractions
• 1 cm dilation
• Sensation that baby is “cramping up”
• Cramps (bearing down)
• Back pain & pressure over thigh
• Vaginal discharge is greater in amount & bloody

• Monitor I/O for dehydration
• Administer tocolytic (mag sulfate)
• Find out about NICU availability
• Observe for indications to no longer continue the pregnancy

Cord that has slipped into a position where it is compressed between maternal pelvis & fetal body

• Three Types
• Complete, cord is visible & at vaginal opening
• Partial, Not visible but palpable with exam
• Occult, Not visible or palpable but vitals indicate so

• Most Often Seen In
• Artificial ROM significantly increases risk
• Breech position & transverse lie
• Premature babies
• High station & not coming down the shute
• Hydramnios

Push head or presenting part upward until section

Position mom so hips are higher than her head (To relieve pressure off the cord)

Use pillows while on her side

Give oxygen 8-10 L by mask

• Tocolytic drugs (no more contractions wanted)
•  
• Cord Treatment
• Do NOT push the cord back in place
• Moisten with warm saline

• Delivery is Rapid
• Keep parents calm because it happens very fast
• Check on them post-op (because it all goes so fast during)

Occurs when baby is exposed to additive opiate while in womb

Cluster of withdrawal symptoms are observed within 48-72 hours

Often given morphine by mouth around the clock

• Symptoms
• Inconsolable
• High pitched crying
• Flailing of limbs (keep them swaddled tight)
• Difficulty sleeping, eating
• Spastic (startle & scale easily)

An infection of the female reproductive organs, contracted during or after childbirth (or miscarriage)

Used to be called "childbed fever"

• Manifestations
• Fever 100.4° F or higher occurring after the first 24 hours after delivery
• Fever occurs for 2 days in the first 10 days after birth

• Causes
• C-sections, forceps, trauma (during birth)
• Use of foley cath
• Rapid or prolonged labor
• General poor health of mother

Mastitis is the most common type in US

Common virus in herpes group that rarely causes symptoms except in pregnant women & those immuosuppressed

Young children are typically a reservoir

Often seen in daycare centers where employees pick it up from kids

A history of severe depression and bi-polar disorder

• Relentless obsessive thinking
• Sleep disorders
• Agitation leading to delusions
• Preoccupation with guilt, worthlessness
• Talking about suicide or killing child
• Overly concerned about baby’s health
• Constantly worrying that the baby is defective or dead
• Lack of appetite

• Mother Is
• Younger than 16 or older than 35
• Nonwhite race
• Multiparity
• Low socioeconomic status
• Dependent on public assistance
• Obese
• Has a low pre-pregnancy weight
• A smoker
• Less than 5 feet tall
• Uses alcohol or illegal drugs

• Birth of previous baby weighing more than 8.8 pounds
• Previous pre-term birth
• Previous fetal or neonatal death
• Rh sensitization

• Diabetic
• Thyroid (hypothyroidism or hyper)
• Cardiac Disease
• Renal Disease
• Concurrent Infections

Median (Mid-line) is straight up & down

Mediolateral is diagonal

• Advantages
• Less blood loss
• Neat healing with little scarring
• Less postpartum pain

• Disadvantages
• May extend into anal sphincter
• Limited enlargement

• Advantages
• More enlargement for opening
• Won't extend into anus

• Disadvantages
• More blood loss
• More pain postpartum
• More scarring & irregular scarring
• Prolonged dyspareunia (painful intercourse)