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How can you decrease the “flight-fight” response in a mother?
Promote her relaxation by offering several comfort measures
What are some comfort measures one can offer during the first stage of labor?
Massage, Hydrotherapy, Warmth, Music, Respecting silence, maintaining calm tone of voice, allowing for mobility in labor (suggesting different positions)
What are some of the pain management options you may offer a mother in the first stage of labor?
1) Knowing the difference between normal and abnormal pain, 2) Listening to mother (validating her experience), 3) Counter pressure on back 4) Offering relaxation and breathing techniques 5) position changes 6) non-allopathic treatments (massage. Acupuncture, hypnobirthing, etc.)
What are some objective assessments that you, as the midwife, can make of a mother's “progress” during first stage of labor?
1) Vitals 2) Input/Output 3) Dipstick urine analysis 4) uterine contractions 5) cervical changes
What are some objective measures the midwife can use to assess fetal well-being?
1) Fetal descent/ position/ lie/ presentation 2) Fetal heart tones
What qualifies as “progress” during labor?
1) Fetal descent (station/ descent/ position) 2) cervical change over time 3) quality of contractions 4) Maternal condition 5) Condition of fetus
What are the ways in which you can assess fetal descent/ position/ lie/ presentation?
1) Visual observation 2) Abdominal palpitation 3) vaginal examination
What visual observations of the uterus clue you in to a anterior position of baby? Of posterior position?
Anterior position: maternal abdominal wall looks convex, umbilicus may pop out, momma reports movement in upper quadrant opposite to back. Posterior: maternal abdominal wall looks concave, depressed in region of umbilicus, feels movement midline “Everywhere”
What abdominal palpitations finding confirm an anterior position?
Maternal abdominal wall (where back is) feels smoth and firm, and the opposite side, small parts can easily be felt.
What abdominal palpitations finding confirm an posterior position?
Difficult to palpate any smooth back, fetal limbs can be palpated easily.
When is a vaginal examination indicated?
1) At beginning (to establish baseline) 2) When a large period of time with seeming no change in contractions 3) To see if there is an effect of a implementation change. 4) Non-reassuring fetal patterns 5) Mother requests 6) Urges to push
How often should one take fetal heart tones in active labor?
very 30 minutes. Important to listen during and after a contraction (to know how the baby recovers after a contraction)
What are early decels? And what  do early decels suggest?
Gradual decrease in FHT with contraction, and gradual return to baseline after contraction acme. Vagal nerve response caused by head compression, Considered benign.
What are late decels? And what do they suggest?
Gradual decreases in FHT AFTER the peak of a contraction, and a return to baseline after contraction is over. Suggest: Poor placenta suffusion.
What are variable decels? And what do they suggest?
Abrupt decreases in FHT, not necessarily with a contraction. This is a sign of cord compression, and if it is persistent than they become of concern.
How does one assess contractions?
Frequency, Duration, Strength (can be felt by palpitation (nose, chin, forehead))
What are examples of different fetal lies?
Transverse, oblique, vertex
What is fetal position?
cephalic breech transverse
What is station
Centimeters above or below the level of the ischial spines.
Describe three different ways to asses station.
1) Visual observation: where is the fetus? If mother is upright, the development of a crease which will extend across her abdomen when she is complete. 2) Abdominal palpation: Divide fetal head into 5 finger width sections. If all 5 fingers palpate the head, head is above pubic symphysis – Floating head. 2 fingers palpate (2/5 palpable) partially engaged. 0/5: Deeply engaged (cannot feel the head above the symphysis) 3) By Vaginal Exam: Station:  sometimes the spines are blunt and difficult to find. Find sacrospinous ligament and follow it with two fingers t the place of insertion on the sidewall. These is where the “pudendal” nerve is also(mother will feel an achy sensation)- and this is where the ischial spine is. Where the leading edge of the presenting part is in relation to the ischial spines is where the station.
Elizabeth Davis says: 2 fingers on same horizontal plane, one finger on spine, the other reaches for presenting part
When assessing station using an internal exam, what developments can prevent accurate assessment of station?
The formation of caput
What is caput?
Accumulation of fluid in tissue of scalp as a result of pressure on the fetal head Can cross suture lines.
What is the purpose of urinalysis during labor?
To check for ketones, High levels suggest that there is a disrupted electrolyte imbalance and that the mother needs fluid and calories.
If a mother has SROM, what is the appropriate management?
1) keep well hydrated (increase fluids) 2) nothing in the vagina 3) Maintain good proper hygiene 4) take 250 mg of calcium/ vit C q few hours 5) loose underclothing 6) Eat good quality non-constipating foods 7) Take temperature (monitor for signs of infection) 8) If no contractions come on, work to stimulate labor. 9) Monitor FHT 10) Refer as necessary
How does one diagnose SROM?
1) cough test 2) FERN test 3) Sterile Speculum exam (though Davis does not recommend this) 4) Note Color Odor Amount and Time 5) VE (do you feel a bag? Or hair?) 6) Nitrazine Test
What are different ways to assess cervical changes?  
Consistency (softness), effacement (shortening of the cervical canal), dilation (opening of the cervix), location (anterior, posterior, center), station of the head.
What can a midwife suggest to work with maternal dehydration and/or vomiting
1) Fluids by mouth 2) Ice chips (what??) 3) IV 4) Herbs: ginger root for dehydration 5) Homeopathics: China, Carbo Veg, Ustilago 200 c 6) Dose of Joyal jelly 7) Enema of warm water/honey/chicken broth
What is a cervical lip, and what are some potential causes?
Fully dilated cervix except for the anterior lip, can be caused by either uneven pressure of the presenting part OR if the anterior lip is caught btw the pubic bone and the head of the baby
What are some maternal positions that can work on reducing/eliminating a cervical lip?
Anti-gravity positions or gravity neutral positions (hands/knees,  open knee chest position, kneeling on top of birth ball (like hands/knees)) Positions to reduce pressure off of cervix: side lying, semi prone, standing and leaning forward)
What are some other methods used to reduce/eliminate a cervical lip?
Glove filled with ice, homeopathic (sepia, arnica 200C), immersion in bath, manually pushing the cervix over the baby's head as the mother is pushing. Cervical massage to reduce swelling, blowing/relaxation btw contractions,
KC has been in labor for 7 hour, as has stalled at 6cm. After abdominal palpation, auscultation, and finally, a VE, you confirm that the baby is OP. What can you do?
1) Suggest different positions (forward leaning positions with one foot up) 2) Suggest different motions  (walking up steps, rebozo) 3) Rest or relaxation (with massage, hot compresses, sterile water papules) 4) Non-allopathic treatments (??) for stronger ctxs (cohosh tincture to pulstilla,) 5) Manual internal rotation 6) pelvic press
Describe “dialing the telephone”
dislodge head from the pelvis  fingers push up on parietal bones to encourage flexion), mother to recline, pressure on bony part anterior fontanelle  and rotate to transverse, push to flex, quickly go for posterior fontanelle, and complete the rotation to anterior, as you flex the head, your assistant will push baby's head and shoulders towards the anterior position); mother should be in knees chest position
What are different positions used to facilitate rotation from a posterior position during second stage?
Kneeling (on foot of bed, leaning on partner, on raised head of bed), hands & knees, standing (leaning), sitting forward on toilet, squatting assymetrical kneeling, assymetric standing, same side side-lying, opposite semi prone, supported squat, dangle
What are different movements that would help rotate a posterior baby?
Pelvic rocking, lunging, kneeling lunge, slow dancing
What qualifies a momma as a good candidate for a vaginal breech delivery?
Adequate pelvis (proven-multip), baby is frank breech, good support in community, labor is progressing well
You have a momma who has had slightly large for dates FH in the 3rd trimester. You want to do follow-up when she calls you later on that night reporting a rupture of membranes. When she comes in upon a VE you notice movement in the the lower quadrants. What do you suspect?
breech
When you check her, you note that the water is clear and odorless. She is 9 cm! However, your glove has meconium it after the  check. What does this confirm?
A breech presentation
What do you do to prepare for delivery?
Warm the room/ Have resuscitation equipment ready/ be ready to call back-up personnel/ Have towels ready/ have momma be in upright position/ momma blow for one hour until the urge to push becomes unbearable.
What are the mechanisms of descent and delivery for a  breech?
Engagement/ Descent, Birth of Butt by lateral flexion (posterior hip born/ then anterior)- You can do pinard maneuver here/ HANDS off baby other wise/ but is born, and RST becomes RSA/ Make sure umbilical cord is loose/ put towel on baby/ Shoulders go into AP diameter; Downward traction (with your hands on hips) to bring the shoulder down (you can bring hands down by sweeping them across the chest) / afters shoulder come, the head is engaged/ apply subrapubic pressure to maintain flexion of the head/ downward traction, when maxilla delivers, place one hand into mouth to hold it down/ once chin delivers, upward traction for the rest of the baby.
If the legs are splinted, preventing descent, what do you do?
The pinard maneuver, which is adducting the legs across and bringing them down.
What are signs at a birth that you might have a multiple delivery?
1) Hard to access heart tones 2) Hard to palpate fetal position 3) After birth of first baby- placenta does not come
How do you prepare for a twin birth?
1) Ensure bladder is empty before pushing begins 2) Prepare for resuscitation 3) Keep room warm 4) Confirm presentation 5) As first baby is born, check on the heart tones of the second baby 6) Direct the second baby into a good position by abdominal guidance 7) Clamp the cord of the first twin and pass off to someone else (you want the momma to resume her contractions) 8) Do a check and ensure that the baby is engaged in a good position 9) Rupture the membranes 10) Second baby delivers her/him self
How do you work with a VBAC momma in labor?
1) Treat her no different than any othe rmomma (in terms of birthing positions/ labor positions, etc) 2) Pay close attention to her heart tones/ sensations/ contractions 3) If you know that her surgery happened when she was 4 cm, if you find she's reached 4 cm, tell her she's 5 cm!
What is a pendulous abdomen caused by?
1) Weak abdominal muscles 2) polyhydramnios 3) multiples 4) contracted pelvis 5) tumors 6) Spine: scoliosis
What are consequences of a pendulous abdomen?
1) Poor circulation (edema/ variscosities) 2) pain (uterine ligaments, back pain) 3) Malpresentations 4) Cord prolapse 5) Discoordinate labor
What can one do to assist the position of the uterus over the pelvis?  
1) Belly binding (corset/ rebozo) 2) Assisted by a partner 3) Self initiated 4) check heart tones as you hold up abdomen (just to make sure there is no cord compression) 5) coupled with a pelvic tilt
What are maternal positions that can help direct a baby into the pelvis if the mother has pendulous abdomen?
1) Semi-sitting (reclining back) 2) Lithotomy 3) Some supine positions
What are different reasons that labor might stall/ stop?
1) Emotional dystocia 2) Fetal dystocia 3) Uterine dystocia 4) Cervical dystocia 5) Pelvic Dystocia 6) Iatrogenic dystocia
What are things you can do to affect emotional dystocia?
1) Ask her- what was going through your mind in that last contraction?- Help her state her fears- validate this fear and provide reassuring (not false reassurance) 2) Provide comforting/ reassuring stimuli (music/ candles/ etc) 3) Offer reassurance and praise 4) Reduce fear stimuli and action 5) Homeopathic: Rescue Remedy, Sepia 200C (If afraid of contractions), pulsitilla (if whiny/clingy)
What are things you can do if there are inadequate contractions?
1) Make sure momma is well hydrated (urinalysis) 2) Make sure momma is eating (easy to assimilate carbs) 3) Rest if needed 4) Change her position 5) Check on fetal position? Is baby not fitting in right? 6) Momma movement (dancing/ walking / stair walking can help shift/ move baby into her pelvis) 7) Herbs (Black and blue cohosh) 8) Homeopathic (Caulophyllum) 9) Nipple stimulation 10) Offer support/ guidance
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