• one year of unprotected sex with no pregnancy
• 1. primary subfertility- no previous conceptions
• 2. secondary subfertility- previous viable pregnancy
• 3. sterility- known reason for subfertility

• bad spermatogenesis/sperm production
• obstructed seminiferous tubules/ducts
• change in seminal fluid that prevents sperm motility
• autoimmunity to immobilize sperm
• ejaculation problem
• inadequate sperm count

20-50 mL per ejaculation

50% of sperm should be motile

• increase in temperature
• congenital abnormalities (cryptorchiclism- undescended testes)
• varicocele- caricosity of sperm vein increases temp
• trauma to testes
• drug/alcohol use
• x-ray exposure

• mumps orchitis- testes inflammation and scarring
• epididymitis
• tubal infection (gonorrhea or ascending urethral infection)
• benign hypertrophy in prostate
• vasectory causes autoimmune reaction
• anomoly of penis
• hydospadias- urethral open on ventral penis surface
• epispadias- urethral opening on dorsal penis surface

• anvolution- absence of ovulation
• tubal transport problems
• uterine problems
• cervical problems

• Turner's
• hormonal imbalance
• hypothyroidism
• ovarian tumor
• stress
• increase glucose
• bad nutrition
• polycystic ovary syndrom-ovaries produce excess testosterone and decreased FSH and LH

• scarred fallopian tubes
• chronic pelvic inflammatory disease
• infection of pelvic organs
• STD's or IUD's

• tumors
• decreased estrogen or progesterone
• endometriosis-implantation of uterine endometrium nodules from interior and exterior uterus

Cervical problems that cause infertility

• D and C scar tissue
• thick cervical mucus

1. semen alaysis
2. ovulation monitoring
3. tubal potency test

• HIV test
• syphillis test
• CBC, blood type, Rh factor
• erythrocyte sedimentation rate (increased rate leads to inflammation)
• protein bound idodine (tests thyroid function)
• cholesterol levels (arterial plaques interfere with pelvic blood flow)
• gonadotrophin and testosterone levels

• rubella titer
• syphillis test
• HIV test
• thyroid uptake determination and TSH levels
• FSH, estroge, LH, progesteone levels
• serum prolactin levels
• pelvic ultrasound

• 2-4 days of abstinence
• masturbate into clean jar
• number of sperm countes (minimum is 20 million sperm)
• repeat after 2-3 months

• records basal body temperature for 4 mos each morning
• plot on a graph
• at ovulation, body temp decreases by .5 degrees F and increases to higher than normal body temp until 3-4 days before her next period

increase in LH before ovulation

FSH abnormally high = ovaries not reponding well

• xray or ultrasound for fallopian tubes and depth of endometrial lining
• sonohysterography- any time in cycle, non invasive, uterus filled with sterile saline, transvaginal ultrasound
• hysterosalpingography- examine fallopian tubes, makes sure there is no reflex of menstrual debris up tubes after menstration 
• SE: pain, risk of infection, allergic reaction, and embolism
• CI: infectino of vagina, cervix, or uterus

• reveals endometrial problems (luteal phase defect)
• endometrium remobed by biopsy in last 1/2 of menstrual cycle
• done 2-3 days before menst. flow (day 25-26 of cycle)
• paracervical block used
• SE: discomfort, bleeding, infection, uterine perferation, spotting (call if temp over 101 F or excess bleeding/clots)
• CI: suspected pregnancy or infection

• visual inspection of uterus through tube

• thin tube through incision in abdomen under umbilicus
• examines proximity between tubes and ovaries (large distance=ovum can't enter tube)
• done in follicular phase of menstrual flow
• CO2 infused after procedure may escape and cause pain/bloating
• general anesthesia used for pain

• GnRH to stimulate ovulation
• human menopausal gonadotropins (FSH, LH, hCG) to produce ovulation
• if increased prolactin identified, Bromociptine given to decrease prolactin (allows rise of gonadotropins)

• sperm form dad/donor into partner's cervix/donor's cervix
• frozen sperm have decreased motility
• record BBtemp, assess mucus, predict day of ovulation and sperm is instilled
• blood type and Rh of donor matched with woman
• takes 6 mos to achieve insemmination 

• one or more mature oocytes removed from donor/woman's ovary by laposcopy and fertilized by exposure to sperm outside body
• 40 hrs after fertilization, fertilized ova inserted into uterus
• used if woman has damaged fallopian tubes
• BEFORE PROCEDURE: GnRH/ovulation stimulating agent, menopausal gonadotrophin, clomiphene citrate given
• 10th day of cycle, ovaries examined to see number and size of ovarian folicles
• injection of hCG when follicles are mature, causes ovulation in 38-42 hrs
• oocyte aspirated from folicle (3-12 removed) (can cause injury to corpus leutum and decrease in progesterone)
• oocyte incubated for 8 hrs
• 40 hrs = zygote have 1st cell division
• progesterone given to aid implantation
• 38-42% IVF cycle chance of pregnancy

• ova from ovaries
• sperm given in hours
• fertilization in fallopian tubes
• CI: fallopian tube that is blocked (causes ectopic pregnancy)

• oocyte retrieved transvaginally with ultrasound guided apsiration
• culture and insemmination in labratory
• fertilized eggs trasferred by laproscopy at 24 hrs
• fertilization outside of body (difference from GIFT)
• CI: no functioning in fallopian tube
• allows for genetic analysis

• woman can't ovulate
• donor oocyte
• menstral cycle of donor and recipient synchronized with gonadotrophic hormon
• donor's ovum removed at ovulation (transvaginal/ultrasound guided)
• oocyte fertilized by donor/partner sperm in lab
• placed in uterus

• before fetal viability (24 wks)
• ends pregnancy that threatens woman's life, fetus found on amniocentesis to have chromosome abnomality, rape/incest, too young, single, not wanting children, failed contraceptives, etc
• 1st trimester abortions legal (less than 12 wks)
• states regulate 2nd and 3rd tri abortions

mifepristone

• abortifacient, progesterone antagonist to stimulate contractions, slough endometrium, loosen trophoblast
• used up to 49-63 days gest age
• 600 mg PO once
• SE: n/v, headache, diarrhea, heavy bleeding
• Prostoglandin/misoprestol given 48-72 hrs after (400 mcg PO or 800 mcg vaginal)
• may need D and C for heavy bleeding or Rhogam for Rh incompatibility

Methotrexate

• antimetabolite that causes trophoblast death
• used for ectopic pregnancy or trphoblastic disease

• spotting/cramping for 2 wks
• no tampons/douche
• acetaminophen or ibuprofen for pain (do not use aspirin, increases bleeding)
• period in 4-6 wks
• no sex until 2 wk post procedure checkup (avoid infection) 
• call doc:
• temp over 100.4
• passing clots
• heavy bleeding (2 pads saturated in 1 hr)
• ab pain
• severe depression

• simple, 5-7 wks after lmp
• woman voids, perineum washed with antiseptic
• speculum through vagina
• catheter into uterus that sucks lining through vaccuum
• pain free, some cramping
• lay supine for 15 min after until craps slow (prevents ortho hypotension)
• Risk of hemorrhage/infection

• gestational age less than 13 wks
• paracervical anesthesia
• void, perineum washed with antiseptic
• uterus scraped clean of zygote, trophoblasts, lining
• stay at clinic for 1-4 hrs for monitoring
• oxytocin to decrease bleeding
• risk of hemorrhage/infection
• Call doc if:
• temp higher than 100.4
• heavy bleeding (2 pads saturated in an hour)
• clots
• ab pain
• severe depression

dilatation and vacuum extraction (D&E)

• 2nd tri (12-16 wks)
• Misoprostol or laminaria tent (seaweek in cervix to absorb fluid) 24 hrs before procedure
• dilates cervix
• seaweed used for young moms to gradually dialate
• antibiotic given before procedure
• narrow suction with negative pressure evacuates uterus for 15 mins
• pain as cervix dilates, pressure and cramps during suction
• flat for 15 mins post procedure to prevent ortho hypotension
• stay for 4 hrs to monitor
• oxytocin to slow bleeding
• risk of uterine perfusion and infection

• 16-24 wks
• inpatient or outpatient
• prostoglandin F2x injection or prostoglandin t2 suppository
• cervix dilatation and cramping
• expels everything
• oxytocin in large amounts to induce labor
• check for water intoxication or increase in body fluid (headache, confused, drowsy, edema, decrease in urine)
• always use oxytocin as a piggyback so it can be stopped suddenly
• examine tissue to make sure fetus was expelled
• check for hemorrhage and DIC from prolonged labor/trauma

• oral misoprostol or vaginal laminora for cervix dilation
• labor takes hours after administratino of prostoglandin/misoprostol, but you can shorten this by giving dilute IV oxytocin

• hypertonic (20%) saline fluid causes fluid shifts and sloughing of placenta and endometrium
• preperation: void to decrease bladder size/risk of puncture
• sterine spinal needle inserted into uterus through anesthetized ab wall
• 100-200 mL amniotic fluid removed and replaced by the 20% hypertonic saline solution
• labor contractions in 12-36 hrs after injection
• SE: hypernatremia if injected into uterine blood vessle
• body fluid shifts to blood vessles to try and = pressure
• sx: dehydration, tachycardia, flushed face, headache
• STOP the infusion, give 5% dextrose

• gestational age more than 16-18 wks
• removal of fetus by c-section
• uterus resistant to oxytocin at this stage in development
• uterus won't contract, could cause hemorrhage

• last 3 mos of pregnancy
• congenital anomoly, incompatible with life, encepholocele meningocele
• labor induced by oxytocin and cervical ripening
• fetus turned breech, clamp on skull, head collapsed

• hypothalamus produces LHRH for pituitary
• pituitary produces gonadotrophic hormones (FSH and LH)
• ovary produces estrogen and progesterone for uterus and pituitary

• usually tipped forward
• anteversion- too far forward
• tretroversion- too far back
• anteflexion- body tipped forward at junction of cervix
• retroflexion- body tipped back at junction of cervix

1. proliferative/estrogenic/follicular/postmenopausal
1. immediately after start of menstrual flow, first 4-5 days of cycle
2. thin endometrium (increases x8 by day 5-14)
3. ovaries produce estrogen because of FSH
2. secretory/progestational/luteal/premenstrual
1. after ovulation
2. formation of progesterone in corpus leutum because of LH
3. glands of uterine endometrium twist and dilute with glycogen and mucin
4. cappillaries increase in amount, lining rich and velvety
3. ischemic
1. no fertilization
2. corpus luteum regresses after 8-10 days
3. endometrium disinigrates (day 24-25)
4. rupture of capillaries, minute hemorrhage, endometrium sloughs
4. menses
1. menstrual flow (30-80 mL blood)
2. mucin and fragments of endometrial tissue with microscopic unfertilized ovum
3. meses = END of cycle
4. decrease of 11 mg iron with cycle

• high levels of estrogen before ovulation
• cervix mucus forms fernlike patterns caused by NaCl crystlizations on slide
• high levels of progesterone before ovulation or at beginning of leuteal phase
• no fern pattern, normal
• no obulation - fern always present

• high levels of estrogen at ovulation = thin mucus, good sperm survival
• high progesterone at second half of cycle = thick mucus, poor sperm survival

thick mucus before ovulation, thin mucus at ovulation

assess secretions each day

• refrain from sex on days of menstrual cycle when most likely to concieve (3-4 days before ovulation and 3-4 days after ovulation)
• ovulation - day 15 of cycle
• find fertile time frame:
• first fertile day = shortest cycle -18
• last fertile day = longest cycle - 11

• monophasic: fixed doses of estrogen and progesterone in 21 day cycle
• biphasic: constant estrogen, increased progesterone in last 11 days
• triphasic: varried estrogen and progesterone through entire cycle
• mimics natural cycle
• decreasesbreakthrough bleeding

• decreased dysmenorrhea, premenopausal dysmorphic syndrome and acne, iron deficiency anemia, PID, endometrial/ovarian/colon cancer, ovarian cysts, ectopic pregnancy, fibrocystic preast disease, osteoporosis, fibroid uterine tumors, rheumatoid arthritis

• risk for thromboembolitic symptoms
• can't be used until 2 yrs into cycle
• not effective until 7 days post
• nausea, weight gain, headache, breasts tender, spotting, monililial vaginal infection, mild HTN, depression
• SERIOUS: chest pain, SOB, severe headache, leg pain, eye problems
• will not become pregnant until 1-2 (or even 6-8) monthes after discontinuation

• slow, continuous release of estrogen and progesterone
• each week for three weeks, no patch on 4th week
• SE: thromboembolytic symptoms, mild irritation at patch site
• if patch comes loose, take it off and replace to start new cycle, USE ANOTHER FORM OF CONTRACEPTION FOR ONE WEEK!

• silicone ring around cervix
• releases progesterone and estrogen
• left in place for three weeks, removed for one week
• avoids liver, directly to vagina (unlike pill)
• fertility remains after discontinuation

• 5 subdermal implants in upper arm
• contain etonogestrel (same progestin/synthetic progesterone as vag ring)
• looks like small veins, stay in for 3-5 years
• releases hormones, supresses ovulation, causes thick cervical mucus and change in endometrium so implantation is difficult
• local anesthtic used during implatation and removal
• inserted directly after elective termination or 6 wks after birth
• cost $500
• SE: weight gain, irregular menst cycle, depression, scarred insertion site, infection at insertion site
• CI: desire to be pregnant in 1-2 years, undiagnosed bleeding

• single IM injection of medroxyprogesterone acetate (a progesterone)
• given q12 wks to inhibit ovulation
• 100% effective
• don't massage injection site
• return to fertility in 6-12 mos after discontinued
• SE: headache, irregular menst cycle, weight gain, depression, impaired glucose tolerance, decrease bone mineral density (increase Ca to 1200 mg/day)

• 1. copper 7380- T shaped plastic with copper, 10 yrs effectiveness
• 2. LNG-IUS- drug reservoir of progesterone in stem, 5 yrs effectiveness

• small object in uterus
• causes inflammation to prevent implantation
• copper decreases sperm motility
• inserted before sex and after period, causes sharp cramp when inserted
• SE: PID (copper resists infection, ab tenderness, fever, increased pain on intercourse), heavy menst flow for 2-3 months, cramps and spotting, increased risk of STI
• CI: abnormal uterus shape, severe dysmennorhea (painful mestration), menorrhagia (bleeding between periods), ectopic pregnancy history
• if pregnancy occurs, leave IUD in or remove it to prevent infection

• death of sperm before entering cervix and changes vaginal pH
• doesn't protect from STI's
• use 1 hr before sex (15 min if cocoa butter or glycerine)
• SE: acute cervicitis, fails 20% of time

• placed over cervix before sex
• fit by NP, physician, or midwife every time cervix changes or if there is a gain/loss of more than 15 lbs
• remains in place for 6-24 hrs after sex
• left in for over 24 hrs = stasis of fluid, cervical inflammation and erosion, urethral irritation
• remove with finger, wash with soap, dry, put in case
• lasts for 2-3 years
• not effective if odd uterus shape or if woman is in superior position during sex
• SE: UTI's

• soft rubber over uterine cervix
• 26% failure rate
• cervix may be too short

• small incision in each side of scrotum
• vas deferens cut, tied, cauterized, or plugged
• local anesthesia
• analgesia and ice for pain
• fertile for 6 mos, must have 2 (-) sperm reports
• can have sex within one week after procedure
• SE: hematoma, kidney stones, chronic pain, autoimmunity against own sperm

• fallopian tubes occluded by cauterizing, crushing, clamping, or blocking
• prevent passage of sperm and ova
• decreases risk of ovarian cancer
• laproscopy
• after menst flow, before ovulation
• 1 cm incision under umbilicus
• general/local anesthesia
• laproscope through incision locates fallopian tube
• electric current to coagulate dissue
• SE: bloating from CO2, bowel perferation, hemorrhage, risk of general anesthesia
• sex two days after procedure

• difficult/dysfunctional labor

1. problem with contractions
2. problem with passenger/fetus
3. problem with birth canal
4. problem with women's psyche

1. hypotonic contractions- number of contractions low or infrequent
2. hypertonic contractions
3. uncoordinated contractions

• less than 2-3 contraction sin 10 minutes
• resting tone of uterus less than 10 mmHg
• strength of contractions less than 25 mmHg
• usually occurs in active phase
• after analgesia
• start with dilation less than 3-4 cm
• bowel or bladder distension
• overstretched uterus (high parigy, multiples, hydramnios)
• increases length of labor
• Tx: oxytocin

• increased resting tone, over 15 mmHg
• frequently seen in latent phase
• muscle fivers don't repolorize or relax after contraction
• painful (anoxia) and can lead to fetal anoxia
• Tx: sedation or c-section (if FHR low or 1st stage labor doesn't progress)

• more than one pacemaker initiating contractions
• close together

1. latent: 
1. nullipara: 8.6 hrs (avg) 20 hrs (upper limit)
2. multipara: 14 hrs (avg and upper limit)
2. active:
1. nullipara: 5.8 hrs (avg) 12 hr (upper limit)
2. multipara: 2.5 (avg) 6 hr (upper limit)
3. transitional:
1. nullipara: 1 hr (avg) 1.5 hr (upper limit)
2. multipara: 15 min (avg)

• ineffective contractions
• longer than 20 hr null or 14 hr multi
• cx: 
• cervix not ripe
• excess analgesia
• contract less than 15 mmHg
• hypertonic contractions
• inadequate relaxation periods
• tx: 
• help uterus relax
• fluids
• morphine sulfate for pain relief
• change linen, darken room, decrease noise
• c-section, amniotopy, oxytocin

• longer than 12 hr null or 6 hr multi
• Cx:
• cephalopelvic disproportion
• hypotonic contractions
• fetal malposition
• no cervical dilation
• less than 1.2 cm/hr null or 1.5 cm/hr multi
• Tx:
• ultrasound to rule out cephalopelvic disproportion
• oxytocin
• c-section

no progress in cervical dilation for longer than 2 hrs

tx: c-section

• prolonged descent
• arrest of descent
• deficient fluid volume
• contraction rings
• precipitate labor and birth
• uterine rupture
• inversion of uterus
• amniotic fluid embolism

• less than 1 cm/hr null or 2 cm/hr multi
• contractions are good quality and duration, effacement and dilation begin
• contractions become poor quality and dilatation stop
• rule out cephalopelvic disproportion or poor fetal presentation
• tx: 
• fluid for hypertonic contractions
• rupture membranes 
• IV oxytocin
• semi fowlers, squat, kneel

• no descent occurs within 2 hr null or 1 hr multi
• failure: expected descent does not begin, no engagement
• Cx: cephalopelvic disproportion
• Tx: c-section

• low levels of serum electrolytes or body fluid
• cx: 
• interval between eating and labor 
• nausea and vomitting
• test for voiding, clucose, protein, ketones, specific gravity
• decreased fluid volume increases blood viscosity and the risk of thrombophlembitis
• Tx: IV fluid

• hard band across uterus at junction of upper and lower segments, interferes with descent
• pathologic retraction ring most common (horizontal ab indent, excess retraction of upper segment)
• Cx: 
• early labor uncoordinated contractions
• pelvic division of labor = obstetric manipulation or oxytocin
• identified through ultrasound
• Tx:
• IV morphine sulfate or inhaled amylnitrate
• tocolytic to halt contractions
• c-section
• Can lead to uterine rupture or neurologic damage to fetus or massive hemorrhage (placenta can't be delivered)

• Cx:
• strong contractions and woman gives birth with only a few rapid contractions
• less than 3 hrs
• precipitate dilatatioin= more than 5 cm/hr prima or 10 cm/hr multi
• Cx: high parity, amniotomy, oxytocin
• can cause premature placenta seperation, hemorrhage, lacerations

• induction of labor- labor is started artificially
• augmentation of labor- assisting labor that started spontaneously but isn't effective

• fetus is at term
• preeclampsia
• eclampsia
• severe HTN
• postmaturity (past 42 wks)
• diabetes
• Rh sensitization
• prolonged ROM
  intrauterine growth restriction 

risks for induction and augnmentation of labor

use cautiously in...

• uterine rupture
• decreased fetal blood supply from poor cotyledon filling
• premature placental seperation

• longitudinal lie
• ripe cervix
• engaged
• no cephalopelvic disproportion
• mature fetus and l:s ratio

• each category scored from 0-3, total score needs to be 8 or more to be considered a ripe cervix

1. dilatation (0=0cm, 1=1-2 cm, 2= 3-4 cm, 3 = 3-4 cm)
2. effaced (0= 0-30%, 1=40-50%, 2=60-70%, 3=80% or more)
3. station (0=-3, 1=-2, 2=-1-0, 3= +1 or +2)
4. consistency (0=firm, 1 = medium, 2 = soft)
5. position (0=posterior, 1= mid, 2 = anterior)

• strip membranes (seperate membranes from lower uterine segment manually)
• hygroscopic suppository to urge dilation
• prostoglandin gel/misoprostol
• interior or external surface of cervix 
• 2-3 total doses given q6hr
• SE: vomit, fever, diarrhea, HTN
• oxytocin started 6-12 hrs after last prostaglandin dose
• CI: past c-sections

oxytocin  for induction of labor

dosing and set up

• administered by piggyback IV (in port closest to woman) for easy discontinuation
• half life of 3 min
• pitocin (form of oxytocin) mixed with 10 IU in 1000 mL Ringers
• 15 IU oxytocin to 250 mL of IV solution (60 mU/1mL concentration)
• infusions start at .5-1 mU/min
• no response, increase every 15-60 min by 1-2 mU/min until contractions begin
• most women respond at 16 mU/min
• 20 mU/min can cause tetanic contractions

• SE: hypotension, decrease uterine blood flow, antidiuretic, water intoxication, headache/vomit (HALT INFUSION), seize, coma, death, hyperbillirubin and jaundice in infant
• contractions shouldn't:
•  occur more than every 2 min
• be stronger than 50 mmHg
• last more than 70 sec
• resting pressure shouldn't be more than 15 mmGg
• if stopping oxytocin doesn't stop hyperstimulation, give the antidote (beta adrenergic receptor drug like terbutaline sulfate or magnesium sulfate) to decrease myometrial activity 

• aggressive administration of oxytocin (increase by 6 mU/min)
• shortens labor to 12 hrs
• decrease risk of c-section, postpartal infection, postpartalfevers, dehydration
• maximum dose should be 36-40 mU/min

• vertical scar from c-section or hysterectomy tear
• prolonged labor
• multiple gestation
• abnormal presentation
• unwise oxytocin
• obstructed labor
• forceps

1. complete
• contractions immediately stop
• two sellings on abdomen (retracted uterus and extrauterine fetus)
• hemorrhage and shock (tachycardia, weak pulse, hypotension, cold/clammy skin, air hunger)
• FHR absent
2. incomplete
• localized tenderness/aching of lower uterine segment
• no FHR and contractions

• fetal death folllows unless c-section performed
• c-section hysterectomy to remove damaged uterus or tubal ligation at time of laparotomy
• IV oxytocin to minimize bleeding
• viability of fetus depends on extent of rupture and EBL

• uterus turns inside out with birth of of fetus or delivery of placenta
• Cx: 
• traction applied to umbilical cord to remove placenta
• pressure to fundus so fetus pulls fundus down at birth
• can be totally inverted and protrude from vag or just lie in uterine cavity
• large amount of blood from vagina in sudden gush
• Sx of bloood loss (hypotension, pale, dizzy, sweat)
• NEVER try and replace uterus, it just causes more blood loss
• Tx: 
• IV fluid
• oxygen by mask
• general anesthesia
• NG or tocolytic
• oxytocin after replacing fundus
• antibiotics for exposed uterus
• CPR
• c-sections needed for future pregnancy

• occurs when am flu is forced into an open maternal uterine blood sinus through defect in membranes or AFTER membrane rupture/partial premature seperation of placenta
• Cx: oxytocin, abruptio placentae, hydramnios
• Sx: sharp chest pain, can't breath, going from pale to blue/grey coloring
• Tx: oxygen through mask, CPR

• premature ROM
• non cephalic presentation
• small fetus
• cepholopelvic disproportion
• placenta previa
• intrauterine tumors
• hydramnios
• multiple gestation

• relieve pressure on cord to prevent fetal anoxia (knee to chest or trendelenborg position)
• 10 L/min O2 in mask
• if cord is exposed to room air, don't push it back in (can cause kinking)
• cover cord with sterile saline compress to prevent drying
• iff fully dilated, use forceps to birth baby
• incomplete dilation = upward pressure on presenting part until c-section
• amnio infusion- adds sterile fluid to uterus to supplement am flu through catheter
• normal saline or lactated ringers, 500 mL
• lie in lateral recumbant to prevent hypotension
• check for infection signs
• fetal blood sampling
• PO2 and PCO2, pH, O2 sat, Hct
• hypoxic fetus = acidic or lower than normal pH (less than 7.2)

• c-sections decrease risks
• anemia and preg HTN occur commonly (assess Hct and BP)
• increase risk for cord prolapse because of small fetal head
• uterine dysfunction from long labor
• most twins have vertex presentation
• after 1st infant is born, both ends of cord are tied permenantly (not with clamps that could slip) to prevent hemorrhage
• lie of 2nd twin analyzed by palpation and ultrasound
• oxytocin to assist contractions, Nitro Glycerin  to relax uterus
• sometimes placenta of 1st infant separates before 2nd fetus is born, causes hemorrhage
• difficult because uterues can't contract due to second fetus
• if placenta is shared, FHR of other babies are absent
• c-section

• ROP or LOP
• fetus must do internal rotation of 135 degrees (normal is 90 degrees)
• mom can squat, hands on knees position, or lie on L if ROP or R if LOP
• Cx:
• mom has android, anthropoid, or contracted pelvis
• posterior isn't as snug as anterior (risk of prolapsed cord and long labor)
• fetal head rotates against sacrum = maternal lower back pain
• counterpressure, back rub, heat and cold, lie on side or hands and knees, void q2hr, IV glucose

• Cx:
• gestational age less than 40 wks
• ancepholy, hydrocephalus, meningocele
• hydramnios
• congenital anomoly of uterus (mid septum)
• mass in pelvis
• pendulous abdomen/lax abdomen muslces
• multiple gestation
• most preg are breech in early preg but turn cephalic by 38 wks
• types: frank, footling, or complete
• increases risk for prolapse cord/anozia, injury to head/incracranial hemorrhage, fracture of spine/arm, dysfunctional labor, early ROM
• FHR sounds in upper abdomen
• full dilation means it is ok to be born vaginally
• pressure of passing head on cord

• head that feels prominent with no engagement in Leopold maneuvers
• concave back 
• ultrasound done
• if the chin is posterior, do a c-section
• vaginal birth = facial edema and bruising

• rarest form
• Cx: multipara, relaxed ab muscles
• causes obstructed labor (head jammed in brim of pelvis)
• c-section done
• bruising on fontanelle and face

• Cx: pendulous abdomen, uterine tumors, contraction of pelvic brim, congenital abnormality of uterus, hydramnios, hydrocephalus, premature infant, multiple gestation, short cord
• horizontal in leopolds or ultrasound
• c-section
• risk for early ROM, cord prolapse, shoulder obstructions

• 4000-4500 g or 9-10 lb
• Cx: diabetes/gestational diabetes, multiparity
• Increased risk for: overstretched uterus, uterine rupture, fractured clavicale, hemorrhage
• c-section

• occurs in 2nd stage of labor
• shoulders too big for pelvic outlet
• can cause fractured clavical or brachial plexus injury
• Cx: diabetes, multiparas, post term birth
• increased risk for prolonged 2nd stage, arrest of descent, retracting/turtling head
• Tx: flex thighs sharply on abdomen (McRoberts maneuver) to widen pelvic outlet

hydrocephaly

anecephaly

hydrocephaly= fluid filled ventricles

anencephaly = absence of cranium

• narrowing of anteroposterior diameter to less than 11 cm or transverse diameter to less than 12 cm
• Cx: rickets
• prima = head engages btwn 36-38 weeks before labor begins
• if engagement doesn't occur, there may be a fetal or pelvic abnormality 
• engagement does not begin until labor in inlet contraction

narrowing of transverse diameter at outlet to less than 11 cm

• if inlet measure and fetal lie are good, trial labor is used to assess if labor can progress
• continues as long as descent of presenting part and dilation of cervix continues
• monitor FHsounds and uterine contractions
• woman should void q2hr

• turning of fetus from breech to cephalic before birth
• as early as 34-35 wks, usually at 37-38 wks
• FHR and ultrasound
• tocolytic used to relax uterus
• gentle pressure on abdomen to rotate fetus
• CI: multiple gestations, oigohydramnio, vaginal birth, cord around neck, 3rd tri bleeding (placenta previa)
• rhogam given if Rh-

• membranes ruptured
• cephalopelvic disproportion not present
• cervix fully dilated
• bladder empty

• woman is unable to push with contraction in pelvic division of labor
• cessation of descent in 2nd stage
• abnormal position/immature fetus
• fetus is in distress (prolapsed cord, etc)

• may lead to rectal sphincter tears (dyspareunia, anal incontinence, urinary stress incontinence)
• good way to reduce pressure on fetal head and avoid subdural hemorrhage
• forceps applied after head reached perineum
• low forceps birth= head at 2+ or more
• mid forceps birth = head at +2 or less
• episiotomy and anesthesia (at least pudendal block) used
• record FHR before and after forceps (prolapsed cord can occur)
• record time of first void after procedure to rule out bladder damage
• make sure no laceration
• check for facial palsy and subdural hematoma on newborn
• marks on fetal head/cheeks fade in 1-2 days

• fetal head at perineum, disk shaped cup on posterior fontanells, vacuum applied, fetus extracted
• little anesthesia to reduce chance of respiratory distress
• few lacerations
• causes marked caput on fetal head with some swelling
• CI: premature infant

• placenta with one or more accessory lobes connected to the main placenta by blood vessles
• doesn't cause fetal abnormality
• small lobes may be retained

• normally, chorion membrane begins at edge of placenta and spreads to envelop fetus
• in placenta circumvallata, no chorion covers fetal side of placenta
•  cup-shaped placenta having raised edges and a thick, white, opaque ring around its periphery
• umbilical cord enters placenta at midpoint
• large vessels spread but end where chorion folds back onto surface

cord inserted marginally instead of centrally

very rare

cord seperates into small vessles before inserting into placenta

Cx: multiple gestation

causes fetal anomalies

deep attachemtne, doesn't remove manually

causes hemorrhage

Tx: hysterectomy or methotrexate

absence of an artery

causes heart and kidney anomalies

1. laceration
2. uterine atony
3. retained placental fraggments
4. uterine inversion
5. DIC

• relaxation of uterus 
• abrubt rush of blood vaginally
• most frequent cause of hemorrhage

• anything that distends the uterus beyond capacity:
• multiple gestation
• hydramnios
• large baby
• uterine tumors

• treat blood loss (Sx of shock and gluid loss)
• weigh/count saturated pads to find EBL
•  
• when you know it is hemorrhage:
• palpate/massage uterus/fundus
• observe fundal height and lochia 
• dilute IV oxytocin/pitocin (10-40U/1000 mL Ringer's Lactate in one hour)
• hemabate/carboprost tromethamine (a prostaglandin) q15-90 min for 8 doses OR methylorgonovine meleate IM shot or rectal misoprostol (a prostaglandin) or prostoglandin F22 IM shot
• do not give if woman has HTN
• SE of prostoglandin F22 IM shot: n/v, diarrhea, tachycardia, HTN
• bed pan to ensure voiding or ambulate to bathroom q4h
• oxygen at 4L/min
• bimanual massage (hand in vagina while pressure on outside ab)
• analgesia, anesthesia, and uterine packing
• blood replacement
• hysterectomy and suturing
• watch for embolism of pelvic uterine rupture

• operative or rapid birth
• primigravidas
• large infant
• lithotomy position
• instruments used

cervical lacerations 

definition and Tx

• on sides near branches of uterine artery
• arterial bleeding (bright red)
• Tx
• repair is difficult because of bleeding
• regional anesthesia

• rare, hard to repair
• packed after repair
• catheter for voiding

• 1st degree: vaginal mucous membrane and skin of perineum to fourchette
• 2nd degree: vaginal mucous membrane, perineal skin, fascia, levator muscle, perineal body
• 3rd degree: entire perineum to external sphincter of rectum
• 4th degree: entire perineum, rectal sphincter, some of rectum mucous membrane 

• like an episiotomy repair
• increase fluids, use stool softener for a week
• no enemas, rectal temps, or suppositories in 3rd or 4th degree laceration

• conditions that vary placenta site/attachment:
• placenta previa
• placenta accreta
• premature seperation
• succenturiate placenta (accessory lobes)
• conditions that leave uterus unable to contract readily:
• anesthesia/analgesia
• oxytocin
• high parity
• advanced maternal age
• previous uterine surgery
• long/difficult labor
• chorioamniocentesis
• maternal illness
• Hx of postpartum hemorrhage
• endometritis
• magnesium sulfate or tocolytics
• ultrasound or blood sample that contains hCG means there is a retained placenta

• manual removal
• D and C
• balloon occlusion and embolism of internal iliac arteries
• methotrexate to destroy remaining placenta

• prolapse of fundus of the uterus through the cervix 
• uterus turns inside out

• definiciency of clotting caused by vascular injury
• caused by premature placental seperation, missed early miscarriage, fetal death

• incomplete return of uterus to prepregnancy shape
• soft and enlarge uterus with lochia at 4-6 wks
• Cx:
• retained placenta
• endometritis (infection of endometrium)
• uterine myoma/tumors
• Tx: 
• methylergonovine PO .2mg q.i.d. to improve tone and involution

• blood in subq perineum
• pain/pressure
• 2-8 cm firm globe
• Tx:
• analgesia
• ice pack
• absorbed in 3 days-6 wks

• infection of reproductive tract
• risk:
• ROM over 24 hrs before birth
• retained placenta fragments
• postpartal hemmorhage
• anemia
• prolonged and difficult labor
• internal FHR
• local vaginal infection at time of birth
• edema and trauma

• IV antibiotics (can cause thrush on infant's tongue if breastfeeding)
• can decrease breast milk
• isolation if temp over 100.4 F twice in 24 hrs
• can hold child if it is a closed infection

• infection of endometrium (lining of uterus)
• Sx:
• fever on 4th post partum day (over 100.4 for 48 hrs)
• WBC elevated to 20-30,000
• chills, decreased appetite, tired, painful uterus not contracted, dark brown lochia
• Tx:
• antibiotic
• oxytocic agent (methylergonovine)
• fowler's to encourage lochia drain

• suture lines from episiotomy or laceration
• Tx:
• remove sutures and drain/pack
• systemic or topical antibiotic
• analgesia
• sitz bath

• infected peritoneal cavity
• major cause of death (lymphatic system)
• Sx:
• guarding/ab pain
• high fever
• rapid pulse
• vomit
• uterus not contracted
• paralytic ileus (blocked/inflammed intestines)

• NG tube
• bowel rest
• prevents vomitting
• becomes infertile because of adhesions on fallopian tubes

• inflammation of blood vessle lining with formation of blood clots

• superficial vein disease 
• deep vein thrombosis
• femoral thrombophlebitis
• pelvic thrombophlebitis

• endometrial infection
• high fibrinogen levels (increase clotting)
• dilation of lower extremity veins
• inactivity (pooling in lower extremities)
• obesity
• cigarrettes
• varicose veins
• previoius thrombophlebitis
• high parity
• older than 35 yrs

• femoral, saphenous, or popliteal vein
• inflammation in vein with accompanying arterial spasm
• decreased venous and arterial circulation and edema 
• Sx:
• increased temp
• chill
• painful and red legs for ten days
• swelled, shiny, white skin
• positive Homan's sign

• Dx: doppler and ultrasound
• Tx:
• bed rest with affected leg elevated
• anticoagulants for 3-6 mos
• heat
• NEVER MASSAGE CLOT (could cause PE)
• 4-6 wks to resolve

• ovarian, uterine, hypogastric vein
• same risk factors as femoral thrombophlebitis
• 14-15th day post partum
• lasts 6-8 wks
• Sx:
• very acutely ill
• high fever
• chills
• malaise
• pelvic, lung, heart, kidney absess
• Tx: located by sonogram, incised by laporotomy

• obstruction of pulmonary artery as complication of thrombophlembitis
• Sx: 
• sudden chest pain
• tachypnea
• tachycardia
• orthopenia (only breathe upright)
• cyanosis
• Tx:
• oxygen

• infection of breast
• 7th day post partum-months after birth
• Sx:
• red, swollen breasts
• fever
• scant milk

• prevntion
• correct latch
• release grasp before detaching
• wash hands
• expose nipples to air
• vit e ointment
• cause: staph aureus from infant's nose or candiddiasis
• Tx:
• antibiotics against penicillen resistant staph (cephalosporin or dicloxacillin) 
• ice and supportive bra
• will relieve in 2-3 days

inadequate bladder emptying

anesthesia causes overdistention

• woman can't void at all for more than 8 hrs

• woman is able to void
• infrequent and inadequate voiding
• less than 100 mL per void

• Sx:
• burning
• blood
• frequency
• low grad fever
• lower ab pain
• Tx:
• sulfa drugs (CI for breastfeeding)
• antibiotics

• Cx: placenta retention
• Sx: mild HTN after birth, proteinuria, edema
• Tx: antihypertensive, D and C
• can cause seizures 6-24 hrs post birth