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Quiz 3
OB
| Question | Answer |
|---|---|
| Stages of labor: 1st stage dilation & effacement | Cervix dilates 0 to 10cm; effacement occurs Latent phase (0 to 6cm); mild cramp like contractions, excited, long phase Active phase (6 to 10cm); stronger, more regular contractions, patient anxious/focused |
| Stages of labor: 1st stage dilation & effacement | Transition (8 to 10cm); strongest contractions, shorter phase; patient may feel out of control/irritable |
| Stages of labor: 1st stage dilation & effacement timing | Latent: variable (hrs-days) Active: faster progression Transition: 15-60 min |
| Stages of labor: 1st stage dilation & effacement key nursing priorities | Monitor contractions frequency, duration, intensity Assess cervical dilation q1–2h (or PRN) Fetal heart rate per protocol Support coping; offer pain management Encourage position changes & ambulation |
| Stages of labor: 2nd stage : Birth of baby | Fully dilated to delivery of baby 7 cardinal movements of labor Strong urge to push Fetal station progresses to +3/crowning |
| Stages of labor: 2nd stage : Birth of baby timing | 20 min – 4 hrs (longer with epidural or nullipara) |
| Stages of labor: 2nd stage : Birth of baby key nursing priorities | Coach pushing effectively Monitor fetal heart rate q5–15 min If nearing 4 hrs →provider notified; consider operative birth or C/S Longer push time = increased PPH risk Prepare delivery area |
| Stages of labor: 3rd Placental delivery | Delivery of placenta Signs of separation: cord lengthens, gush of blood, urge to push, uterus globular Uterus contracts to close decidual vessels |
| Stages of labor: 3rd Placental delivery timing | 5–30 minutes >30 min = retained placenta |
| Stages of labor: 3rd Placental delivery key nursing priorities | NEVER pull cord to separate placenta (can cause inversion) Give oxytocin after delivery of baby Assess for signs of separation Monitor VS and bleeding If >30 min: large-bore IV, monitor for hemorrhage |
| Stages of labor: 4th stage recovery | Birth through 1–4 hrs postpartum Uterine involution begins Fundus at umbilicus immediately after birth → descends 1 FB/day → non-palpable day 10 Lochia rubra (bright red) is normal |
| Stages of labor: 4th stage recovery timing | ≥4 hours or until stable |
| Stages of labor: 4th stage recovery key nursing priorities | VS & fundus assessment q15 min × 1 hr, then q30 min Assess lochia: amount, color, clots Encourage void (full bladder displaces uterus → ↑ bleeding risk) Skin-to-skin; initiate breastfeeding (30–60 min after birth) |
| Stages of labor: 4th stage recovery key nursing priorities | RISKIEST time for hemorrhage — do not leave unattended |
| Stages of labor clinical pearl | Boggy uterus in Stage 4 = uterine atony = #1 cause of PPH. If displaced to right of midline = EMPTY BLADDER FIRST, then massage. If midline but boggy = MASSAGE NOW. |
| premonitory signs of impending labor | Lightening (fetal descent) — 2 weeks before labor; patient feels relief of pressure on diaphragm but ↑ pressure on bladder Bloody show — blood-tinged mucus from cervical ripening; normal finding Nesting behavior — surge of energy to prepare home |
| premonitory signs of impending labor | GI upset — nausea, diarrhea, cramping Weight loss of 1–3 lb from hormonal fluid shifts |
| premonitory signs of impending labor | Cervical ripening — softening (like a ripe banana), effacement, anterior movement Regular contractions — the definitive sign; confirm with cervical check |
| The Five Ps of labor | Dysfunction in ANY one of the 5 Ps can cause dystocia (difficult or arrested labor) |
| The Five Ps of labor: Power | Uterine contractions (primary) + maternal pushing (secondary) |
| The Five Ps of labor: Power normal/ideal | Regular contractions q2–3 min, 60–90 sec, moderate–strong intensity; adequate MVU (montevideo units) ≥200 |
| The Five Ps of labor: Power dysfunction | Hypotonic (too weak), hypertonic (too frequent), or incoordinated contractions |
| The Five Ps of labor: Power nursing interventions | Oxytocin augmentation for hypotonic; terbutaline for hypertonic/tachysystole; position changes |
| The Five Ps of labor: Passageway | Bony pelvis shape & size + soft tissue (cervix, vagina) + pelvic floor |
| The Five Ps of labor: Passageway normal/ideal | Gynecoid pelvis (round, wide subpubic arch) is ideal for vaginal birth |
| The Five Ps of labor: Passageway dysfunction | Android/platypelloid pelvis; CPD; full bladder = soft tissue obstruction |
| The Five Ps of labor: Passageway nursing interventions | Catheterize before diagnosing CPD (cephalopelvic disproportion); upright positions widen pelvic outlet; C/S if true CPD |
| The Five Ps of labor: Passenger | Fetal size, presentation, lie, attitude (flexion), and station |
| The Five Ps of labor: Passenger normal/ideal | Station Cephalic (vertex), full flexion (LOA), engaged at 0 station |
| The Five Ps of labor: Passenger dysfunction | Malpresentation (breech, transverse, face); macrosomia; OP position; asynclitism |
| The Five Ps of labor: Passenger nursing interventions | Leopold maneuvers to assess; position changes to rotate OP; ECV for breech; C/S if unresolvable |
| The Five Ps of labor: Psyche | Patient's emotional state: fear, anxiety, pain tolerance, support system, cultural beliefs |
| The Five Ps of labor: Psyche normal/ideal | Calm, supported, informed patient; low anxiety facilitates oxytocin release |
| The Five Ps of labor: Psyche dysfunction | High anxiety → catecholamines → inhibit uterine contractions; fear-tension-pain cycle |
| The Five Ps of labor: Psyche nursing interventions | Continuous labor support (doula/nurse); non-pharm comfort measures; therapeutic communication; include support person |
| The Five Ps of labor: Position | Patient's emotional state: fear, anxiety, pain tolerance, support system, cultural beliefs |
| The Five Ps of labor: Position normal/ideal | Upright, mobile, frequent position changes promote fetal descent |
| The Five Ps of labor: Position dysfunction | Supine or lithotomy = ↓ pelvic dimensions, aortocaval compression |
| The Five Ps of labor: Position nursing interventions | Encourage walking, squatting, hands-knees (especially for OP), side-lying; can shorten Stage 1 by up to 90 min |
| Fetal station | -3 to -1: presenting part above ischial spines — not engaged 0: at ischial spines — engaged +1 to +3: below ischial spines — progressing to delivery Crowning occurs at +3 station |
| Premature rupture of membranes (PROM) | ≥37 weeks, before labor onset Physiologic; expect labor within 12–24 hrs; induce if not progressing |
| Preterm premature rupture of membranes (PPROM) | Before 37 weeks Not normal; major risks: infection (chorioamnionitis), cord prolapse; preterm birth |
| C-O-A-T assessment | every patient with ROM - rupture of membranes |
| C-O-A-T assessment (C) color | normal finding: clear or straw colored = normal amniotic fluid abnormal/ action required: green or yellow green = meconium (fetal stress); bloody = concerning |
| C-O-A-T assessment (O) odor | normal finding: should have no odor; amniotic fluid is slightly sweet. abnormal. action required: foul, offensive odor = infection (chorioamnionitis) |
| C-O-A-T assessment (A) amount | normal finding: can be a large gush (rupture) or slow continuous trickle abnormal/ action required: quantity- saturated pad vs. scant; distinguish from urine/discharge |
| C-O-A-T assessment (T) time | normal finding: document exact time of rupture abnormal/ action required: affects management- prolonged ROM (>18-24 hours) increases infection risk. |
| Confirming ROM | Nitrazine test: amniotic fluid turns paper BLUE (pH 6.5–7.0); vaginal pH is acidic (~4.5) Ferning test: amniotic fluid forms fern-like crystals under microscope |
| Confirming ROM | AmnioSure test (PAMG-1 protein): most specific, used when Nitrazine is inconclusive False positives: blood, semen, bacterial vaginosis |
| Nursing actions after any ROM | Check FHR IMMEDIATELY — sudden decel = cord prolapse Assess fluid using C-O-A-T; document time Temperature every 2 hours (chorioamnionitis surveillance) |
| Nursing actions after any ROM | Limit vaginal exams — each exam ↑ infection risk For PPROM <34 wks: betamethasone, Magnesium sulfate <32 wks, antibiotics, tocolytics (if no infection) Notify provider; continuous EFM |
| Fetal heart rate monitoring | normal baseline: 110-160 bpm, no intervention; document, reassuring, category I tachycardia: >160 bmp >10 min; assess cause, infection/fever, hypoxia, medications (terbutaline), maternal anxiety. INVESTIGATE category II |
| Fetal heart rate monitoring | bradycardia: <110 bmp >10 min; assess cause, cord compression, maternal hypotension, prolonged deceleration, may need immediate intervention, URGENT category III |
| Fetal heart rate monitoring Variability - most important feature of the FHR strip | Variability = fluctuations in the baseline FHR. It reflects fetal CNS health and oxygenation. Moderate variability is the single most reassuring FHR feature — it means the baby is compensating well regardless of what else is on the strip. |
| Fetal heart rate monitoring Absent | Amplitude: 0 beats per minute Clinical significance: MOST CONCERNING — suggests fetal hypoxia, central nervous system depression, or acidosis Category III - act immediately |
| Fetal heart rate monitoring Minimal | Amplitude: ≤5 beats per minute Clinical significance: Can indicate hypoxia, sedating medications (opioids, magnesium sulfate), or fetal sleep cycle (sleep cycles last 20–40 minutes) Category II - monitor closely |
| Fetal heart rate monitoring Moderate | Amplitude: 6-25 beats per minute Clinical significance: NORMAL AND REASSURING — the best indicator that the fetus is well oxygenated Category I - document |
| Fetal heart rate monitoring Marked | Amplitude: >25 beats per minute Clinical significance: May be a very active baby (benign) or early sign of hypoxia — investigate context and other strip features Category II - investigate cause |
| Fetal heart rate monitoring clinical pearl | Moderate variability with late decelerations is still a CONCERN — the decelerations matter. Absent variability WITH late decelerations = Category III emergency regardless of baseline rate. |
| Electronic Fetal Monitoring Frequency Guidelines | low risk patient, active phase of 1st stage: every 30 minutes low-risk patient, 2nd stage (pushing): every 15 minutes high-risk patient, 1st stage: every 15 minutes high-risk patient, 2nd stage (pushing): every 5 minutes standard practice in the United States: continuous electronic fetal monitoring for all laboring patients |
| Electronic Fetal Monitoring Categories | Category I (Normal): baseline 110–160 bpm, moderate variability, no late or variable decelerations, with or without early decelerations or accelerations → Routine care, continue monitoring Category II (Indeterminate): does NOT fit Category I or III → Requires close evaluation, continuous monitoring, intrauterine resuscitation measures, and frequent reassessment |
| Electronic Fetal Monitoring Categories | Category III (Abnormal): absent variability WITH recurrent late decelerations, recurrent variable decelerations, bradycardia, OR sinusoidal pattern → Immediate evaluation and intervention; prepare for cesarean section |
| Fetal Heart Rate Decelerations — VEAL CHOP | VEAL = what you SEE on the strip · CHOP = what CAUSED it · Variable=Cord · Early=Head · Accelerations=OK · Late=Placenta |
| VEAL CHOP - VARIABLE (V) | visual appearance: Abrupt onset and offset; V-shaped or W-shaped; vary in timing relative to contractions; may drop suddenly. cause: Cord compression — umbilical cord is being squeezed during contractions or fetal movement. clinical significance: Occur in approximately 50% of labors; usually transient and correctable. Concerning if severe (below 70 beats per minute) or prolonged. |
| VEAL CHOP - VARIABLE (V) nursing interventions in order/ urgency | 1. Reposition mother (left lateral, right lateral, knee-chest, hands-knees) 2. Discontinue oxytocin 3. Oxygen at 10 L/min via non-rebreather mask 4. Intravenous fluid bolus 5. Notify provider if persistent or severe 6. Amnioinfusion if ordered by provider 7. Prepare for cesarean section if unresolved urgency - escalate if persist |
| VEAL CHOP - EARLY (E) | visual appearance: Gradual onset that mirrors the contraction; smooth U-shape; nadir (lowest point) at peak of contraction; uniform and symmetric. Cause: Head compression — fetal head pressed against cervix during contraction triggers a vagal nerve response. Clinical significance: NORMAL pattern; not associated with fetal hypoxemia or low APGAR scores; benign and reassuring. Nursing intervention: No intervention needed. prepare for imminent delivery. document in the chart. urgency- normal |
| VEAL CHOP - ACCELERATIONS (A) | visual appearance: ≥15 beats per minute above baseline lasting ≥15 seconds (term); ≥10 beats per minute × ≥10 seconds (preterm) cause: Normal fetal response — fetal well-being. Caused by fetal movement, scalp stimulation, vaginal examination, or external sounds. clinical significance: Spontaneous accelerations are the BEST sign of fetal well-being. A reactive non-stress test = 2 accelerations in 20 minutes. |
| VEAL CHOP - ACCELERATIONS (A) | nursing interventions: Document only. No clinical intervention needed. Reassure patient that baby is doing well. urgency: reassuring, document only |
| VEAL CHOP - LATE (L) | visual appearance: Gradual onset AFTER the peak of the contraction; smooth, symmetric; nadir occurs after the peak; slow return to baseline. cause: Uteroplacental insufficiency — placenta cannot deliver adequate oxygen to the fetus during contractions. clinical significance: ABNORMAL — OMINOUS SIGN. Associated with fetal hypoxemia, low APGAR scores, fetal acidemia. Especially dangerous when combined with tachycardia and absent variability. |
| VEAL CHOP - LATE (L) | nursing interventions: 1. Reposition: left lateral decubitus position 2. Discontinue oxytocin and prostaglandins immediately 3. Oxygen at 10 L/min via non-rebreather mask 4. Intravenous fluid bolus (lactated Ringer's) 5. Correct hypotension (ephedrine if epidural-related) 6. Palpate uterus to rule out hyperstimulation 7. Notify provider STAT 8. Prepare for emergency cesarean section urgency: EMERGENCY ACT NOW |
| Additional Fetal Heart Rate Patterns prolonged deceleration | definition: Drop ≥15 beats per minute lasting ≥2 minutes but less than 10 minutes. causes: Cord compression, maternal hypotension, uterine hyperstimulation, vagal response from vaginal exam. Required action: Reposition, oxygen, discontinue oxytocin, intravenous fluid bolus, call for help, terbutaline order if hyperstimulation. If lasting >7 minutes: emergency cesarean section likely. |
| Additional Fetal Heart Rate Patterns sinusoidal pattern | definition: Smooth, sine-wave oscillation at 3–5 cycles per minute; absent short-term variability; looks like smooth ocean waves. causes: Fetal anemia (Rh isoimmunization, fetal-maternal hemorrhage), twin-to-twin transfusion syndrome, neurological condition. required action: OMINOUS pattern — Category III. Notify provider STAT. Prepare for emergency delivery immediately. |
| Preterm Labor & magnesium sulfate safety | Preterm labor = regular contractions causing cervical change before 37 weeks gestation. Affects approximately 10% of all births. The patient may have only ONE sign. Even a single symptom warrants evaluation. |
| Preterm Labor & magnesium sulfate safety, signs & risk factors | Pelvic pressure or low back pressure/pain Change in vaginal discharge (watery, bloody, or increased amount) Mild, irregular, or regular contractions Spontaneous rupture of membranes Risk factors: prior preterm birth, PPROM, multiple gestation, infection, short cervix (<25 mm), substance use, high stress, low socioeconomic status |
| Preterm Labor & magnesium sulfate safety, treatment goals | 1. Delay delivery ≥48 hours to allow antenatal corticosteroids to work 2. Betamethasone 12 mg intramuscular × 2 doses (24 hours apart) — promotes fetal lung maturity 3. Magnesium sulfate before 32 weeks — fetal neuroprotection; reduces risk of cerebral palsy 4. Tocolytics (indomethacin, nifedipine, terbutaline) — goal is DELAY only, not indefinite suppression 5. Antibiotics if PPROM or Group B Streptococcus status unknown |
| Magnesium Sulfate Toxicity Monitoring — Must Know Cold | ANTIDOTE: Calcium Gluconate 1 gram IV over 5–10 minutes Must be drawn up and labeled BEFORE starting magnesium sulfate infusion Keep the syringe at the bedside AT ALL TIMES during the infusion Do not wait until symptoms appear — have it ready immediately |
| Magnesium Sulfate Toxicity Monitoring Therapeutic level | serum concentration: 4-7 mEq/L signs & symptoms: Flushing, sensation of warmth, nausea (expected side effects) nursing action: Continue infusion; reassure patient that these feelings are expected. |
| Magnesium Sulfate Toxicity Monitoring loss of deep tendon reflexes | serum concentration: 7-10 mEq/L signs & symptoms: Patellar reflex absent; patient feels very heavy; early sign of toxicity. nursing action: HOLD infusion → notify provider immediately → do not restart without order. |
| Magnesium Sulfate Toxicity Monitoring respiratory depression | serum concentration: 10-13 mEq/L signs & symptoms: Respiratory rate less than 12 per minute; somnolence; oxygen saturation declining nursing action: STOP infusion → calcium gluconate 1 gram IV STAT → oxygen → call for help |
| Magnesium Sulfate Toxicity Monitoring cardiac arrest | serum concentration: >15 mEq/L signs & symptoms: Cardiac conduction failure; patient unresponsive nursing action: CODE team → CPR → calcium gluconate → emergency delivery |
| Magnesium Sulfate Toxicity Monitoring Clinical Pearl | Monitor magnesium sulfate patients EVERY HOUR: deep tendon reflexes, respiratory rate, urine output (≥30 mL/hour), and level of consciousness. Magnesium is excreted by the kidneys — oliguria significantly raises toxicity risk |
| Chorioamnionitis — Intrauterine Infection | Diagnosis requires: Fever ≥38°C (100.4°F) PLUS at least ONE additional criterion. |
| Chorioamnionitis — Intrauterine Infection FEVER + CRITERIONS | 1. fetal tachycardia, finding: >160 beats per minute on electronic fetal monitoring. why: Fetus responds to maternal infection and inflammatory mediators. 2. uterine tenderness, finding: Fundal tenderness or pain on palpation. why: Inflammatory response within the uterine wall 3. foul amniotic fluid, finding: Malodorous vaginal discharge or amniotic fluid. why: Bacterial infection of the amniotic sac |
| Chorioamnionitis — Intrauterine Infection FEVER + CRITERIONS | 4. maternal leukocytosis, finding: White blood cell count >15,000 cells/mm³. why: Systemic inflammatory response to infection 5. maternal tachycardia, finding: Heart rate >100 beats per minute. why: Systemic infection triggering sympathetic response |
| Risk Factors for Chorioamnionitis | PPROM or prolonged rupture of membranes (>18–24 hours) Multiple vaginal examinations after membrane rupture Prolonged labor, especially active phase arrest Internal fetal monitoring (intrauterine pressure catheter, fetal scalp electrode) Group B Streptococcus colonization Meconium-stained amniotic fluid |
| Chorioamnionitis nursing ma | Broad-spectrum antibiotics IMMEDIATELY (ampicillin + gentamicin) Delivery is the DEFINITIVE treatment — tocolytics are CONTRAINDICATED Continuous electronic fetal monitoring (fetal tachycardia = early sign of neonatal sepsis) Temperature assessment every 2 hours Notify NICU team before delivery to prepare for neonatal resuscitation Document all interventions and maternal and fetal response |
| Placenta Previa | Placenta implants over or near the cervical os. Types: Low-lying (near but not over), Marginal, Partial, Complete (fully covers os). ALL types confirmed by ultrasound. |
| Placenta Previa classical presentation | Painless, bright-red vaginal bleeding — sudden onset, without warning or provocation Soft, non-tender uterus (no pain because the placenta is not shearing from the wall) Fetal heart rate usually normal initially Bleeding may be heavy and can recur throughout the pregnancy First episode often resolves; subsequent episodes tend to worsen Diagnosis confirmed by transabdominal or transvaginal ultrasound — NEVER digital exam |
| Placenta Previa CRITICAL NURSING RULE — NEVER PERFORM A VAGINAL EXAM | NO digital vaginal examination EVER in any patient with known or suspected placenta previa One digital exam can trigger catastrophic, potentially fatal hemorrhage Use speculum examination (by provider only) if absolutely required Vaginal birth is NOT possible with a complete previa Cesarean section is required for delivery If heavy bleeding: two large-bore intravenous lines, type and crossmatch, continuous electronic fetal monitoring, nothing by mouth, notify OB STAT |
| Placenta Previa clinical pearl | CLINICAL PEARL: Painless + bright red + soft uterus = placenta previa until proven otherwise. Think "previa" and keep your hands OUT. Confirm with ultrasound, not examination. |
| Placental Abruption | Placental Abruption — premature separation of a normally implanted placenta from the uterine wall |
| Placental Abruption presentation | Painful, dark-red vaginal bleeding; rigid or board-like, severely tender uterus. IMPORTANT: hemorrhage may be CONCEALED — blood collects behind the placenta with no visible external bleeding while the patient is deteriorating rapidly. |
| Placental Abruption fetal status | Fetal distress, non-reassuring fetal heart rate patterns (Category II or III); absent fetal heart rate in severe complete abruption |
| Placental Abruption causes & risk factors | Hypertension (most common cause); cocaine or stimulant use; blunt abdominal trauma; tachysystole (uterine hyperstimulation); prior abruption; tobacco use; short umbilical cord |
| Placental Abruption disseminated intravascular coagulation risk | Severe abruption releases thromboplastin into circulation → triggers DIC cascade. Watch for: petechiae, oozing from intravenous sites, blood in urine, nosebleeds, blood that will not clot |
| Placental Abruption diagnosis | Clinical diagnosis — ultrasound may MISS the abruption because a retroplacental clot is not always visible on imaging. Clinical signs combined with fetal heart rate changes confirm the diagnosis. |
| Placental Abruption emergency nursing response | Two large-bore intravenous lines immediately Type and crossmatch; complete blood count; coagulation studies (PT, PTT, fibrinogen, D-dimer) Continuous electronic fetal monitoring — Category II or III fetal heart rate = emergency cesarean section |
| Placental Abruption emergency nursing response | Prepare for emergent cesarean delivery; notify OB STAT Notify NICU team before delivery to prepare for neonatal resuscitation Activate massive transfusion protocol if hemorrhaging Monitor for disseminated intravascular coagulation: replace fresh frozen plasma, platelets, and cryoprecipitate as ordered |
| Vasa Previa | fetal blood vessels overlie the cervical os without protection of the placenta or umbilical cord |
| Vasa Previa key facts & nursing roles | Fetal vessels lie OVER or near the cervical os — completely unprotected by Wharton's jelly or placental tissue When membranes rupture (spontaneous or artificial), fetal vessels rupture → fetal exsanguination in MINUTES — baby bleeds out Classic presentation: painless vaginal bleeding that occurs AT THE EXACT TIME of membrane rupture, followed immediately by severe fetal bradycardia Management: scheduled cesarean section at 34–35 weeks (before any chance of labor or membrane rupture) |
| Vasa Previa key facts & nursing roles | NEVER perform a vaginal examination in any patient with suspected vasa previa Diagnosis: transvaginal ultrasound with color Doppler in the third trimester |
| Shoulder Dystocia — HELPERR Protocol | Fetal head delivers → anterior shoulder is impacted behind the pubic symphysis → shoulder cannot deliver. Turtle sign = fetal head retracts back against the perineum after delivery. Brain injury begins within 4–5 minutes without intervention. |
| Shoulder Dystocia recognition & risk factors | TURTLE SIGN: fetal head delivers then retracts back ("turtles") against the perineum Provider unable to deliver the anterior shoulder with gentle downward traction Risk factors: fetal macrosomia (>4,000–4,500 grams), maternal diabetes, prior shoulder dystocia, prolonged 2nd stage, maternal obesity |
| Shoulder Dystocia recognition & risk factors | IMPORTANT: Many cases have NO identifiable risk factors — every provider must be prepared NEVER apply fundal pressure — drives shoulder further into the pubic symphysis NEVER pull on the fetal head or neck — causes brachial plexus injury, Erb palsy, or cervical spine damage |
| HELPERR Protocol — Perform in Order | H — Help: Call obstetrician, NICU team, and additional nurses STAT; announce "shoulder dystocia" E — Episiotomy: Only if needed to allow room for maneuvers; does NOT release the bony obstruction L — Legs (McRoberts): Sharp hip hyperflexion against the abdomen; flattens lumbar lordosis and widens the pelvic outlet |
| HELPERR Protocol — Perform in Order | P — Pressure: Suprapubic pressure — push the fetal anterior shoulder downward and laterally E — Enter: Internal rotation maneuvers — Rubin II (push anterior shoulder toward fetal face) or Woods Screw R — Remove posterior arm: Insert hand posteriorly, locate the posterior arm, sweep it across the chest to deliver R — Roll: Gaskin all-fours maneuver — patient repositions to hands and knees; gravity assists delivery |
| Shoulder Dystocia Clinical pearl | McRoberts (L) + Suprapubic Pressure (P) together resolve approximately 40–50% of shoulder dystocia cases. Always perform BOTH simultaneously as your first maneuvers. Do NOT skip steps or repeat only one maneuver repeatedly without progressing |
| Umbilical Cord Prolapse | Umbilical cord slips below the presenting fetal part after membrane rupture → cord compressed between the presenting part and the maternal pelvis → fetal hypoxia and death within minutes without immediate intervention. |
| Umbilical Cord Prolapse risk factors | Membrane rupture when the presenting part is not engaged (high fetal station) Footling breech presentation — foot comes down alongside or before the cord Polyhydramnios (excessive amniotic fluid) — cord floats freely |
| Umbilical Cord Prolapse risk factors | Multiparity — loosely fitted presenting part Amniotomy performed before the presenting part is engaged Premature or preterm rupture of membranes Multiple gestation — second twin after delivery of first twin |
| Umbilical Cord Prolapse response | 1. IMMEDIATELY push presenting part UP off the cord with gloved hand — do NOT remove your hand under any circumstances 2. Call for help STAT — obstetrician, operating room team, NICU 3. Position: knee-chest OR steep Trendelenburg — gravity keeps pressure off the cord |
| Umbilical Cord Prolapse response | 4. Oxygen via non-rebreather mask at 8–10 liters per minute 5. Intravenous access; continuous fetal heart rate monitoring 6. Emergency CESAREAN SECTION — surgeon to operating room immediately 7. Keep cord moist with warm saline-soaked gauze; NEVER push cord back; NEVER pull on cord |
| Uterine Rupture | Tear through the full thickness of the uterine wall — fetal parts may enter the peritoneum. Massive internal hemorrhage. Usually occurs at the site of a prior uterine scar. Life-threatening to both mother and fetus. |
| Uterine Rupture risk factors | Trial of labor after cesarean section (most common setting) Oxytocin hyperstimulation — overstretched uterus Grand multiparity (5 or more births) — excessive uterine scarring Blunt abdominal trauma Prior classical (vertical midline) uterine incision Abnormal placentation (placenta accreta, percreta) |
| Uterine Rupture warning signs | Sudden onset Category II or III fetal heart rate patterns (most common early sign) Scar pain or tenderness BETWEEN contractions — not during them Contractions suddenly STOP (uterine wall collapses) Loss of fetal station — presenting part moves UP as fetus floats into abdomen Maternal tachycardia, hypotension — signs of internal hemorrhage Patient reports feeling something "tear" or a sudden relief of pain |
| Uterine Rupture important clinical point | Hemorrhage is often INTERNAL — blood fills the abdominal cavity, not visible externally. Patient may deteriorate rapidly with minimal or no visible external bleeding. Monitor vital signs closely in all trial of labor after cesarean patients. |
| Uterine Rupture emergency management | Two large-bore intravenous lines immediately Type and crossmatch; activate massive transfusion protocol Emergency CESAREAN SECTION NOW — no time for delay Obstetrician surgeon and operating room team STAT NICU team for newborn resuscitation Prepare for possible hysterectomy if rupture cannot be repaired |
| Postpartum Hemorrhage | Blood loss >500 mL after vaginal birth or >1,000 mL after cesarean section, within 24 hours of delivery (primary postpartum hemorrhage). All four causes are remembered as the Four Ts. |
| Postpartum Hemorrhage Tone (uterine atony) | description: Uterus fails to contract after delivery — PRIMARY CAUSE of approximately 80% of all postpartum hemorrhage assessment findings: Boggy (soft, poorly contracted) uterus; heavy lochia; uterus may be displaced from midline if bladder is full nursing interventions: Fundal massage; oxytocin intravenous infusion (first-line); methylergonovine (avoid if hypertension); misoprostol rectally; carboprost intramuscularly; surgical options (B-Lynch suture, hysterectomy) |
| Postpartum Hemorrhage Tone (trauma) | description: Lacerations of cervix, vagina, or perineum; uterine inversion (fundus turns inside out) assessment findings: Heavy bleeding DESPITE a firm uterus; visible lacerations; with uterine inversion: fundus is absent abdominally or visible at vaginal introitus nursing interventions: Surgical repair of lacerations; manual reduction of uterine inversion (Johnson maneuver); NEVER remove placenta before reducing inversion |
| Postpartum Hemorrhage Tissue | description: Retained placenta or placental fragments that prevent the uterus from contracting fully assessment findings: Uterus does not remain firm despite massage; placenta not fully expelled; delivery of placenta takes longer than 30 minutes nursing interventions: Manual removal of retained placenta by provider; uterine exploration; dilation and curettage; two large-bore intravenous lines; type and crossmatch; continuous vital sign monitoring |
| Postpartum Hemorrhage Thrombin | description: Coagulopathy — disseminated intravascular coagulation, thrombocytopenia, HELLP syndrome, amniotic fluid embolism assessment findings: Bleeding from intravenous insertion sites, petechiae on skin, blood in urine, nosebleeds, blood does not clot in sample tubes |
| Postpartum Hemorrhage Thrombin | nursing interventions: Replace clotting factors: fresh frozen plasma, cryoprecipitate (for fibrinogen), platelets; treat underlying cause; activate massive transfusion protocol (1:1:1 ratio of packed red blood cells : fresh frozen plasma : platelets) |
| Postpartum Hemorrhage | CLINICAL PEARL: FUNDAL ASSESSMENT RULE: Midline + boggy = MASSAGE NOW. Displaced to the right = EMPTY BLADDER FIRST (full bladder prevents uterine contraction), THEN massage. The 4th stage of labor is the highest-risk period for hemorrhage — assess every 15 minutes. |
| Disseminated Intravascular Coagulation (DIC) | Disseminated intravascular coagulation is ALWAYS secondary to another condition — it is never a primary diagnosis. It causes simultaneous pathological clotting AND bleeding by consuming clotting factors faster than the body can replace them. |
| Obstetric Triggers for DIC | Placental abruption — MOST COMMON obstetric trigger Severe preeclampsia and HELLP syndrome Amniotic fluid embolism Massive postpartum hemorrhage Sepsis from chorioamnionitis or endometritis Prolonged fetal demise (dead fetus retained for extended period) Acute fatty liver of pregnancy |
| Postpartum hemorrhage Assessment and Management | Signs: petechiae, purpura, oozing from intravenous sites, blood in urine, nosebleeds, gingival bleeding, blood that will not clot Laboratory findings: decreased platelets, decreased fibrinogen, elevated PT/PTT, elevated D-dimer, elevated fibrin degradation products TREATMENT: Identify and treat the UNDERLYING CAUSE first |
| Postpartum hemorrhage Assessment and Management | Replace blood products: fresh frozen plasma (clotting factors), cryoprecipitate (fibrinogen), platelets, packed red blood cells Massive transfusion protocol: 1:1:1 ratio (packed red blood cells : fresh frozen plasma : platelets) Monitor vital signs, urine output, and coagulation studies every 1–2 hours |
| Amniotic Fluid Embolism (AFE) | Amniotic fluid (containing fetal cells, hair, vernix) enters maternal circulation → triggers an anaphylactic-like and inflammatory reaction → cardiovascular collapse. Rare (approximately 1 per 40,000 births) but mortality is 40–60% |
| Amniotic Fluid Embolism (AFE) timing | Most common during active labor or within 30 minutes of delivery. Can occur up to 48 hours postpartum. |
| Amniotic Fluid Embolism (AFE) classic triad | 1. Sudden severe hypotension or cardiovascular collapse 2. Acute respiratory failure and hypoxia 3. Altered mental status, seizures, or coma This triad progresses rapidly to cardiac arrest within minutes |
| Amniotic Fluid Embolism (AFE) coagulopathy | Disseminated intravascular coagulation develops in approximately 80% of cases within minutes; simultaneous massive hemorrhage and intravascular clotting |
| Amniotic Fluid Embolism (AFE) risk factors | Labor induction or augmentation, multiparity, macrosomia, placenta previa, placental abruption, advanced maternal age. However, many cases have NO identifiable risk factors. |
| Amniotic Fluid Embolism (AFE) nursing response | Activate CODE team IMMEDIATELY — do not wait Call for help: obstetrician, anesthesia, NICU, additional nurses Begin CPR if patient is pulseless Vasopressors for hypotension (norepinephrine first-line) Massive transfusion protocol + fresh frozen plasma, platelets, cryoprecipitate for disseminated intravascular coagulation |
| Amniotic Fluid Embolism (AFE) nursing response | Emergency cesarean section within 5 minutes if fetus not yet delivered (perimortem cesarean) Arterial line and central venous pressure monitoring Transfer to intensive care unit after stabilization |
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