You're in the bay. Once you get over to the bed,
we'll give you the story. Everything's going
to happen super fast. Welcome to the emergency
room. What if I told you that doing exactly what
you see in the movies is actually dangerous.
I mean, a pregnant woman laying completely flat
on her back, holding her breath and pushing with
all her might while a room full of people yells
at her to count to 10. It's actually the absolute
worst, most physiologically dangerous way to
deliver a baby. It really is. It's the great
Hollywood medical myth. If you walk into a labor
and delivery unit expecting it to look like a
sitcom finale, you are going to be completely
unprepared. Right. And honestly, if you're a
nursing student walking into your obstetrics
exam with those movie images in your head, you're
going to fail. Which brings us to the exact reason
we're doing this today. This is not just some
casual overview of maternal health. We are shifting
gears entirely for you. Exactly. Today's deep
dive is an elite, highly specialized obstetric
nursing exam prep and clinical coaching session.
The mission here is to take you inside the minds
of the safest, most effective labor and delivery
nurses on the floor. We're going to break down
how they think. you know how they prioritize
and how you can use those exact same mental frameworks
to not only crush your nursing exams but to actually
save lives when you are the one standing at the
bedside. Yeah and to do that we have to completely
change the way we approach studying. Like you
can't just memorize everything. No you can't.
We are aggressively applying the Pareto principle
here. Yeah. I am not going to sit here and read
an OB textbook to you from cover to cover. Thank
goodness for that. Right. Trying to memorize
every single obscure fact equally is exactly
how nursing students get overwhelmed. And more
importantly, it is how they miss the critical
safety alerts when the pressure is really on.
So we're sifting out the high yield stuff? Yes.
The 20 % of high yield concepts, the classic
NCLEX traps, and the safety critical facts that
are going to provide 80 % of your exam value.
Clinical judgment isn't about memorizing random
disconnected bullet points. It's about spotting
patterns. Okay, let's unpack this. Because I
remember when I was prepping for exams, I just
relied on flashcards. It worked for history,
right? You memorize the date of a battle, you
write it down, and it's a static fact. But if
Stetrix feels... incredibly dynamic. It really
does. You could have two laboring patients with
the exact same vital signs, the exact same dilation,
and their priority nursing interventions might
be like polar opposites. That is the literal
definition of clinical judgment in muddy waters.
You constantly have at least two lives in your
hands, sometimes more. Wow, yeah. And the correct
intervention depends entirely on understanding
the specific phase of labor, the fetal presentation,
and the underlying physiology of that exact second.
So as we go through this material we're going
to constantly separate what is expected from
what is concerning. Exactly and we are going
to focus heavily on the why behind every single
priority nursing action. So let's set the scene
for you. We have a patient rolling into triage.
They're contracting. Before we even get to the
dramatic moments of birth we have to lay down
the mechanical and environmental foundations
of labor. Because if the foundation is flawed,
the entire process just stalls. The timeline
of labor is broken down into very specific stages.
You absolutely must know the hard boundaries
of each one. OK, so the first stage. The first
stage of labor officially begins with the onset
of regular rhythmic uterine contractions that
actually cause cervical change. That means effacement
and dilation. Right, so it doesn't count if the
cervix isn't actually changing. Exactly. False
labor doesn't change the cervix. And that first
stage ends the absolute moment the client is
completely dilated to 10 centimeters. So 0 to
10 centimeters is the first stage. But it's not
just about waiting for a number on a chart, right?
The exam focus is usually on the mechanics of
how that happens. Yes, the textbook refers to
this as the five P's of labor. You've got passenger,
passageway, powers, position, and psychological
response. Let's break those down really quickly.
The passenger is obviously the baby. Right, the
fetus. The passageway is the maternal pelvis
and soft tissues. The powers are the uterine
contractions. But the most highly tested element,
I think, is position. It absolutely is. Because
it's the one nurses have the most direct control
over. Specifically, how maternal positioning
drastically alters the physical dimensions of
that passageway. This goes right back to our
movie myth. If laying flat on your back in a
hospital bed is so bad, why does positioning
actually matter so much? It comes down to basic
physics, really. Gravity and mobility. When a
laboring client is in an upright position standing,
sitting on a birthing ball, kneeling or squatting,
gravity is physically pulling the fetal head
down against the cervix. And that pressure helps
the cervix dilate faster. Yes. But more importantly,
the bones of the maternal pelvis are not fused
rigidly together. they have slight mobility.
Oh, that's right. The relaxant hormone loosens
the joints. Exactly. So when a client gets off
their back and moves into an upright or squatting
position, the pelvic outlet actually increases
in dimension. You are physically creating a wider
anatomical space for the fetus to navigate. So
by standing or squatting, the patient is quite
literally widening the exit door while simultaneously
using gravity to push the baby toward it. Precisely.
And the clinical outcomes completely reflect
this. Upright positions are proven to decrease
maternal pain because the client feels more in
control of their body. Which makes sense. And
evidence shows it can shorten the active pushing
phase by anywhere from 3 to 10 minutes. Wow.
When you're exhausted and pushing with everything
you have, shaving 10 minutes off that process
is a massive victory. It's huge. But if upright
positions are the expected beneficial standard,
we need to clearly define the concerning positions
for you. The red flags that exams love to test.
Right. The two most concerning positions are
the strictly supine position, lying completely
flat on the back, and the lithotomy position.
Lithotomy is when they're lying supine but with
the legs strapped up into stirrup. That's the
one. I always think of it this way. Trying to
push a baby out while completely supine is like
trying to push a heavy boulder up a hill while
simultaneously standing on the garden hose that
supplies your drinking water. That is a great
analogy. The boulder is the baby fighting against
the upward curve of the birth canal without any
help from gravity. And that squashed garden hose
is the maternal inferior vena cava. Yes. That
is the exact physiological mechanism you need
to understand for the exam. It's called aortic
oval compression. Break that down for us. When
a pregnant client lies flat on their back, the
entire weight of the gravid uterus, which is
a baby, amniotic fluid, and a placenta, weighing
several pounds, rests directly onto the inferior
vena cava and the descending aorta. It just traps
them against the maternal spine. Exactly. It
compresses them. So if the vena cava is compressed,
blood can't return from the lower body back to
the mother's heart. Right. Venous return plummets.
And when venous return drops, maternal cardiac
output plummets. This causes severe maternal
hypotension. So the mother feels, what, dizzy,
nauseous? Dizzy, nauseous, clammy. But the real
danger is to the fetus. If the mother's blood
pressure bottoms out, the profusion of oxygen
-rich blood through the uterine arteries to the
placenta completely tanks. Oh, wow. The fetus
is suddenly cut off from its oxygen supply. And
you will see immediate, severe decelerations
on the fetal heart rate monitor. Not to mention,
if the mother is strapped into the lithotomy
position, her pelvis is locked, right? It can't
expand. It cannot. So you are decreasing oxygen,
fighting gravity, and keeping the exit door as
narrow as possible. This dramatically increases
the risk of severe perineal tearing. The perineum
can't stretch evenly when the legs are forced
apart and immobilized in stirrups like that.
It can't. So from a nursing standpoint, your
priority action is extremely clear. You must
actively encourage maternal position changes
every 30 to 60 minutes. Keep the pelvis mobile.
Keep the patient off their back. But wait, if
hospitals are using the lithotomy position so
frequently, there must be some clinical benefit
to the mother, right? I mean, doctors wouldn't
just do it for their own convenience at the expense
of the patient. Well, that is the ultimate exam
trap. and it requires you to understand the harsh
reality of historical medical practice versus
physiological ideals. Okay, hit me. Lithotomy
is not optimal for the maternal pelvis or fetal
descent. It became the standard almost entirely
for provider convenience. Wait, really? Yes.
It provides the doctor with a perfect seated
line of sight. It makes continuous fetal monitoring
easier to keep strapped to the belly. crucially,
if the delivery becomes an absolute emergency,
lithotomy provides immediate unobstructed access
for the provider. Access for like forceps or
a vacuum. Exactly. Forceps, vacuum extractors,
or to perform an episiotomy. So it's basically
an emergency access position that just became
a routine habit over the decades? That's exactly
what it is. And exams will heavily test your
ability to separate those two concepts. Upright
is for maternal and fetal benefit. Lithotomy
is for provider access and emergency maneuvers.
So the memory anchor you want to write down is
this. Upright equals open, supine equals stress.
Upright equals open, supine equals stress. Perfect.
Now before we move on to what happens when the
cervix is fully dilated, there's another critical
piece of the environment the sources emphasize.
And that's the support system in the room. Specifically,
the role of doulas. This is a highly testable
priority concept regarding non -pharmacological
interventions. A doula is a professionally trained
support person. They provide continuous physical,
emotional, and informational support before,
during, and just after childbirth. But they aren't
medical professionals, right? Correct. It is
vital to note they are not medical providers.
They do not catch the baby. They do not prescribe
medication. But their continuous presence exerts
a profound, measurable, physiological effect
on the laboring client. Because they lower the
fear and anxiety in the room? Yes. And lowering
fear isn't just a nice psychological bonus. It
is a physiological imperative. How so? When a
client is terrified, their sympathetic nervous
system floods their body with catecholamines.
Think stress hormones like cortisol and adrenaline.
Fight or flight. Exactly. And high adrenaline
literally counteracts oxytocin. Oxytocin is the
hormone responsible for uterine contractions,
so fear literally stalls labor. Wow, so being
scared stops the contractions. It does. By providing
continuous calming support, a doula helps lower
those stress hormones. When adrenaline drops,
natural oxytocin surges, uterine contractions
become more effective, and utero placental blood
flow actually increases. And the data on this
isn't subtle. The sources we're looking at are
incredibly explicit about the impact doulas have,
especially on historically marginalized demographics.
The statistics are staggering. In the United
States, black maternal clients face a tragically
disproportionate risk of severe morbidity and
mortality from pregnancy related complications.
It's awful. It is. But the evidence clearly shows
that continuous support from a doula significantly
reduces these risks for historically marginalized
racial groups and clients with low socioeconomic
status. They act as advocates, right? Yes, doulas
act as vital advocates and liaisons, ensuring
that the client's cultural beliefs are respected,
their pain is taken seriously, and their voice
is actually heard by the medical team. So a safe,
effective nurse views the doula as a critical
collaborator, not as someone in the way. Collaborative
care improves outcomes, always. If an exam question
asks about the best action regarding a doula,
the answer is always to facilitate their involvement
and incorporate them into the care plan. All
right, let's organically synthesize this foundation
for you. If you only remember a few things from
this section, we know the first stage is all
about getting to 10 centimeters. We know to change
the patient's position every half hour to keep
the pelvis open. Avoiding the supine position
at all costs to protect that vena cava. Right.
We know upright positions speed things up. And
we know integrating continuous emotional support
physiologically accelerates labor by dropping
adrenaline. Perfect summary. OK, so she hits
10 centimeters, the physical space is maximized,
the cervix is completely out of the way. What
happens next? The exact moment you confirm 10
centimeters of dilation, you have officially
crossed the boundary into the second stage of
labor. Stage two. Yes. The second stage lasts
from complete dilation until the final expulsion
of the fetus. But This is where clinical judgment
gets really muddy and where students make fatal
errors on exams. The instinct is to think, oh,
10 centimeters, the door is open. Let's get this
baby out right now. Why on earth would a nurse
ever tell a fully dilated patient to just sit
there and not push? Because complete dilation
is only one piece of the puzzle. To safely initiate
active pushing, you need three physiological
criteria to align perfectly. OK, what are they?
First, yes, complete dilation at 10 centimeters.
Second, the client must actually have an overwhelming,
involuntary physiological urge to bear down.
This is often referred to as the Ferguson reflex.
And third, the fetal station needs to be low
enough in the pelvis. We are looking for a station
of zero or lower, meaning The widest part of
the baby's head has engaged deeply into the maternal
pelvis. But wait, what if the patient has an
epidural? I imagine that completely numbs the
Ferguson reflux, doesn't it? It absolutely can.
A dense regional anesthetic might leave the client
completely numb from the waist down. You check
their cervix and they are 10 centimeters, but
they feel absolutely zero pressure. They have
no urge to push. So I'm confused. If the cervix
is fully open, what is the actual harm in forcing
them to push? Even if the baby is high up at
a minus two station, wouldn't bearing down just
manually force the baby down faster? It is incredibly
harmful. If you demand that a client actively
push when the fetus is still high up in the pelvic
canal, you are demanding an immense agonizing
expenditure of energy for almost zero movement.
Because the baby still has so far to go. Exactly.
Pushing is an athletic event. If you force them
to push prematurely, they will suffer severe
maternal exhaustion. By the time the baby actually
gets low enough to require a massive push to
crown, the mother will have nothing left in the
tank. And what happens to the tissue? This is
the critical safety issue. If you force pushing
before the cervix is genuinely 100 % effaced
and retracted out of the way, the immense force
of the fetal head grinding against the remaining
lip of the cervix causes severe trauma. Oh, that
sounds bad. It is. That cervical tissue will
bruise, swell massively, and can even result
in cervical prolapse, where the swollen, bleeding
cervix pushes outside the vagina. It also causes
horrific fetal head compression, which leads
to immediate fetal distress. So the expected
safe practice is something completely different
than what we see on TV. The gold standard expected
practice is called laboring down, or passive
fetal descent. If a client is 10 centimeters
dilated but the baby is high or the urge is absent,
we do absolutely nothing but wait. You just let
them rest at 10 centimeters. For how long? For
up to two hours. We allow the natural involuntary
contractions of the uterus to slowly, gently
act like an elevator, bringing the baby down
through the pelvis over the course of one to
two hours. That is wild. Up to two hours of just
waiting. Yes. It conserves maternal energy. drastically
decreases the incidence of severe perineal tears,
and significantly reduces the need for the doctor
to intervene with forceps or vacuums. So the
concerning finding the red flag intervention
is the nurse cheering like a football coach and
forcing active pushing before the physiology
is actually ready. Yes, do not be the cheerleader
for premature pushing. But during those two hours
of laboring down, or once active pushing finally
begins, the nurse isn't just kicking back right,
we are constantly monitoring. Frequent fetal
monitoring during the second stage is paramount.
The contractions are getting stronger, which
means the placenta is getting squeezed tighter.
This restricts blood flow to the baby with every
single contraction. So how often are we checking
the heart rate? If you are using intermittent
monitoring, you must assess the fetal heart rate
every 15 minutes during that passive laboring
down phase. Yeah. Once the client begins active
pushing, you are assessing that heart rate every
five to 15 minutes. And what if we are dealing
with a medical induction? What if they are on
a continuous oxytocin drip? The stakes immediately
skyrocket. Yeah. If synthetic oxytocin like pedosin
is running, you must assess the fetal heart rate
every five minutes during active pushing. No
exceptions. Every five minutes, that's intense.
Why so frequent? Because oxytocin stimulates
incredibly powerful, smooth muscle contractions.
High doses can cause tachycystally. That's when
the uterus contracts too frequently, more than
five contractions in 10 minutes, or the contractions
last too long without a resting tone. And if
the uterus never relaxes? The placenta never
refills with oxygenated blood. You will cause
severe fetal hypoxia. Which brings us to another
massive exam trap regarding the actual technique
of pushing. We briefly touched on the movie myth
of holding your breath and pushing until your
face turns purple. Why exactly is that so dangerous?
That movie method is medically known as closed
glottis pushing, or the Valsalva maneuver. The
patient takes a deep breath, forcefully slams
their glottis shut, and bears down as hard as
they can for 10 seconds. Right, like they're
lifting a heavy weight. Physiologically, this
is a disaster. When you hold your breath and
strain that intensely, you drastically spike
the intra -thoracic pressure inside your chest
cavity. And if the pressure in the chest is too
high, blood from the body can't fight its way
back into the heart. Exactly. Venous return plummets.
Cardiac output drops. Maternal blood pressure
bottoms out. And the moment maternal cardiac
output drops... The profusion of blood to the
placenta plummets. So not only is the mother
exhausting herself and popping blood vessels
in her eyes, but she is actively depriving the
fetus of oxygen right at the most critical moment
of descent. Exactly. So the alternative is open
glottis pushing. Explain open glottis pushing
for us. Open glottis pushing is spontaneous,
physiological pushing. The client breathes deeply,
and when they feel the peak of the urge, they
bear down while exhaling. They might grunt, moan,
or literally breathe out through the push. They
do not hold their breath. And the outcomes are
measurably better. Massly superior. Open glottis
pushing decreases the total duration of the second
stage. It lessens maternal fatigue because the
muscles are continually oxygenated. That makes
total sense. It prevents those sudden, dangerous
drops in fetal heart rate, which yields much
higher Apgar scores for the newborn. And because
the stretching is more gradual, it decreases
severe perineal lacerations. To remember this,
keep it incredibly simple for the exam. Don't
hold your breath to have a baby keep the glottis
open. It sounds so obvious, but it completely
contradicts decades of bad medical television.
It really does. And just to tie up perineal trauma
routine, episiotomies are a thing of the past.
Cutting the perineum prophylactically is no longer
the standard of care. So what's the expected
intervention then? To prevent trauma as the fetal
head crowns, the expected priority nursing interventions
are perineal massage and applying warm compresses
to the tissue to help it stretch naturally. OK,
the tissue stretches, the head crowns, the shoulders
pass, and the baby is born. The second stage
is officially complete. You hear that first cry
and the relief in the room is palpable. Everyone
is so happy. Everyone is taking photos, looking
at the newborn. But from a clinical nursing perspective,
you're The maternal alarm bell should actually
be ringing louder than ever because medically
the danger to the mother is peaking at this exact
second. This is the transition into the third
stage of labor. And this is where SHRP clinical
judgment prevents maternal death. The third stage
begins the moment the newborn is delivered and
ends the moment the placenta is expelled. It's
a really short window, right? Terrifyingly short.
It typically lasts only five to 30 minutes. Why
is this specific window so incredibly dangerous?
Because of the anatomy of the uterus. When the
placenta is attached to the uterine wall during
pregnancy, it is fed by a massive network of
high flow spiral arteries. Okay, visualizing
that. The moment the placenta detaches, it leaves
behind a wound the size of a dinner plate inside
the uterus with dozens of open pumping blood
vessels. Wow, a dinner plate. If the uterine
muscle does not immediately and violently cramp
down to physically pinch those vessels shut,
the mother can lose a catastrophic amount of
blood in a matter of minutes. Yes, postpartum
hemorrhage or PPH is one of the leading causes
of maternal mortality worldwide. So what are
we looking for? How do we know the placenta is
actually detaching safely? You are watching for
the three classic expected signs of placental
separation. This is very testable. First, you'll
see a sudden gush or surge of dark blood from
the vagina as the placenta pulls away. Okay,
a gush of blood. Second, the umbilical cord protruding
from the vagina will visibly lengthen. And third,
if you look at the maternal abdomen, the fundus,
the top of the uterus, will change from a flat
discoid shape to a firm globular shape as it
rises upward in the abdomen. Cushive blood, long
cord, globular fundus. Got it. Let's talk about
the umbilical cord for a second, because before
the placenta comes out, we have to cut the cord.
Is that done immediately? No. The expected evidence
-based practice is delayed cord clamping. We
intentionally wait 30 to 60 seconds after the
baby is born before clamping and cutting the
cord. Why wait? Because in those first 60 seconds
the placenta is still actively pulsing transfusing
a massive amount of blood up to a third of the
newborn's total blood volume into the baby. A
third of their blood volume. Yes. This physiological
boost significantly increases the newborn's hemoglobin
levels, builds up their iron stores for the first
several months of life, and is linked to improved
cognitive and motor development. What is the
concerning finding that would force a nurse to
skip that weight and clamp immediately? Because
there are always exceptions on the NCLEX. You
only perform immediate cord clamping if the newborn
is severely compromised, meaning they are not
breathing, they are floppy, and they require
urgent, immediate neonatal resuscitation away
from the mother. Otherwise, you delay. OK, the
cord is cut. The placenta is expelled. What is
the absolute priority nursing action to stop
the bleeding from those open spiral arteries?
We don't just cross our fingers and hope the
uterus cramps down on its own, right? No, we
aggressively intervene. This is called active
management of the third stage of labor, or AMTSL.
And the cornerstone of AMTSL is immediately administering
uterotonic medications. Uterotonics? Yes. Utero
referring to the uterus and tonic referring to
tone. These are incredibly powerful pharmacological
agents that force the smooth muscle of the uterus
to contract violently, clamping those bleeding
vessels shut. Grab a pen, everyone listening,
because this is where the pharmacology gets heavily
tested. Nursing instructors absolutely love testing
uterotonic contraindications. Because giving
the wrong drug to the wrong patient here doesn't
just fail to stop the bleeding, it actively causes
a secondary life -threatening emergency. It really
does. Let's break down the big four uterotonics.
You must know these inside and out. First is
oxytocin or pitocin. This is the universal first
-line recommendation for postpartum hemorrhage
prophylaxis. Think of uterotonics like bouncers
clearing out a rowdy violent nightclub. The nightclub
is the bleeding uterus and the bouncers are kicking
the blood and the placenta out to shut the club
down. They all get the job done. But they have
very different styles. Oxytocin is your standard
reliable head bouncer. Exactly. For the third
stage of labor, giving oxytocin intramuscularly,
or via a slow IV push, has the highest efficacy
with the lowest severe side effects. But exams
will set a trap here regarding the side effects
of prolonged use. What's the trap? Oxytocin has
a severe antidiuretic effect. If a patient is
hemorrhaging and you run massive IV doses of
oxytocin over a long period, their kidneys stop
excreting urine. Oh, they hold on to water. They
retain fluid to a dangerous degree, which can
lead to water intoxication, cerebral edema, coma,
and even fatal seizures. So oxytocin is reliable,
but you have to watch out for fluid overload.
What about the second bouncer, methylurganafine?
also known as methylgene or ergot. Methylurganavine
is the hyperaggressive bouncer. It forces a sustained
tannic contraction of the uterus, which stops
bleeding brilliantly, but it achieves this by
causing intense systemic vasoconstriction. Systemic.
As in everywhere? Everywhere. It clamps down
blood vessels everywhere in the body. So if a
patient already has high blood pressure and you
give them a drug that aggressively constricts
all their blood vessels. You will cause a catastrophic
hypertensive crisis. The absolute never do it
contraindication that you'll see on the NCLEX.
Never give methylurganavine to a patient with
chronic hypertension, preeclampsia, or cardiovascular
disease. You'll cause a stroke, palpitations,
or deadly arrhythmias. Okay, so methylarganavine
wrecks the blood pressure. No methyl gene for
high BP. What about the third bouncer? Carboprost,
also known as hemidate. It's a synthetic prostaglandin.
Carboprost is highly effective, but it severely
irritates smooth muscle outside the uterus as
well, specifically in the respiratory tract.
It causes severe bronchospasm. Oh, asthma! Yes.
The absolute contraindication trap here is, never
give carbaprost to a patient with a history of
pulmonary issues, specifically asthma. If an
exam scenario describes a laboring client with
asthma who is hemorrhaging, carbaprost is a lethal
choice. It will shut their airway down. Wow.
It is also contraindicated in patients with hepatic
or renal disease. Let me summarize that. Methyl
argonamine equals NO for high blood pressure.
Carbaprost equals NO for asthma. Spot on. And
the fourth common uteratonic is mesoprostal,
or cytotech. This is also a prostaglandin. It
is cheap, shelf -stable, and can be given orally,
subliminally, or rectally, making it incredibly
versatile. What's the catch with misoprostol?
There's always a catch. The side effect profile.
Because it's a prostaglandin, it causes intense
gastrointestinal upset. We are talking about
severe shivering, fever, abdominal pain, nausea,
and explosive diarrhea. Having explosive diarrhea
moments after delivering a baby sounds like an
absolute nightmare, but it is infinitely better
than bleeding to death. Exactly. It is a highly
effective bouncer, but it leaves a mess. To survive
the pharmacology section of your exam, simply
remember the contraindications. High blood pressure
means no methyl -argonamine. Bad lungs mean no
carboprost. While one nurse is hyper -focused
on the mother, aggressively managing the third
stage, monitoring the bleeding, and pushing those
uteratomics, there is an entirely different drama
unfolding two feet away. The baby. Another nurse
is entirely focused on the newly arrived passenger.
This brings us to the golden hour, the critical
transition of the newborn. The transition from
intrader in life to extradorn life is the most
precarious physiological leap a human being ever
makes. It's crazy to think about. For nine months,
this baby has lived in a warm, dark, wet environment,
floating in amniotic fluid, getting 100 % of
its oxygen passively from the placenta without
ever having to take a single breath. And a boom.
Suddenly, they are thrust into a cold, bright
room. They have to inflate fluid -filled lungs,
breathe room air, regulate their own core temperature,
and completely reroute their cardiovascular system
as the umbilical cord is clamped. The high -yield
core metric for this transition is the Apgar
score. It is the most famous medical assessment
in the world. And you must know precisely how
to calculate it. The ATGAR score is performed
strictly at one minute and five minutes after
birth. Why are there specific times? The one
minute score is a snapshot of how well the baby
tolerated the physical trauma of the birthing
process itself. The five minute score tells you
how well the baby is neurologically transitioning
to extruder in life and how effectively they're
responding to any resuscitation efforts. And
if the score is low? If the score is less than
seven, at the five minute mark, You must continue
scoring every five minutes until 20 minutes post
-birth. Let's break down the categories. It's
conveniently an acronym. A, appearance, which
assesses skin color. P, pulse, which assesses
heart rate. G, grimace, which assesses reflex
irritability in response to stimulation. A, activity,
which assesses muscle tone. R, respiration. which
assesses breathing effort. And each is scored
0 to 2. Right. Each category is scored as a 0,
1, or 2. So a perfect, robust baby scores a 10.
I want to look closely at expected versus concerning
findings here, especially for appearance. If
I looked at a newborn and their hands and feet
were entirely blue, my instinct would be to panic.
Which is exactly why exams test this. An expected
totally normal finding in a newborn is called
acrocyanosis. This means the newborn has a pink,
well -oxygenated core body, but their hands and
feet remain somewhat blue. So blue hands are
normal? Yes. This is a benign result of peripheral
vasoconstriction, as their tiny circulatory system
adjusts to pumping blood against gravity in the
cold air. Because of expected acrocyanosis, almost
every healthy baby scores a 1 for color, making
an Avgar of 8 or 9 completely normal and expected.
So blue hands and feet are fine. What is concerning?
Central cyanosis. If the baby's central chest,
lips, face, or mucus membranes are blue, that
is a score of zero. That indicates systemic hypoxia
and is a massive immediate red flag requiring
oxygenation. What about the heart rate and respiratory
parameters? A newborn heart beats incredibly
fast. The expected normal heart rate is 110 to
160 beats per minute. That earns a score of two.
If it drops below 100, that's a one. Absent is
zero. And breathing? For respirations, we want
40 to 60 breaths per minute accompanied by a
strong, vigorous, angry cry. That earns a two.
And what concerning respiratory signs should
a nurse immediately intervene for? You are looking
for signs that the newborn is fighting for air,
nasal flaring with every breath, an audible grunt
on exhalation, and chest retractions where the
skin aggressively sucks inward around the ribs
and sternum. These indicate severe respiratory
distress. So the timer hits one minute. What
are we physically doing to the baby before we
even calculate that score? The absolute first
priority actions are to dry the baby vigorously
with warm towels, stimulate them by rubbing their
back or flicking the soles of their feet, clear
their airway of any mucus, and immediately place
them skin -to -skin on the mother's bare chest.
And once they are stable on the chest, we have
two mandatory pharmacological interventions.
The eye goop and the shot. Yes. Erythromycin
ophthalmic ointment. and the vitamin K injection.
Exams will always ask you for the rationale behind
these medications. Let's start with the eyes.
Why are we smearing antibiotic ointment into
a newborn's eyes? We use erythromycin 0 .5 %
ointment to prevent a condition called ophthalmia
neonitorum. When a baity descends through the
vaginal canal, they are exposed to the mother's
natural flora, but they are also exposed to undiagnosed
sexually transmitted infections. Like gonorrhea
and chlamydia. Exactly. Neisseria gonorrhea and
chlamydia trachymitis. If those specific bacteria
infect the newborn's eyes, the resulting infection
is so aggressive it can cause permanent blindness
within days. The ointment is a mandatory preventative
prophylaxis. That makes perfect sense. Now, let's
pause on the vitamin K. Why does a baby need
a shot of vitamins immediately upon entering
the world? Like, what's the urgency? Because
it isn't just a nutritional vitamin. It is a
critical life -saving clotting necessity. Phytonidione,
or vitamin K, is required by the human liver
to synthesize clotting factors 2, 7, I, X, and
X. OK. Here is the fascinating physiological
quirk. Humans do not produce vitamin K on our
own. It is synthesized by the bacterial flora
living in our gut. But when a newborn is delivered,
their gastrointestinal tract is completely 100
% sterile. Because they've never eaten anything.
Right. They have no gut bacteria. Therefore,
they cannot produce vitamin K, which means they
cannot produce clotting factors. So every baby
is born with a massive bleeding disorder. Exactly.
They are at extreme risk for a condition called
vitamin K deficiency bleeding. Without intervention,
a minor bump could cause a spontaneous, fatal
intracranial hemorrhage. Wow. You must give them
an intramuscular injection of vitamin K into
the vastus lateralis muscle of the thigh within
the first hour of life to bridge the gap until
their gut bacteria develops from feeding. That
physiology is wild and it makes it very easy
to understand why it's a priority. Now you mentioned
earlier that the very first thing we do is dry
the baby vigorously with warm towels. Let's dig
into newborn thermoregulation because I know
this is a massive NCLEX trap. Thermoregulation
is arguably the most tested newborn concept.
Newborns are terrible at keeping themselves warm.
They have a massive body surface area relative
to their body mass, a very thin epidermal layer,
and almost zero subcutaneous insulating fat.
So they just lose heat instantly. Incredibly
rapidly. And they cannot shiver to generate warmth.
Instead, they burn specialized brown fat, which
rapidly depletes their blood sugar, leading to
life -threatening hypoglycemia. So keeping them
warm literally keeps their blood sugar stable.
The exam trap here usually involves identifying
the four specific mechanisms of heat loss. They
will give you a scenario and ask which type of
heat loss is occurring. Let's break down the
four mechanisms so you never miss these questions.
Number one, evaporation. This is heat lost when
liquid moisture on the skin turns into a vapor,
taking body heat with it. Give me a scenario
for evaporation. The classic trap scenario. A
baby is born covered in warm amniotic fluid,
and the nurse leaves them red on the warmer,
or the nurse gives the baby their first bath
and doesn't dry them quickly enough. And the
fix is just to dry them? Yes. Vigorously dry
the baby immediately with warm blankets. Wet
is evaporation. What's the second? Number two,
conduction. This is heat lost through direct
physical contact with a cold or solid surface.
Heat transfers from the warm baby to the cold
object. Okay, scenario for conduction. A nurse
places a bare newborn directly onto a cold metal
weighing scale or assesses their heart with a
freezing cold stethoscope. The fix is to always
place a warm blanket or paper pad on the scale
first and warm your hands and instruments. Touch
is conduction. Number three. Number three. Convection.
This is heat lost to cooler ambient air currents
actively moving across the body, stripping away
the heat envelope. It's like a fan. Right. The
trap scenario. The baby is placed under an air
conditioning vent near an open window, or people
are rapidly walking past the bassinet creating
a draft. The fix. Keep the baby away from drafts
and maintain a warm ambient room temperature.
Drafts are convection. And the last one. Number
four. Radiation. This one is tricky. This is
heat lost to a colder solid surface that the
baby is not physically touching but is in close
proximity to. Heat radiates through the air toward
the cold object. Proximity. Okay, what's the
scenario? The baby's crib is placed right next
to a cold, uninsulated exterior window in the
middle of winter, even though the room air is
warm. The fix. Move bassinets away from cold
exterior walls or windows. Okay, to cement that
into your brain, what is evaporation? Touch is
conduction. Drafts are convection. Proximity
is radiation. Memorize those scenarios because
they appear on almost every OB exam. All right.
The baby is stable, dry, and resting on the mother's
chest. The bleeding is temporarily controlled.
We are now entering the final phase of our deep
dive, the fourth stage of labor focusing on maternal
recovery. We are in that critical one to two
hour post -birth window. The fourth stage is
defined by one primary nursing objective. aggressive,
continuous surveillance for postpartum hemorrhage.
The danger does not end when the placenta delivers.
Because the uterus can still relax. Exactly.
The uterus must maintain its contracted state.
To ensure this, you are constantly assessing
three interdependent things. The fundus, the
bladder, and the lochia. Let's start with the
fundus. We touched on this earlier, but what
is the fundus actually doing during this recovery
phase? The fundus is the rounded, thickest, top
portion of the uterine muscle. Now that it is
empty, it must undergo a process called involution.
It has a forcefully contract, shrinking down
into a tight, hard ball in the pelvis to keep
those placental blood vessels clamped shut. And
if it doesn't? If the muscle gets exhausted and
relaxes, if it loses its tone, that is called
uterine anthony. The vessels pop open and the
mother will silently hemorrhage. So when a nurse
presses deeply into a postpartum patient's abdomen,
what are the expected reassuring findings? The
expected finding is that the fundus feels incredibly
firm, almost like a hard grapefruit beneath the
skin. Location -wise, it must be perfectly midline
in the abdomen, located somewhere between the
umbilicus, the belly button, and the symphysis
pubis bone. Where is it usually right after birth?
In the immediate hours after birth, it is usually
right at or slightly below the level of the umbilicus.
Yeah. Expected progress is that it drops about
one finger width or one centimeter lower into
the pelvis every single day. And the lochia.
the expected vaginal bleeding. Expected is lochirubra,
which is dark or bright red blood. It should
be a moderate amount, perhaps soaking one pad
every two to three hours. And this stage of lochia
typically lasts for the first three to four days
before transitioning to a lighter color. Now,
what are the concerning findings, the red flags
that require immediate intervention? First and
foremost, a boggy fundus. If you press into the
abdomen and the uterus feels soft, mushy or spongy
like dough, it means the muscle has relaxed.
Uterine ethyny. The vessels are open and bleeding.
If I walk into a room, assess the patient, and
feel a mushy, boggy fundus, my immediate instinct
is to hit the call light and yell for the doctor.
Is that the right move? No. And if you choose
that on an exam, you will fail the question.
Your absolute immediate priority nursing action
for a body fundus is to massage it. Don't leave
the room. You do not leave the patient. You do
not wait for orders. You place one hand firmly
just above the pubic bone to support the lower
uterine segment. This prevents you from accidentally
pushing the uterus inside out and prolapsing
it. And you use your dominant hand to deeply
forcefully massage the top of the fundus in a
circular motion. The physical mechanical stimulation
forces the muscle fibers to wake up and contract.
Massage is the immediate fix for a boggy fundus.
But what if I assess the abdomen and the fundus
feels perfectly firm but it's way up high and
pushed all the way over to the right side of
the belly? A displaced fundus is the second major
concerning finding and it introduces a massive
NCLEX trap. Why is it pushed to the side? Because
of the bladder. I think of it this way. The contracting
uterus is like a tightly clenched fist, acting
as pressure to stop a severe bloody nose. But
anatomically, the maternal bladder sits right
underneath and slightly in front of the lower
uterus. Exactly. During labor, IV fluids are
pumping and the mother can't usually feel when
her bladder is full. So that bladder fills up
with urine and expands like a massive water balloon.
Yes. And because the bladder is fixed to the
pelvic floor, as it expands upward, it physically
pushes the entire uterus up and shoves it over
to the side. Usually the right side. And when
that fist is being stretched and balanced precariously
over a giant water balloon, it can't clench properly.
The pressure is lost and the bleeding from the
placental site resumes. That is precisely the
mechanism. And here is the trap, which is the
number one missed concept by nursing students.
The exam will give you this scenario. The nurse
assesses a postpartum client and notes a firm
fundus displaced to the right, slightly above
the umbilicus, with moderate to heavy lochia.
What is the priority intervention? Students choose
massage the fundus because they've been drilled
that bleeding means massage. Exactly. But read
the serial. The fundus is already firm. Massaging
a firm displaced fundus does nothing but cause
severe pain. The uterus doesn't need massage.
It needs anatomical room to sit back down deep
into the pelvis so it can do its job. So what's
the intervention? Your priority intervention
is to empty the bladder. You assist the client
to the bathroom, or if they have an epidural
and cannot walk, you perform a straight catheterization
to drain the urine. The moment the bladder empties,
the uterus drops back to midline and the bleeding
stops. drain the bladder. It's a critical distinction.
Now the third concerning finding you mentioned
earlier was lochia exceeding 1 ,000 milliliters.
How are we accurately measuring that? Because
looking at a soaked pad and guessing seems incredibly
subjective and dangerous. Visual estimation is
notoriously dangerously inaccurate. A nurse might
look at a pad and guess 200 milliliters, when
in reality it's 600 milliliters. The absolute
gold standard priority action is QBL, quantitative
blood loss. How does QBL actually work? You meticulously
weigh everything. You take every single blood
-soaked pad, chuck or sponge, and you weigh them
on a gram scale. You then subtract the known
dry weight of those items. So you need to know
the dry weight beforehand. Yes. The medical conversion
you must memorize is exactly one to one. One
gram of measured weight equals exactly one milliliter
of blood loss. One gram equals one ml. If that
calculated number crosses 1 ,000 milliliters,
regardless of whether it's a vaginal birth or
a cesarean, you are officially diagnosing a postpartum
hemorrhage and initiating emergency protocol.
It takes the guesswork completely out of the
equation. And it saves lives by catching hemorrhages
before the mother ever shows signs of hypovolemic
shock, like a dropping blood pressure or a spiking
heart rate. Because their vital signs compensate
for a long time, right? Exactly. By the time
a young, healthy pregnant woman shows vital sign
changes from blood loss, she has already lost
a catastrophic amount of blood. QBL catches it
early. And just like that, we have navigated
an incredible clinical journey. We started with
the physical space of the contracting pelvis,
worked through the physiological requirements
for safe pushing, managed the precarious pharmacology
of the third stage, protected the fragile transition
of the newborn, and locked down the recovery
of the postpartum uterus. It is an immense amount
of material, but notice how it all connects.
It's all rooted in the physiological why. Exactly.
And I want to emphasize to you, the listener,
the sheer value of thinking this way. Leaning
into this level of clinical detail isn't just
an academic exercise to help you guess the right
multiple -choice letter on an exam. No, not at
all. When you truly understand the cascade of
aortic oval compression, or why forcing a push
against an unready cervix causes trauma, or exactly
why you are massaging that specific fundus instead
of running for help, you are building the mental
reflexes of an elite nurse. You aren't just going
to pass a test. You are going to literally save
lives on the floor. You absolutely will and as
we conclude this deep dive. I want to leave you
with one final broader perspective to reflect
on well I like this go ahead Throughout all of
these complex labor stages, we rely so heavily
on advanced pharmacology, quantitative measurements,
and continuous monitoring. But think about the
sheer undeniable power of simple skin -to -skin
contact during that golden hour. It's easy to
overlook because it isn't a drug or a machine.
Exactly. We have millions of dollars of advanced
medical technology packed into a single labor
and delivery room. We have specialized radiant
warmers, complex neonatal cardiac monitors, and
synthesized oxytocin drips. Yet... simply placing
a bare, wet newborn directly onto their mother's
bare chest regulates that infant's body temperature
more efficiently than our most expensive warming
beds. It physically stabilizes their erratic
newborn breathing. It prevents their blood sugar
from crashing. And it helps the mother, too.
Miraculously. The sensation of the infant on
the chest triggers the mother's brain to release
massive waves of natural endogenous oxytocin,
which violently clamps down her uterus and saves
her from bleeding to death. In a medical world
that is completely obsessed with expensive high
-tech interventions, isn't it absolutely fascinating
that the most powerful multi -system life -saving
tool in the entire hospital is entirely biological
and completely free?