NSG210 Exam 2: Labor and Birth Study Sheet (Durham Ch. 8-11)
Covers the Week 07 OB Lecture 3A and 3B (October 7). This is a major part of the OB half of Exam 2.
Sources: raw/nsg210lecture_2026October07.md (class notes, the most detailed source), raw/nsg210_wk07_OBLecture3A.md and raw/nsg210_wk07_OBLecture3B.md (slides), Durham Ch. 8-11 in textbooks/exam02/. Sections marked “(Ch. 8, not in notes)” fill gaps in the class notes from the textbook.
Signs of Impending Labor (Ch. 8, not in notes)
- Lightening: the fetus drops into the true pelvis, about 2 weeks before labor in a first pregnancy (at labor onset in later ones). Easier breathing, more urinary frequency.
- Quickening (for contrast): first fetal movements felt by the mother, about 18-20 weeks in a first pregnancy, 14-16 weeks in later ones. Not a labor sign.
- Braxton-Hicks: irregular “practice” contractions, no cervical change.
- Cervical ripening: softens, moves posterior to anterior, begins to efface and dilate.
- Bloody show (mucus plug), nesting burst of energy, slight weight loss, low backache.
True vs False Labor (Ch. 8, not in notes)
| True labor | False labor | |
|---|---|---|
| Contractions | Regular; get closer, longer, stronger | Irregular; no progression |
| Walking | Contractions intensify | Contractions may ease or stop |
| Pain | Starts in the back, wraps to the front | Mostly in the front (abdomen) |
| Cervix | Effaces and dilates | No change |
Key test answer: cervical change is what defines true labor.
Stages of Labor
| Stage | From - to | Key points |
|---|---|---|
| 1st | Onset of true labor to 10 cm | Latent 0-4 cm, active 4-7 cm (some sources 6 cm), transition 7-10 cm |
| 2nd | 10 cm to birth of baby | Pushing; longer with an epidural; avoid supine |
| 3rd | Birth to delivery of placenta | Over 30 minutes = prolonged third stage / retained placenta (hemorrhage and infection risk) |
| 4th | Placenta to 1-2 hours after | “Watch, Prevent, Recover”: fundus, lochia, VS every 15 min first hour |
Placental separation signs (3rd stage): a gush of blood, the cord lengthens, the uterus rises and becomes globular. Active management of the third stage = uterotonic (oxytocin) right after birth; this is the most effective step to prevent PPH.
Transition clues: irritable, “I can’t do this”, nausea and vomiting, shaking, rectal pressure and urge to push.
Rupture of Membranes (Ch. 8, not in notes)
- First nursing action after ROM (spontaneous or AROM): check the FHR (cord prolapse).
- Assess fluid by COAT: Color, Odor, Amount, Time. Normal is clear or straw-colored. Green = meconium; foul-smelling = infection.
- Confirm ROM: sterile speculum exam (pooling), fern test, nitrazine (turns blue, many false results), AmniSure.
- Infection risk rises the longer membranes are ruptured.
The 5 Ps
- Passenger: lie (longitudinal vs transverse), presentation (cephalic, breech, shoulder), attitude (flexion is normal), position, size. Leopold maneuvers find the fetal back - place the ultrasound transducer there.
- Passageway: pelvis is the greatest determinant of vaginal birth. Gynecoid (best, about 50%), anthropoid (OK), android (poor), platypelloid (worst, about 3%).
- Station: 0 = presenting part at the ischial spines (engaged). Negative = above, positive = below; +4 to +5 crowning. High station plus ROM = cord prolapse risk.
- Powers: frequency (start to start, minutes), duration (start to end, seconds), intensity by palpation (mild = easily indented, moderate = resists, strong = cannot indent). An external TOCO cannot measure intensity; an IUPC measures it in mmHg.
- Effacement before dilation in a first-time mother; together in a multipara.
- Position (maternal): change every 30-60 min; left lateral for fetal distress and after an epidural; hands and knees for occiput posterior back labor; avoid supine (vena cava compression, hypotension).
- Psyche: fear raises catecholamines and slows labor; continuous labor support raises the vaginal birth rate.
Cardinal Movements
“Every Darn Fool In Egypt Eats Raw Eggs”: Engagement, Descent, Flexion, Internal rotation, Extension, External rotation (restitution), Expulsion. Internal rotation happens at the ischial spines; extension occurs under the symphysis pubis.
Pain Management in Labor (Ch. 8, not in notes)
Gate control theory: non-painful stimuli (massage, touch, counter-pressure, warm water) “close the gate” on pain signals.
Nonpharmacological: continuous labor support, position changes and movement, birthing ball, hydrotherapy (warm shower or tub), massage and counter-pressure for back labor, breathing techniques, heat or cold, relaxation and focus.
Pharmacological:
| Method | Key points | Nursing |
|---|---|---|
| Parenteral opioids (fentanyl, morphine) | Cross the placenta; neonatal respiratory depression if given close to birth | Have naloxone (Narcan) ready for the newborn; fall precautions |
| Mixed agonist-antagonists (butorphanol, nalbuphine) | Less respiratory depression | Do not give to a woman with opioid use disorder (can trigger withdrawal) |
| Nitrous oxide | 50/50 with oxygen, self-administered by mask between contractions | She stays mobile; quickly cleared |
| Epidural | Most common complication is maternal hypotension; also urinary retention, fever, itching, slower second stage | Before: consent, check platelets and coagulation, IV fluid bolus (LR or NS). After: BP every 5 min after placement or re-bolus, then every 15 min; side-lying, turn side to side; bladder checks or catheter; fall risk - no walking |
| Spinal | Single injection; rapid; used for cesarean | Same as epidural; watch for spinal headache and fluid leak |
| Pudendal block | Second stage, perineum only | Watch for hematoma, return of sensation |
| Local | Perineum for episiotomy or repair | - |
Epidural hypotension priority: turn to her side (left uterine displacement), increase IV fluids, notify anesthesia, give ephedrine or phenylephrine as ordered, check the FHR.
Fetal Heart Rate (Ch. 9)
- Baseline 110-160 over 10 min. Tachycardia over 160 (maternal fever, infection, terbutaline). Bradycardia under 110 (hypoxia, cord prolapse, maternal hypotension).
- Variability: absent, minimal (5 or less), moderate 6-25 (reassuring), marked over 25.
- Accelerations: 15 bpm x 15 sec at 32 weeks or more (10 x 10 before 32 weeks). Reassuring.
VEAL CHOP / MINE:
| Pattern | Cause | Action |
|---|---|---|
| Variable decel (abrupt V, U, W shape) | Cord compression | Move: reposition; check for prolapse; amnioinfusion |
| Early decel (mirrors contraction) | Head compression | Identify labor progress; no action |
| Acceleration | Okay | None |
| Late decel (begins after peak, returns after contraction ends) | Placental insufficiency | Execute: left side, stop oxytocin, IV bolus, O2 per policy, notify provider |
- Prolonged decel: 2-10 minutes. Sinusoidal: smooth sine wave = severe fetal anemia, Category III.
- Categories: I normal (continue), II indeterminate (monitor, intervene), III abnormal (absent variability with recurrent lates, recurrent variables, or bradycardia; or sinusoidal) = immediate action, prepare for delivery.
- Concerning tracing: “think improve oxygenation” - reposition lateral, stop oxytocin, IV bolus, find the cause.
- External monitoring: TOCO plus ultrasound; frequency and duration only; membranes may be intact. Internal: FSE (most accurate FHR) and IUPC (true strength in mmHg); needs ruptured membranes and some dilation; contraindicated with placenta previa, HIV, herpes, hepatitis.
- Intermittent auscultation, low risk: roughly every 15-30 min in active labor and every 5-15 min in the second stage; more often with risk factors or oxytocin.
Complications of Labor and Birth (Ch. 10)
Dystocia (failure to progress), check the Ps:
- Hypotonic: weak contractions in the active phase; give oxytocin, amniotomy, empty bladder, reposition.
- Hypertonic: painful, frequent, uncoordinated in the latent phase, poor resting tone; give rest and sedation; no oxytocin.
- Precipitous labor: under 3 hours; stay with her, support the perineum, never hold the baby back.
Induction and augmentation:
- Ripening (misoprostol, dinoprostone, balloon) leads to induction (oxytocin) leads to augmentation (oxytocin, AROM).
- Bishop score (dilation, effacement, station, consistency, position): 8 or more favorable; 6 or less needs ripening first.
- Oxytocin: IV piggyback on a pump, start low, titrate; continuous FHR and contraction monitoring. Water intoxication with long high-dose use.
- Tachysystole: more than 5 contractions in 10 minutes averaged over 30 minutes. Action: reduce or stop oxytocin, left side, IV bolus, notify; terbutaline if it persists; remove a dinoprostone insert.
Preterm and post-term:
- Preterm labor: contractions with cervical change, 20-37 weeks. Goal: delay 48-72 hours for steroids.
- Tocolytics (24-34 weeks): nifedipine (hypotension), indomethacin (under 32 weeks, max 48-72 hours), terbutaline (hold for maternal HR over 120).
- Betamethasone: 2 IM doses 24 hours apart, 24-34 weeks - fetal lungs. Magnesium sulfate under 32 weeks - fetal brain.
- Post-term (42 weeks or more): placental insufficiency (lates), oligohydramnios (variables), macrosomia, meconium.
Emergencies:
| Emergency | Recognize | Do |
|---|---|---|
| Shoulder dystocia | Turtle sign | Call for help, McRoberts, suprapubic pressure; never fundal pressure. Newborn: check for brachial plexus injury, clavicle fracture |
| Cord prolapse | Sudden variable decels or bradycardia right after ROM; cord seen or felt | Stay with her; hand in vagina lifting the presenting part; knee-chest or Trendelenburg; cover an exposed cord with warm saline gauze; do not push it back; stop oxytocin; O2; emergency cesarean |
| Uterine rupture | Sudden FHR change, severe pain, loss of station, maternal shock; prior cesarean or overstimulation | Emergency cesarean |
| Amniotic fluid embolism | Sudden respiratory and cardiovascular collapse, then DIC | Call for help, airway, CPR, prepare for delivery |
| Vasa previa rupture | Painless bleeding at ROM with fetal distress (fetal blood) | Emergency cesarean |
| Chorioamnionitis (Triple I) | Maternal fever, maternal and fetal tachycardia, foul fluid, uterine tenderness | IV antibiotics, antipyretic |
Operative vaginal delivery (vacuum or forceps): watch the newborn for cephalohematoma and scalp injury (vacuum) and facial bruising or nerve injury (forceps); watch the mother for lacerations and hemorrhage.
Fourth Stage and Postpartum Hemorrhage
- Normal: fundus firm, midline, at or just below the umbilicus.
- Boggy fundus: massage first, then empty the bladder (displaced to the right = full bladder).
- PPH: 1000 mL or more, or bleeding with hypovolemia signs, within 24 hours. 4 Ts: Tone (most common), Trauma, Tissue, Thrombin.
- Firm fundus plus bright red bleeding = laceration. Severe perineal pain = hematoma.
- First vital sign change: tachycardia (BP drops late).
- Uterotonics: oxytocin (first line, never IV push), methylergonovine (not with hypertension or preeclampsia), carboprost (not with asthma), misoprostol, TXA within 3 hours.
Newborn in the First Hour
- Dry, skin-to-skin, warm (heat loss is the biggest risk). Bulb syringe mouth before nose.
- APGAR at 1 and 5 min (Appearance, Pulse, Grimace, Activity, Respiration); 7-10 normal; heart rate most important.
- Vitamin K IM (vastus lateralis), erythromycin eye ointment, hepatitis B vaccine.
- Normal: HR 110-160, RR 30-60, axillary temp 97.7-99.5 F.
Cesarean Birth (Ch. 11, covered in the lecture)
- Pre-op: consent, Foley, IV, labs, antibiotic within 60 min before incision (cefazolin), SCDs, antacid, wedge under right hip.
- Uterine incision: low transverse allows TOLAC/VBAC; classical (vertical) means repeat cesarean.
- Post-op: same fourth-stage checks plus incision, respiratory (turn, cough, deep breathe), early ambulation, pain control, Foley out in 12-24 hours.
- Repeat cesarean risk: placenta accreta spectrum (accreta, increta, percreta).
Maternal Trigger Parameters (MEOWS)
Red: temp under 35 or over 38; SBP under 90 or over 160; DBP over 100; HR under 40 or over 120; RR under 10 or over 30; SpO2 under 95. One red or two yellow triggers = urgent provider review.