010 Mark Klimek

The speaker discusses key points related to maternal-newborn care and pregnancy. They emphasize the importance of calculating a due date based on the first day of the last menstrual period. Weight gain during pregnancy is detailed, with specific amounts for each trimester and how to calculate expected weight gain based on gestational age. Fundal height is explained as a way to determine the stage of pregnancy. Signs of pregnancy are simplified into positive signs, including fetal skeleton on x-ray, fetal presence on ultrasound, and auscultation of fetal heart rate. The importance of understanding these concepts for nursing care is highlighted. Before lunch, I've been trying, page 41, the mother of all lectures, maternal-newborn overview. By the way, try to come back after lunch because after lunch I actually do the most important lecture in the whole review this afternoon, so don't, you know what I mean? It really, it's critical that you do that for that. So, maternal-newborn overview. Pregnancy. You must be able to calculate a due date. If you can't calculate a due date, you're in trouble. Does everybody else know how to do it? So, here's how you do it. Take the first day of the last menstrual period. The first day of the last menstrual period. Add seven days. Subtract three months. Now, you can do it another way, but that's, if you don't have a way, that's a good way. So, I'm going to give you a date, and I want you to figure the due date, and then talk to your buddy. Her last menstrual period was June 10 through June 15. Her last menstrual period was June 10 through June 15. I want you to figure her due date, and then see what your buddy's doing. June 10 through June 15. Okay, what do you say? March 17, exactly. You've got to start with June 10, because that's the first day of the last menstrual period. Add seven, that's 17. Subtract three from six, that's three, that's March. Alright, so that's how you do that. Letter B, the weight gain. You need to know how much weight a woman should or should not have gained. Do not worry about multiples. Don't worry about women that are underweight or overweight to begin with. They don't go there. We're talking about an average, typical pregnancy, which no one has, but the books describe. The total weight gain for pregnancy is 28 pounds plus or minus three. 28 pounds plus or minus three. That's the total weight gain. And here again, we're not talking about multiples, and we're not talking about women who are under or overweight to begin with. Number two, in the first trimester, she gains one pound each month. One pound each month. How long is the first trimester? Three months, so she gains a ton of love. Three pounds in the whole first trimester. So there's not much weight gain in the first trimester. So if they give you a woman who's had a fairly significant weight gain in the first trimester, that's bad. Because you really should not be gaining much weight in the first trimester. Maybe three pounds. In the second and third trimester, she's gaining much faster. She's gaining one pound per week. So how do you calculate? Because here's what you have to be able to do. On your licensing exam, if they give you a woman in a particular week of gestation, you have to be able to predict what her weight gain should be. For example, what if they ask you this question? A woman's in her 28th week. She has gained 22 pounds. What is your impression? And then A says she's defined. B says she's underweight. C says she's overweight. And D says, well, she could be either way, so do an assessment. She gained 22. She's at 28 weeks. How many of you know the answer? No. How many don't know the answer? How many aren't sure? How many aren't voting? The answer is, I'm going to show you an easy way to get that answer. Easy, easy way. Here's how you do it. How do you calculate a woman's ideal weight gain? Do you see the chart there? We're going to fill in the chart. At week 12, that's the end of the first trimester. How many pounds should she have gained? Three, so put three. At 13 weeks, she gained another week, so she gained another pound for a total of four, total of four to that point. 14, another week, another pound for a total of five. 15, another week, another pound for a total of six. 16, another week, another pound for a total of seven. 17, another week, another pound for a total of eight. 18, another week, another pound for a total of nine. 19, another week, another pound for a total of 10. 20, another week, another pound for a total of 11. Do you notice how every time she gains a week, she gains a pound? Now, what is the constant mathematical relationship between the top row, the weeks, and the bottom row, the weight gain? A difference of nine. A difference of nine. Take every top number and subtract nine from it. What do you get? The bottom number. 12 minus nine is three, 13 minus nine is four, 14 minus nine is five, 15 minus five is six, 16 minus five is seven, 17 minus five is eight, 18 minus five is nine. I'm saying five. You're running me. So, if you want to know the ideal weight gain for a pregnant woman, what do you do? Take the week of gestation and subtract nine, and that's what she should have gained, plus or minus a couple pounds. So, let's go back to our example. What week did I say the woman was at in the example? 28 weeks. I said she gained how many pounds? 22. Okay. Well, what should she have gained? 28 minus nine. 28 minus nine is 19 pounds. She gained three more than she was supposed to. That is in the area of something could be wrong, let's assess. If she's within a pound or two, she's okay. If she's three pounds off, you need to assess her. If she's four pounds off, there's trouble. So, if a woman is in her 31st week and she's gained 15 pounds, 31st week, 15 pounds, what answer will you pick? Well, 31 minus nine is? You don't have your calculator. 22. 22. She was supposed to have gained 22. The question says she gained 15. What do you think? We better get, we better, what's that called, a biophysical profile on the baby? Because the baby may have died last month. You see what I'm saying? And we don't know. So, that's that. So, can you predict the ideal weight gain for every week of gestation? Sure. Just subtract nine from it. This is a good OB number to begin with, isn't it? So, ideal weight gain equals week minus nine. That's your formula. Letter C, let's talk about the fundus, fundal height. What's the fundus? Not a river in India. What is it? The fundus is what? The upper part of the uterus. It's the top part of the uterus. Well, it's not palpable until week 12. So, can you palpate the fundus anytime during the first trimester? No. So, if they give you a woman for a first trimester checkup and they say, you can't palpate her fundus, should you panic? No, you're not supposed to feel a fundus. What if she's gained 10 pounds in the first trimester and that fundus is way up here? What do you think? She's either not first trimester or she's got that high-dexiniform mole, that mole of pregnancy, that cancer thing that's bad. Okay, that's in the blue book. All right. Second and third trimesters, they want to know when's it at the belly button. When is the fundus at the umbilicus, the belly button? And that is 20 to 22 weeks of gestation, 20 to 22 weeks of gestation. Now, why in the world would they want to know if you know those two things? What two things? Well, the fact that when do you palpate the fundus at the end of the first trimester? When is it at the belly button? About 22 weeks. Why is that important for a nurse to know? Think about those 12 weeks and 22 weeks. What are those weeks? Close because you're dealing with what idea? Date of viability, which is 22 to 24 weeks, which is in the end of the second trimester. So isn't 12 at the end of the first trimester? And is it 24 at the end of the second? So can you use fundal height to determine in what trimester a woman is in? Yes. That's why they want to know it because if some woman comes in in an auto accident or an accident of some situation, she's brought into the ER, she cannot tell you what trimester she is in because either she's had no prenatal care, she didn't know she was pregnant, or she's unconscious and unable to tell you she's pregnant. You have no history. She's positively pregnant. You need to know what trimester she's in to know what's going on with that baby, right? Well, how can you real quickly put her in the correct trimester? Palpate her fundus. If she's pregnant and you cannot feel the fundus at all, what trimester is she in? And who's the priority, the baby or her? Her. If you can palpate the fundus but it's at or below the belly button, you know she's in the what? Second. And who's the priority, her or the baby? Her. But if that fundus is above the umbilicus, you know she's in the? Third. Who's the priority, the baby or the mom? The baby. Are you seeing how they'll work that and who will get the attention and what they'll decide? So those are gross estimations of gestational age. Okay, signs of pregnancy. There are, do you remember learning probable, presumptive, and positive signs of pregnancy? How many of you remember those three categories? Good news. There aren't three categories on board. There's only two. Positive and everything else. So they lump the probables and presumptives together. You are not going to be asked to tell the difference between a probable and a presumptive. You will be asked to tell the difference between a positive and one of the other two. So you've got to know your four positive signs. They are fetal skeleton on x-ray. If you x-ray the abdomen and there's a skeleton there, you're pregnant. You can protest all you want, but if you're pregnant. Number two, a fetal presence on ultrasound. If they do an ultrasound and there's a baby there, you're pregnant. C, auscultation of a fetal heart rate. Auscultation of a fetal heart. If they put a Doppler down there and there's a rate of 140, it's a baby. Your bladder doesn't have its own pacemaker. You've got a baby down there. Now when does that occur? Somewhere between 8 and 12 weeks. You can hear it somewhere between 8 and 12. Now it starts beating at 5, but you can't hear it until 8. Which brings up a really important point about OB questions. Most OB information, because it's OB, has a range where it occurs. Because every woman is different, right? There's going to be a range for everything. There's a range for quickening. There's a range for lightening. There's a range for viability. There's a range for fetal heart. There's a range for fundal heights. You know, there's always a range for everything. Because of that, be real careful in OB questions. This is critically important to remember. Really carefully read your OB questions. Because there could be three different questions for every fact in OB. The first question would be, when would you first? Got that? When would you first? That's one formal question. The second question would be, when would you most likely? And the third question would be, when should you buy? When would you first? When is it most likely? And when should you buy? Those are three totally different questions for the same fact. In other words, when would you first auscultate a fetal heart? The answer is, a week. When would you most likely auscultate a fetal heart? Ten weeks. When should you auscultate a fetal heart buy? Twelve weeks. You see that? So whenever they say first, pick the earliest part of the range. When they say most likely, pick the midpoint of the range. And when they say should buy, pick the end of the range. And a lot of times you're missing OB questions, not because you don't know the correct range, but you're not paying attention to which one of those they want. So when is quickening, when the baby kicks? Remember, quick, kick, quickening, kicking. When does it happen? Sixteen to twenty. So, when would you first feel quickening? Sixteen. When would it be most likely? Eighteen. When should you buy? Twelve weeks. You see the difference? Three totally different questions for every single fact. If you don't know that, you're going to miss questions even though you know the information. Okay, letter D, the fourth positive sign of pregnancy is when the examiner palpates. Fetal movement or outline. So what does not count as a positive sign? When mom does. It's when the examiner does. Okay, let's turn the page and talk about the other signs, the maybe signs. We lump the probables and presumptives together and we call them maybes. Letter A, all urine and blood tests, all urine and blood pregnancy tests are maybes. They are not positive signs of pregnancy. I'm going to make a statement. You don't have to write it down, but this is the reason why everybody gets confused about this. Here's the true statement. A positive pregnancy test is not a positive sign of pregnancy. That's true. And that's why everybody gets confused about positive signs of pregnancy. Because they think a positive pregnancy test is a positive sign. No, it is not. It's only probable or presumptive. So a positive pregnancy test is not a positive sign of pregnancy. Everybody know that point? Because it only means you have the hormones that go with pregnancy. And many, many times you may have the hormone increases that go with pregnancy, but you don't have a fetus. And so a lot of positive pregnancy tests are false positives. But when you hear a heartbeat down there, there's no false positives on that one. Okay? It's a good question. I could phrase it the other way in relation to what you asked. Positive signs of pregnancy have no false positives. They are things that never have a false positive. Okay, let's talk about some other probable presumptive signs. Have you heard of Chadwick's, Goodell's, and Hegar's signs? Hopefully you've heard of those. Two things you need to know. In what order do they occur? It's easy. They occur in alphabetical order. So who comes first? Chadwick followed by Goodell, followed by Hegar. See, Bords is more interested in if you know the order than if you know the exact weeks. Why? Weeks vary from woman to woman, but the order never varies. So Bords is going to test what does not vary. Because this is statistically more valid to test that. Or reliable, I should say. Well, what is Chadwick's sign? Chadwick's sign is a cervical color change to cyanosis. A cervical color change to cyanosis. What do you notice about all those words? They start with the letter Z, and what does Chadwick's begin with? Z. So Chadwick's is everything that starts with Z. A cervical color change to cyanosis. It turns blue. And if the cervix is doing it, the vagina is too. Okay, Goodell's sign is cervical softening. And Hegar's is uterine softening. Doesn't that order make sense? What would happen first? The cervix would turn blue. Then the cervix would soften. Then that softness would move up into the uterus. So it kind of makes sense, the order. Okay, let's talk about some patient teaching in pregnancy. You need to teach the woman the pattern of office visits. Good prenatal care is a major factor in reducing infant mortality. So you need to know how to teach a woman how often she should come in for good prenatal care. So you teach her to come in once a month until week 28. So through the whole first trimester, and the whole second trimester, and even into the third trimester, she's coming in once a month. Then at week 28, she should come in once every two weeks until week 36. Then she should come in every week until delivery or week 42. What happens at week 42? Do you schedule her for another office visit, C-section, or an induction? So let me ask you this. If a woman comes in for her 12-week checkup, 12-week checkup, when does she come in next? One month. 16. If she comes in for 16, when does she come in? 20. If she comes in at 20, when does she come in? 24. If she comes in at 24, she comes back at 28. At 28, she comes back at 30. At 30, she comes back at 32, 34, 36, 37, 38, 39, 40, 41, 42, and take the baby. So that's basically the way it goes. All right. Another thing you have to teach her is the pattern of office visits. All right. Another thing you have to teach her is that her hemoglobin will fall, and that's normal. We don't worry about low hemoglobin with pregnant women until it gets really low. The normal female hemoglobin level is 12 to 16. In the first trimester, it can fall to 11 and be perfectly normal. 11 is not low tolerable. 11 is normal for a first trimester pregnant woman. It's not low, but tolerable. It's actually normal. It's not low. It's normal. In the second trimester, it can drop to 10.5 and be normal. Not low, but normal. In the third trimester, it can drop all the way to 10 and be normal. So what would you call a 10.1 hemoglobin in a woman's 37th week? Acceptably low or normal? Or normal? Normal. So acceptably low might be as low as 9, you see. So I guess my point is this. Tolerate lower hemoglobin in pregnant women the further along they are than you would with other non-pregnant people. 11. It can fall to 11 and be normal. Which brings up the discomforts of pregnancy that you need to teach her. How do you treat morning sickness? What trimester problem is it? First, and what do you treat it with? Dry carbohydrates. Yep. Dry carbohydrates for breakfast, yes or no? No, it's dry carbohydrates before you get out of bed. Because once you're out of bed, it's too late. Number two. How do you deal with urinary incontinence? This is a first and third trimester problem. Why do they not have a problem with urinary incontinence in the second trimester? Why do you not get urinary incontinence in the second trimester? Because the baby is in an abdominal pregnancy. It's up high off the bladder. But in the first, it's right down on the bladder. And in the third, it's right down on the bladder again. How do you treat it? Voids every two hours. A pregnant woman should void at least every two hours all the way from the day she gets pregnant until six weeks after delivery. Every day, all through labor, delivery, postpartum, pregnancy, void at least every two hours. Number three. Difficulty breathing. This is a second and third trimester problem. And you teach them tripod position. Can anybody explain to me what tripod position is? Feet flat. Arms on the table leaning forward. So that's tripod. Or you can even put your hands on your knees leaning forward. It's what you're seeing COPD clients doing. Okay, how does back pain? People with pregnancy get back pain. It's usually second and third trimester. It just keeps getting worse and worse and worse. How do you treat it? Pelvic tilt exercises. Pelvic tilt exercises. So what that means is tilt is this. A woman should tilt the pelvis forward. You don't want to go on like that because that hurts. So you're going to see women do this. That's what they do. You know, they tilt that pelvis forward. That's classic pelvic tilt. Another way to do it is have them put their foot on a stool and that tilts the pelvis forward. Boards usually says this one. Okay, that's pregnancy. Did you say that's all? Well, there's some in the blue book. But pregnancy is a great place to use your common sense. Because pregnancy is not a disease. It's a healthy disease. And so using good health patterns and ideas. So when you get a pregnancy question you don't know the answer to, what should you say? Well, what would be good for anybody? What would be a really good, healthy response here for anyone? Pick it and you will be surprised at how well you do. Okay, let's get this baby out of here now. Okay, let's go into labor and birth now. Letter A, what is the truest, most valid sign that a woman is in labor? How do you know a woman is in labor? What's the most valid sign she's in labor? Not blood show. Not water breaking. Because you're going to have both of those and never be in labor. Okay, but the woman doesn't call you and say, I'm dilating and I'm effacing. So what will they report? They call that the onset of regular progressive contractions. The onset of regular progressive contractions. That's the most valid sign that a woman is in labor. Isn't it possible to have your membrane rupture and two days later you still aren't in labor and they haven't said C-section yet? So that's not a good indicator. But it's associated with it, but it's not the best. Okay, terms. Here again, you have to know a vocabulary. You have to know what the words mean in OB or you can't answer the question. So I just want to be sure you guys know these words. Dilation is the opening of the cervix. The opening of it. And it goes from zero to ten centimeters. So a cervix that is zero is described as what? Close. A cervix that is ten is described as fully dilated. Because open is not the best. Fully dilated is the best. In America, in the United States, do we use centimeters or inches generally speaking in our lives? We talk about inches. We don't use centimeters. Most Americans don't know what a centimeter is. They know what an inch is, but they don't know what a centimeter is. Then why do we use ten centimeters and zero centimeters in OB? Because OB is inches. Most of our obstetric history comes from England, and we use very much an English system. But I also think in America, just think about marketing and input. I mean, ten centimeters is four inches. I don't know how many women would sign up where they have to push a baby out of a four-inch hole. Do you know what I'm saying? So ten centimeters sounds a lot more what? Generous, doesn't it? Oh, you're ten centimeters. Oh, I can do this. So I know that's interesting. Okay, effacement. Effacement is thinning. Thinning. T-h-i-n-n-i-n-g. Thinning of the cervix. It gets thinner. And it goes from thick to 100%. So a cervix that is not effaced is described as what? Thick. A cervix that is completely effaced is called? 100%. 100%. So how does a woman begin labor? Thick. Thick and? Zero. Zero, or thick and close, or thick and zero centimeters. How does she end labor? Fully dilated and fully effaced. Fully dilated and fully effaced. Which numbers? Ten and 100%. Okay. All right. Station. Station is the relationship between the spine. Oh, I'm a fetal presenter. I was getting in line. Station is the relationship of the fetal presenting part to mom's ischial spine. And you must know the ischial spine. This word is very important to know in OB. Ischial. The ischial spines are the smallest diameter through which the baby has to fit to be born vaginally. It's the tight squeeze, so to speak. It's the narrowest part of the pelvis. And if the baby can't fit through there, it cannot be born vaginally. If it can fit through there, it can be born vaginally. Station will tell you that. Now, negative station means that the presenting part is above this tight squeeze. Positive numbers mean the baby's presenting part is below, has already made it through the tight squeeze. So if a kid stays at negative 1, negative 2, negative 1, negative 2, negative 1, negative 2, negative 1, negative 2, for 17 hours after they're fully dilated in the face, what do you know? Head's too big, C-section that late. But what if a kid stays at plus 4, plus 3, plus 4, plus 3, plus 4, plus 3, plus 4, plus 3, for 17 hours? What's that tell you? Can the baby be born vaginally? Yes, because it's already made it through. It needs a vacuum extractor. You know, it needs an extra little, maybe in the pediatomy or just a forceps. So how many of you have a hard time remembering positive numbers and negative numbers, which one's high, which one's low? Nobody does? Okay, I used to screw that up all the time. So I guess you don't. Okay. I had a way to remember it, though. Since you don't have that problem, we'll go on. Engagement is station zero. So what's that mean? If it's station zero, what's that mean? The presenting part is where? At the ischial spot. Station zero, yes. I always remember that positive numbers are positive news, negative numbers are negative news. So what do I mean by that? Well, if you go into a woman's room and she says, what station am I at? And I tell her a negative number like negative one, negative six, that's negative news to her, which means where's the baby? Way up and it's not coming down. But if I walk into a woman's room and she says, what station am I at? And I give her a positive number like positive four, positive two, what kind of news is that? Positive news, good news. What's good news to a woman in labor? Baby's coming out, it won't be long now. So negative numbers are negative news to a woman, positive numbers are positives. Negative, negative, positive, positive. That's the way I remember it. Otherwise I always got screwed up. Lie. Lie is the relationship between the spine of the mother and the spine of the baby. In other words, between the spine of the mom and the spine of the baby. If mom's spine is like this and baby's spine is like that, that's good. That's called a vertical lie. That's compatible with a vaginal birth, uncomplicated. Another lie is if mom's spine is like this and the baby's spine is perpendicular. That is bad. That is called a transverse lie. You see how I use the perpendicular as the T. And that is also trouble. It's bad. So whenever they give you these questions about lie, they will tell you where mom's spine is in relationship to baby's. All righty? If they tell you that mom's spine and baby's spine are parallel. Touchdown, we got a baby. Score. Good. Baby's coming out. If they tell you the mom's spine is this way and the baby's spine is that way, make that. And what's that make? A letter what? Which means it's trouble and transverse. So you either got a baby or you got trouble. Presentation. Presentation is the part of the baby that enters the birth canal first. This is where you get all those wonderful little alphabet soups. R-O-A, L-O-A, R-O-P, L-O-P, R-M-P, R-S-A, R-S-T. Hunt all of that. You do not need to know all of that. Let me just show you a little poll. How many of you know all of that? How many of you don't know that? My point is proof. Okay, how many know that before you give digitalis you take an apical heart rate? How many know that? How many do not know that? What do you need to know? The presentation or the dig? Because everybody else knows the dig. You better know it. Nobody else knows this other stuff, so why would you spend two weeks memorizing it? You're going to forget it anyhow, right? If they want to ask a hard OB question, they pull this out. What's the damage to you to missing a hard question? There is none. There is no danger to you in missing a hard question. Everybody's going to get hard questions. Everybody will. You can miss every single one of those and still pass with flying colors. You cannot miss the easy ones. So the goal is not to memorize or know everything. The goal is to know what everybody else knows so that your knowledge doesn't look any different than everybody else's. Is that what it's like? It's sort of like a National Geographic special board thing. And you're all a pack of zebras. Who gets picked off by the lions? The one that's what? Lagging, by itself, all... Staying with the herd is good. So in nursing, stay with the herd, okay? So hopefully, now, the most common presentation is ROA or LOA, right occiput anterior, left occiput anterior. Okay, now, so if they ever give you a question where they say, you palpate a bulb here and an irregular there and a lump here and a round there, and then say, what presentation is it? Hey, I'm picking ROA or LOA because I've got much better chances picking those two than anything else and you'll probably be right. So that's just a good guess. ROA, LOA. And I pick ROA. Four stages of labor and delivery. There are four stages of labor and delivery. You must know them. Stage one is labor. All of labor is stage one. And labor has three phases. Do you remember that? There are four stages that are big and then three phases that are small in the first stage. So the phases are latent, active, and transition. And those phases are all in the first stage, which is called labor. Question? Yes. More back to what you said about, you know, those easy questions. Why don't they tell us if we get a bunch of hard questions that's good and we're above that? Yes. If you get a whole bunch of hard questions, you have passed because you can only get to the hard questions by having mastered the easy ones. The only way you can fail is to, for some reason, mess up easy ones, whether due to your anxiety, just not understanding what they were asking, or not having certain basic knowledge that you should have, or not knowing how to answer certain kinds of questions. But I was sitting at a table in Cleveland at a national conference of the National Council of State Boards of Nursing that write the text. And there were eight of us at the table, and Anne Wentz was sitting right there, two people away from me. Anne Wentz is the president of the National Council of State Boards of Nursing. She's the top NCLEX writer kind of person in the nation. And I was asking, we were asking her questions. And one question I asked her, I said, Anne, people are always asking me, what do they need to do to pass? In a nutshell, what do they need to pass? And she looked at me, she said, I'll answer that in one short answer. She said, they have to get to the hard questions. So if you want to pass, you have to what? Get to the hard questions, where you're going to miss a whole lot. But you've got to get to the hard questions, because if you never get to the hard questions, you will never pass. You know what I'm saying? Because you're always bouncing around down on the easy ones. And I didn't think that was that helpful, but at least it tells me that that is a very good thing. It came from the source authority on that. So she says, you've got to get to those hard questions. So the upshot of that is, don't panic when they're asking you about stuff you don't think anyone's ever heard of, because you're probably getting hard stuff. And that's okay. It's okay to get hard stuff. You want to get hard stuff. All right. Stage number two. Oh, by the way, what are the three phases? Lane, active, transition, in that order. What's the first phase? Lane, what are the first three letters of the first phase? L, A, T. What are those? The initials of the phases in order. L for latent, A for active, T for transition. So the first phase, the first three letters of the first phase tell you the order of the phases. Stage two is called delivery of the baby. Stage three is delivery of the placenta. And stage four is recovery. Stage one is what? Labor. Stage two is delivery of baby. Stage three is delivery of placenta. And recovery is the fourth stage. Now, I would ask you, how long does recovery last? Does anyone know? Just two hours. It lasts for just two hours. So let me ask you this. What is the purpose of uterine, and this is what Hettie loves to ask, what's the purpose of uterine contractions in the first stage? In the first stage, what's the purpose of uterine contractions? No, no, no, that's stage two. Dilate and abase the cervix. What is the purpose of uterine contractions in the second stage? Push the baby out. What's the purpose of uterine contractions in the third stage? Push the placenta out. What is the purpose of uterine contractions in the fourth stage? Stop bleeding. If you contract a uterine, too, stop bleeding. So can anybody tell me when postpartum technically begins? When does postpartum technically begin? After recovery. And give me some more data on that. Two hours after recovery. Not after recovery. Two hours after delivery of the placenta. There you go. So two hours after that, placenta comes out, they're in recovery, and then when that ends, they are now in postpartum. Postpartum does not begin when the baby comes out. Does everybody see that? Okay. So do you see where people get messed up? They get messed up between second phase and second stage. Because if I ask you, what is the number one priority in the second phase of labor? Number one priority in the second phase of labor. What would it be? Pain management. Right? But if they change the word phase to stage, and they said what's the number one priority in the second stage, now what's the number one priority in the second stage? Clearing the baby's airway. You see what I'm saying? So you have to be careful if you know what would be an extremely important nursing action to undertake in the third phase. What do nurses do? What kind of actions are nurses engaging in in the third phase? We're checking dilation, we're helping her with pain, we're helping her with breathing because she's in the last intense part of labor to dilate. Right? But if I said what's a major nursing action for the third stage, what would you say? Watching for blood loss. What's the third stage? Okay. So what do you do with that? Make sure it's all there. Make sure there's three vessels in the cord. But you would never do that in the third phase because you understand how if you aren't paying attention to whether they're talking about stages or phases, you're going to get messed up. Can you do that? Please keep phases separate from stages because you have a first phase and a first stage. You have a second phase and a second stage. You have a third phase and a third stage, but you only have a fourth stage. All right. Now let's go through those and we'll go to lunch here in a little bit. Let's try to do the next two pages and then we'll be done, but maybe we won't. The rest of this moves fairly quickly because there's really not a whole lot. I mean, there's a lot still in here. D says the first stage of labor and delivery. What's it all about? The first stage. What's it called? Labor. So what you see here is what we call the labor chart. Bad news. You have to know it all. You have to know the whole labor chart. Good news, though, I'll show you a way to remember it that's really easy so you don't have to memorize it all. So let's talk about this labor chart. How many phases do you see in the labor chart? Three, because how many phases are there to labor? Three, and there's latent, active, and transition. Let's talk about latent. In the latent phase, you dilate from zero to four centimeters. Your contractions are every, excuse me, three to five, I'm sorry, five to 30 minutes apart. That's the first column. We're going down the first column. So the contraction frequency is five to 30 minutes apart. The contraction duration, meaning how long they last, is 15 to 30 seconds. And the intensity of the contractions is described as miles. Now, that's our word, not hers. Now, let's talk about active. Active, because things pick up here. Dilation goes from five to seven centimeters. The frequency is every three to five minutes. They last 30 to 60 seconds, and their intensity is moderate. Again, our word. However, in transition, things pick up even more. The cervical dilation goes from eight to 10 centimeters. The frequency is every two to three minutes, and the duration is 60 to 90 seconds, and the intensity is strong. Now, the way they will test your knowledge of this is they will say, a woman comes into the labor and delivery suite. She is five centimeters. The contractions are every five minutes apart, and they last for 45 seconds. What phase is she in? Active. That's how you do it. But you have to know the numbers to put her in the right one. Good news. This chart is what we call a three-column sequential table, meaning there are three columns, and where one leaves off, the other picks up, and where that leaves off, the next one picks up. The easiest way to master a three-column sequential table is to ignore the size and only memorize the middle column. So I only want you to memorize active labor, just active, which is what? Five to seven, three to five, 30 to 60. And you got the whole chart, don't you? Because anything less intense would be what? Transition. And anything more intense would be? Transition. Transition. So five to seven, three to five, 30 to 60. It can't be simpler than that. Note. Do you see where it says note? Contractions should not be longer than 90 seconds or closer than every two minutes. You must know this. They love to test this one. How do you know a woman's in trouble in labor? Well, when her contractions are longer than 90 seconds and closer than every two minutes. You do not want to see that. They would give you four women in labor and say, who's in trouble? Her contractions are going to be longer than 90 and closer than two minutes. That's bad. They'll also ask it, what are the signs of uterine tetany? Well, contractions longer than 90 seconds, closer than every two minutes. What's uterine hyperstimulation? Contractions longer than 90 seconds, closer than every two minutes. What parameters would make you stop Pitocin? 90 seconds, two minutes. 90 seconds, two minutes. Remember that. You're very likely to see that. Okay, let's talk about assessment of contractions. You have to tell the woman how to do this, how to time her contractions. Well, frequency is beginning, that goes in the blank, beginning of one contraction to the beginning of the next. So, if you're teaching a woman to time frequency and these are two contractions, what letter interval would you tell her to time for frequency? A beginning to C beginning. That actually includes the contraction, doesn't it? So, frequency is beginning to beginning. Duration, on the other hand, is beginning to end of one contraction. Beginning to end of one contraction. So, what number sequence would you tell her to time for duration? A to B or C to D. So, frequency would be A to C, duration would be A to B, C to D. Intensity is the strength of contraction and it's purely subjective. However, that next sentence is really important. You see where it says palpate with? This is very important. So, palpate with one hand, always one hand, because the other hand is timing, one hand over the fundus with the pads of the fingers. So, make sure you teach her to use one hand, make sure you teach her to go over the fundus and make sure you tell her to use the pads of the fingers, which are the fingertips. Okay, let's talk about complications of labor and then go to lunch. Bad news, there are 18 complications that can occur in labor and delivery and you have to know them all. Good news, there are only three protocols you need to know for all 18. So, really, what do you have to memorize, 18 different things or three different things? Three. So, let's talk about these three things you need to know. The first one is painful back labor. Have you heard of painful back labor? It's usually when she's OP, occiput posterior, you know, LOP, ROP, occiput posterior. I always tell people, when you see OP at the end of it, think, oh, pain, because they're going to have it. OP is opaque. So, what do you do for it? Two things. Position, then push. You position her and then you push. In what position would you place her? Does anybody know which position you put a painful back labor in? Not nine. Knee, chest. She goes on her hands and knees with her rear end up and her head down. Because that brings the baby down off the sacrum and up. So, knee, chest. Get her on her hands and knees. Then, push. What do you push? Anybody know what you push? Take your fist and push into her sacrum. That applies counter-pressure and actually relieves the pain. Yes? Knee, chest. No, see, knee, chest. Yeah, people get knee, chest confused with lipotomy. Because in knee, chest and lipotomy, your knees are to your chest in both. This is lipotomy. This is not what we're talking about. This is lipotomy. Okay? Okay? That's lipotomy. This is knee, chest. That's knee, chest. So, your knees are to your chest here and your knees are to your chest here. But this is lipotomy. This is, and here's the nose, that way. And this is knee, chest here. Because, see, the baby then will come down off the coccyx. So, knee, chest is that. Okay? That's knee, chest. And that's what we mean. We don't mean this. Next one, prolapsed cord. This is bad. This is an OB emergency. Prolapsed cord is bad because the baby can kill itself. Prolapsed cord is when the cord is the preventing part, which means it comes out first, so that when the head comes down, what does the head do? Press on the cord and the baby dies. The baby literally commits suicide. It kills itself. So, this is not cool. Painful back labor, high priority, low priority. Low. Prolapsed cord, high priority, low priority. High. Okay, what do you do here? Push, position. Now, what was painful back? Position, push. This one is push, position. So, they're just a flip-flop. Well, what do you push? You don't touch the cord. Push the head back up. Push the head off the cord. Then what do you position her in? Knee chest. The one I just, the one we just talked about. So, she's in knee chest. You've got her hand pushing the head. And you stay that way until they pull it out C-section. So, it's kind of, you have to ride on the cart with her, you know, so you just throw a blanket over everything. You can just go like this. It's like a float, you know, in a parade. It's kind of weird. So, what do you do for painful back? Position, push. Position, push. What do you do for prolapsed cord? Push, position. Do you remember when I said usually I will always position before I do something else? That has an exception, too, because in prolapse, you push, then you position. Why do you push first in prolapse and position second in prolapse? Why? Because delaying pushing in order to position would increase the risk to the baby. See, but it's the same principle. So, when you're sitting there not knowing what to do, it's probably good for you to think about, if I delay doing this to do that, would it, that's probably a good way to think. Number three, interventions for all other complications and labor and birth. And there's like 16 of them. Uterine tetany, uterine apnea, uterine hypertension, uterine hypotension, maternal subclavian syndrome, vena cava syndrome, you name it. There's SOCU complications. They're all treated the same. And they are treated with Lyon, L-I-O-N. L means first you turn them on their left side. There's the L, left side. I is increased IV. O is oxygenated. N is notify physician. So, first you turn them on the left side, you increase the IV, you give them oxygen, and you notify the physician. Now, LPNs, you will be able to do all of those except increase the IV. So, what do you do for maternal hypotension? Lyon. What do you do for eclampsia? Lyon. What do you do for toxemia? Lyon. What do you do for uterine rupture? Lyon. What do you do for something, as long as it's not painful back or prolapsed cord, you're picking what? Lyon. Questions? Questions? Probably the first would be, yeah, the physician. And the best would be top. I would, the left side there might be the best, too. That gets the pressure off, gets the placenta perfused better. So, even if you give oxygen and the placenta's not being perfused, it's not going to get to baby. So, I would say that's one place where first and best are the same one, left side. Does everybody agree with that? And sometimes it's the same. It's just on occasion it's different. Most of the time it's different. It's on occasion it's the same. Okay, pit. Pit means in a crisis, if pitocin is running, stop it. In an OB crisis, if pit is running, stop it. So, could that be the first thing you would do? So, that would catapult all the way to where? Hold the pit, the catapult, to what order? Number one, and that would be L. So, you'd stop the pit, then L-I-O-N. But most of the time they will not tell you pit is running, so pit won't even be there. So, nine times out of 10 you'll be doing L-I-O-N. But if they tell you pit's there, stop pit, L-I-O-N. Okay. Pain medications and labor. Get this down word for word and then we'll go to lunch. Do not administer a pain medication to a woman in labor if the baby is likely to be born when the meds peak. Do not give a pain medication to a woman in labor if the baby is likely to be born when the meds peak. Let me illustrate how you're going to do this, because it's not going to be anything magical, it's just going to be good common sense. What about this question? You have a primagravida. Primagravida means what? First timer. Primagravida at 5 centimeters. Who wants her IV push pain meds? Will you give it to her or not? Well, the question is, is it likely that a primagravida at 5 centimeters is going to deliver in the next, what? Well, IV push meds. We learned the other day that IV push meds peak when? IV meds peak when? 15 to 30 minutes after you give them. So, is it likely that a primagravida at 5 centimeters will deliver the baby in the next 15 to 30 minutes? So, would you give her the meds? Yes. What about this question? You have a multagravida at 8. Who wants her IM pain meds? Well, the question then is, is it likely that a multagravida at 8 centimeters could deliver in the next, well, when do we know IMs peak? 30 to 60. Is it likely that a multagravida at 8 could deliver in the next hour? So, what would you say to her? No. Are you getting it? It's going to be obvious. It's not going to be, they're not going to play around with being real close like your teachers in school and ACI and stuff like that does. You know what I mean? They're going to make it clear. If you can pass HESPI, you can pass ACI, you can do boys. You can't. They are much harder. I would rather take state boys any day of the week than take an ACI or a HESPI. And that would be a no-brainer. It would be a no-brainer. Okay, after lunch, we'll come back and do fetal heart rate spacing. Be back at about... Try to be back at 5 to 1.