WEBVTT 00:00:07.880 --> 00:00:10.759 You're in the bay. Once you get over to the bed, 00:00:10.919 --> 00:00:13.560 we'll give you the story. Everything's going 00:00:13.560 --> 00:00:17.339 to happen super fast. Welcome to the emergency 00:00:17.339 --> 00:00:44.960 room. What if I told you that doing exactly what 00:00:44.960 --> 00:00:47.380 you see in the movies is actually dangerous. 00:00:47.899 --> 00:00:49.880 I mean, a pregnant woman laying completely flat 00:00:49.880 --> 00:00:52.539 on her back, holding her breath and pushing with 00:00:52.539 --> 00:00:54.700 all her might while a room full of people yells 00:00:54.700 --> 00:00:57.520 at her to count to 10. It's actually the absolute 00:00:57.520 --> 00:01:01.100 worst, most physiologically dangerous way to 00:01:01.100 --> 00:01:04.200 deliver a baby. It really is. It's the great 00:01:04.200 --> 00:01:06.959 Hollywood medical myth. If you walk into a labor 00:01:06.959 --> 00:01:09.120 and delivery unit expecting it to look like a 00:01:09.120 --> 00:01:12.120 sitcom finale, you are going to be completely 00:01:12.680 --> 00:01:14.400 unprepared. Right. And honestly, if you're a 00:01:14.400 --> 00:01:16.159 nursing student walking into your obstetrics 00:01:16.159 --> 00:01:18.579 exam with those movie images in your head, you're 00:01:18.579 --> 00:01:21.040 going to fail. Which brings us to the exact reason 00:01:21.040 --> 00:01:22.939 we're doing this today. This is not just some 00:01:22.939 --> 00:01:26.340 casual overview of maternal health. We are shifting 00:01:26.340 --> 00:01:29.459 gears entirely for you. Exactly. Today's deep 00:01:29.459 --> 00:01:32.980 dive is an elite, highly specialized obstetric 00:01:32.980 --> 00:01:35.640 nursing exam prep and clinical coaching session. 00:01:36.079 --> 00:01:38.459 The mission here is to take you inside the minds 00:01:38.459 --> 00:01:40.920 of the safest, most effective labor and delivery 00:01:40.920 --> 00:01:42.829 nurses on the floor. We're going to break down 00:01:42.829 --> 00:01:45.510 how they think. you know how they prioritize 00:01:45.510 --> 00:01:49.170 and how you can use those exact same mental frameworks 00:01:49.170 --> 00:01:52.670 to not only crush your nursing exams but to actually 00:01:52.670 --> 00:01:56.150 save lives when you are the one standing at the 00:01:56.150 --> 00:01:59.010 bedside. Yeah and to do that we have to completely 00:01:59.010 --> 00:02:01.650 change the way we approach studying. Like you 00:02:01.650 --> 00:02:04.609 can't just memorize everything. No you can't. 00:02:04.609 --> 00:02:06.969 We are aggressively applying the Pareto principle 00:02:06.969 --> 00:02:09.090 here. Yeah. I am not going to sit here and read 00:02:09.090 --> 00:02:11.270 an OB textbook to you from cover to cover. Thank 00:02:11.270 --> 00:02:13.310 goodness for that. Right. Trying to memorize 00:02:13.319 --> 00:02:17.180 every single obscure fact equally is exactly 00:02:17.180 --> 00:02:19.439 how nursing students get overwhelmed. And more 00:02:19.439 --> 00:02:21.659 importantly, it is how they miss the critical 00:02:21.659 --> 00:02:23.879 safety alerts when the pressure is really on. 00:02:24.419 --> 00:02:26.599 So we're sifting out the high yield stuff? Yes. 00:02:26.900 --> 00:02:29.240 The 20 % of high yield concepts, the classic 00:02:29.240 --> 00:02:32.120 NCLEX traps, and the safety critical facts that 00:02:32.120 --> 00:02:33.979 are going to provide 80 % of your exam value. 00:02:34.600 --> 00:02:37.020 Clinical judgment isn't about memorizing random 00:02:37.020 --> 00:02:39.159 disconnected bullet points. It's about spotting 00:02:39.159 --> 00:02:41.939 patterns. Okay, let's unpack this. Because I 00:02:41.939 --> 00:02:44.180 remember when I was prepping for exams, I just 00:02:44.180 --> 00:02:46.280 relied on flashcards. It worked for history, 00:02:46.419 --> 00:02:48.300 right? You memorize the date of a battle, you 00:02:48.300 --> 00:02:50.840 write it down, and it's a static fact. But if 00:02:50.840 --> 00:02:53.949 Stetrix feels... incredibly dynamic. It really 00:02:53.949 --> 00:02:56.090 does. You could have two laboring patients with 00:02:56.090 --> 00:02:59.289 the exact same vital signs, the exact same dilation, 00:02:59.289 --> 00:03:01.590 and their priority nursing interventions might 00:03:01.590 --> 00:03:04.810 be like polar opposites. That is the literal 00:03:04.810 --> 00:03:07.349 definition of clinical judgment in muddy waters. 00:03:07.810 --> 00:03:09.789 You constantly have at least two lives in your 00:03:09.789 --> 00:03:12.949 hands, sometimes more. Wow, yeah. And the correct 00:03:12.949 --> 00:03:15.310 intervention depends entirely on understanding 00:03:15.310 --> 00:03:18.610 the specific phase of labor, the fetal presentation, 00:03:18.889 --> 00:03:21.719 and the underlying physiology of that exact second. 00:03:21.840 --> 00:03:23.960 So as we go through this material we're going 00:03:23.960 --> 00:03:26.319 to constantly separate what is expected from 00:03:26.319 --> 00:03:28.139 what is concerning. Exactly and we are going 00:03:28.139 --> 00:03:31.159 to focus heavily on the why behind every single 00:03:31.159 --> 00:03:33.340 priority nursing action. So let's set the scene 00:03:33.340 --> 00:03:36.300 for you. We have a patient rolling into triage. 00:03:36.419 --> 00:03:39.000 They're contracting. Before we even get to the 00:03:39.000 --> 00:03:41.280 dramatic moments of birth we have to lay down 00:03:41.280 --> 00:03:43.139 the mechanical and environmental foundations 00:03:43.139 --> 00:03:46.000 of labor. Because if the foundation is flawed, 00:03:46.560 --> 00:03:49.979 the entire process just stalls. The timeline 00:03:49.979 --> 00:03:52.860 of labor is broken down into very specific stages. 00:03:53.400 --> 00:03:55.520 You absolutely must know the hard boundaries 00:03:55.520 --> 00:03:57.960 of each one. OK, so the first stage. The first 00:03:57.960 --> 00:04:00.219 stage of labor officially begins with the onset 00:04:00.219 --> 00:04:04.099 of regular rhythmic uterine contractions that 00:04:04.099 --> 00:04:07.300 actually cause cervical change. That means effacement 00:04:07.300 --> 00:04:09.860 and dilation. Right, so it doesn't count if the 00:04:09.860 --> 00:04:12.060 cervix isn't actually changing. Exactly. False 00:04:12.060 --> 00:04:14.479 labor doesn't change the cervix. And that first 00:04:14.479 --> 00:04:17.759 stage ends the absolute moment the client is 00:04:17.759 --> 00:04:20.439 completely dilated to 10 centimeters. So 0 to 00:04:20.439 --> 00:04:22.980 10 centimeters is the first stage. But it's not 00:04:22.980 --> 00:04:25.019 just about waiting for a number on a chart, right? 00:04:25.180 --> 00:04:27.680 The exam focus is usually on the mechanics of 00:04:27.680 --> 00:04:29.860 how that happens. Yes, the textbook refers to 00:04:29.860 --> 00:04:32.579 this as the five P's of labor. You've got passenger, 00:04:33.040 --> 00:04:35.300 passageway, powers, position, and psychological 00:04:35.300 --> 00:04:37.139 response. Let's break those down really quickly. 00:04:37.199 --> 00:04:39.480 The passenger is obviously the baby. Right, the 00:04:39.480 --> 00:04:41.639 fetus. The passageway is the maternal pelvis 00:04:41.639 --> 00:04:44.019 and soft tissues. The powers are the uterine 00:04:44.019 --> 00:04:46.339 contractions. But the most highly tested element, 00:04:46.339 --> 00:04:49.939 I think, is position. It absolutely is. Because 00:04:49.939 --> 00:04:52.139 it's the one nurses have the most direct control 00:04:52.139 --> 00:04:55.360 over. Specifically, how maternal positioning 00:04:55.360 --> 00:04:58.399 drastically alters the physical dimensions of 00:04:58.399 --> 00:05:00.420 that passageway. This goes right back to our 00:05:00.420 --> 00:05:03.329 movie myth. If laying flat on your back in a 00:05:03.329 --> 00:05:05.449 hospital bed is so bad, why does positioning 00:05:05.449 --> 00:05:08.310 actually matter so much? It comes down to basic 00:05:08.310 --> 00:05:11.370 physics, really. Gravity and mobility. When a 00:05:11.370 --> 00:05:13.850 laboring client is in an upright position standing, 00:05:14.350 --> 00:05:17.389 sitting on a birthing ball, kneeling or squatting, 00:05:17.589 --> 00:05:19.790 gravity is physically pulling the fetal head 00:05:19.790 --> 00:05:21.970 down against the cervix. And that pressure helps 00:05:21.970 --> 00:05:25.649 the cervix dilate faster. Yes. But more importantly, 00:05:26.029 --> 00:05:28.509 the bones of the maternal pelvis are not fused 00:05:28.509 --> 00:05:30.709 rigidly together. they have slight mobility. 00:05:30.910 --> 00:05:32.730 Oh, that's right. The relaxant hormone loosens 00:05:32.730 --> 00:05:34.689 the joints. Exactly. So when a client gets off 00:05:34.689 --> 00:05:36.870 their back and moves into an upright or squatting 00:05:36.870 --> 00:05:39.589 position, the pelvic outlet actually increases 00:05:39.589 --> 00:05:42.730 in dimension. You are physically creating a wider 00:05:42.730 --> 00:05:45.389 anatomical space for the fetus to navigate. So 00:05:45.389 --> 00:05:47.649 by standing or squatting, the patient is quite 00:05:47.649 --> 00:05:50.709 literally widening the exit door while simultaneously 00:05:50.709 --> 00:05:53.889 using gravity to push the baby toward it. Precisely. 00:05:54.310 --> 00:05:56.990 And the clinical outcomes completely reflect 00:05:56.990 --> 00:06:00.170 this. Upright positions are proven to decrease 00:06:00.170 --> 00:06:02.850 maternal pain because the client feels more in 00:06:02.850 --> 00:06:04.949 control of their body. Which makes sense. And 00:06:04.949 --> 00:06:07.029 evidence shows it can shorten the active pushing 00:06:07.029 --> 00:06:09.870 phase by anywhere from 3 to 10 minutes. Wow. 00:06:10.220 --> 00:06:13.060 When you're exhausted and pushing with everything 00:06:13.060 --> 00:06:15.819 you have, shaving 10 minutes off that process 00:06:15.819 --> 00:06:19.759 is a massive victory. It's huge. But if upright 00:06:19.759 --> 00:06:22.319 positions are the expected beneficial standard, 00:06:22.519 --> 00:06:25.040 we need to clearly define the concerning positions 00:06:25.040 --> 00:06:28.180 for you. The red flags that exams love to test. 00:06:28.279 --> 00:06:30.800 Right. The two most concerning positions are 00:06:30.800 --> 00:06:33.300 the strictly supine position, lying completely 00:06:33.300 --> 00:06:35.720 flat on the back, and the lithotomy position. 00:06:35.959 --> 00:06:38.259 Lithotomy is when they're lying supine but with 00:06:38.259 --> 00:06:40.649 the legs strapped up into stirrup. That's the 00:06:40.649 --> 00:06:43.209 one. I always think of it this way. Trying to 00:06:43.209 --> 00:06:45.970 push a baby out while completely supine is like 00:06:45.970 --> 00:06:48.269 trying to push a heavy boulder up a hill while 00:06:48.269 --> 00:06:50.629 simultaneously standing on the garden hose that 00:06:50.629 --> 00:06:52.709 supplies your drinking water. That is a great 00:06:52.709 --> 00:06:55.610 analogy. The boulder is the baby fighting against 00:06:55.610 --> 00:06:58.110 the upward curve of the birth canal without any 00:06:58.110 --> 00:07:01.250 help from gravity. And that squashed garden hose 00:07:01.250 --> 00:07:05.589 is the maternal inferior vena cava. Yes. That 00:07:05.589 --> 00:07:08.110 is the exact physiological mechanism you need 00:07:08.110 --> 00:07:10.509 to understand for the exam. It's called aortic 00:07:10.509 --> 00:07:13.329 oval compression. Break that down for us. When 00:07:13.329 --> 00:07:15.870 a pregnant client lies flat on their back, the 00:07:15.870 --> 00:07:17.930 entire weight of the gravid uterus, which is 00:07:17.930 --> 00:07:21.029 a baby, amniotic fluid, and a placenta, weighing 00:07:21.029 --> 00:07:23.810 several pounds, rests directly onto the inferior 00:07:23.810 --> 00:07:26.550 vena cava and the descending aorta. It just traps 00:07:26.550 --> 00:07:28.730 them against the maternal spine. Exactly. It 00:07:28.730 --> 00:07:30.930 compresses them. So if the vena cava is compressed, 00:07:31.250 --> 00:07:33.350 blood can't return from the lower body back to 00:07:33.350 --> 00:07:36.050 the mother's heart. Right. Venous return plummets. 00:07:36.279 --> 00:07:39.220 And when venous return drops, maternal cardiac 00:07:39.220 --> 00:07:41.980 output plummets. This causes severe maternal 00:07:41.980 --> 00:07:44.839 hypotension. So the mother feels, what, dizzy, 00:07:45.160 --> 00:07:47.879 nauseous? Dizzy, nauseous, clammy. But the real 00:07:47.879 --> 00:07:50.740 danger is to the fetus. If the mother's blood 00:07:50.740 --> 00:07:53.540 pressure bottoms out, the profusion of oxygen 00:07:53.540 --> 00:07:55.360 -rich blood through the uterine arteries to the 00:07:55.360 --> 00:07:58.360 placenta completely tanks. Oh, wow. The fetus 00:07:58.360 --> 00:08:01.360 is suddenly cut off from its oxygen supply. And 00:08:01.360 --> 00:08:04.160 you will see immediate, severe decelerations 00:08:04.160 --> 00:08:06.620 on the fetal heart rate monitor. Not to mention, 00:08:06.800 --> 00:08:08.899 if the mother is strapped into the lithotomy 00:08:08.899 --> 00:08:12.220 position, her pelvis is locked, right? It can't 00:08:12.220 --> 00:08:15.420 expand. It cannot. So you are decreasing oxygen, 00:08:15.819 --> 00:08:17.720 fighting gravity, and keeping the exit door as 00:08:17.720 --> 00:08:20.339 narrow as possible. This dramatically increases 00:08:20.339 --> 00:08:22.939 the risk of severe perineal tearing. The perineum 00:08:22.939 --> 00:08:25.079 can't stretch evenly when the legs are forced 00:08:25.079 --> 00:08:27.319 apart and immobilized in stirrups like that. 00:08:27.459 --> 00:08:30.699 It can't. So from a nursing standpoint, your 00:08:30.699 --> 00:08:33.669 priority action is extremely clear. You must 00:08:33.669 --> 00:08:36.049 actively encourage maternal position changes 00:08:36.049 --> 00:08:39.330 every 30 to 60 minutes. Keep the pelvis mobile. 00:08:39.730 --> 00:08:42.009 Keep the patient off their back. But wait, if 00:08:42.009 --> 00:08:44.190 hospitals are using the lithotomy position so 00:08:44.190 --> 00:08:47.029 frequently, there must be some clinical benefit 00:08:47.029 --> 00:08:49.549 to the mother, right? I mean, doctors wouldn't 00:08:49.549 --> 00:08:51.450 just do it for their own convenience at the expense 00:08:51.450 --> 00:08:54.409 of the patient. Well, that is the ultimate exam 00:08:54.409 --> 00:08:57.200 trap. and it requires you to understand the harsh 00:08:57.200 --> 00:09:00.220 reality of historical medical practice versus 00:09:00.220 --> 00:09:02.879 physiological ideals. Okay, hit me. Lithotomy 00:09:02.879 --> 00:09:05.440 is not optimal for the maternal pelvis or fetal 00:09:05.440 --> 00:09:08.419 descent. It became the standard almost entirely 00:09:08.419 --> 00:09:11.919 for provider convenience. Wait, really? Yes. 00:09:12.379 --> 00:09:14.480 It provides the doctor with a perfect seated 00:09:14.480 --> 00:09:17.440 line of sight. It makes continuous fetal monitoring 00:09:17.440 --> 00:09:20.460 easier to keep strapped to the belly. crucially, 00:09:20.799 --> 00:09:23.120 if the delivery becomes an absolute emergency, 00:09:23.720 --> 00:09:26.500 lithotomy provides immediate unobstructed access 00:09:26.500 --> 00:09:29.639 for the provider. Access for like forceps or 00:09:29.639 --> 00:09:32.580 a vacuum. Exactly. Forceps, vacuum extractors, 00:09:32.860 --> 00:09:35.259 or to perform an episiotomy. So it's basically 00:09:35.259 --> 00:09:37.519 an emergency access position that just became 00:09:37.519 --> 00:09:39.860 a routine habit over the decades? That's exactly 00:09:39.860 --> 00:09:42.379 what it is. And exams will heavily test your 00:09:42.379 --> 00:09:45.240 ability to separate those two concepts. Upright 00:09:45.240 --> 00:09:47.840 is for maternal and fetal benefit. Lithotomy 00:09:47.840 --> 00:09:50.179 is for provider access and emergency maneuvers. 00:09:50.320 --> 00:09:51.960 So the memory anchor you want to write down is 00:09:51.960 --> 00:09:55.120 this. Upright equals open, supine equals stress. 00:09:55.639 --> 00:09:58.100 Upright equals open, supine equals stress. Perfect. 00:09:58.179 --> 00:10:00.200 Now before we move on to what happens when the 00:10:00.200 --> 00:10:02.500 cervix is fully dilated, there's another critical 00:10:02.500 --> 00:10:04.500 piece of the environment the sources emphasize. 00:10:04.940 --> 00:10:07.480 And that's the support system in the room. Specifically, 00:10:07.759 --> 00:10:10.860 the role of doulas. This is a highly testable 00:10:10.860 --> 00:10:13.679 priority concept regarding non -pharmacological 00:10:13.679 --> 00:10:16.860 interventions. A doula is a professionally trained 00:10:16.860 --> 00:10:19.600 support person. They provide continuous physical, 00:10:20.120 --> 00:10:22.840 emotional, and informational support before, 00:10:23.120 --> 00:10:25.399 during, and just after childbirth. But they aren't 00:10:25.399 --> 00:10:27.500 medical professionals, right? Correct. It is 00:10:27.500 --> 00:10:29.299 vital to note they are not medical providers. 00:10:29.419 --> 00:10:31.980 They do not catch the baby. They do not prescribe 00:10:31.980 --> 00:10:35.240 medication. But their continuous presence exerts 00:10:35.240 --> 00:10:38.139 a profound, measurable, physiological effect 00:10:38.139 --> 00:10:40.659 on the laboring client. Because they lower the 00:10:40.659 --> 00:10:43.299 fear and anxiety in the room? Yes. And lowering 00:10:43.299 --> 00:10:45.649 fear isn't just a nice psychological bonus. It 00:10:45.649 --> 00:10:48.830 is a physiological imperative. How so? When a 00:10:48.830 --> 00:10:51.370 client is terrified, their sympathetic nervous 00:10:51.370 --> 00:10:53.850 system floods their body with catecholamines. 00:10:54.090 --> 00:10:56.169 Think stress hormones like cortisol and adrenaline. 00:10:56.409 --> 00:10:58.470 Fight or flight. Exactly. And high adrenaline 00:10:58.470 --> 00:11:01.590 literally counteracts oxytocin. Oxytocin is the 00:11:01.590 --> 00:11:03.389 hormone responsible for uterine contractions, 00:11:03.509 --> 00:11:06.590 so fear literally stalls labor. Wow, so being 00:11:06.590 --> 00:11:10.129 scared stops the contractions. It does. By providing 00:11:10.129 --> 00:11:13.950 continuous calming support, a doula helps lower 00:11:13.950 --> 00:11:16.730 those stress hormones. When adrenaline drops, 00:11:17.110 --> 00:11:19.549 natural oxytocin surges, uterine contractions 00:11:19.549 --> 00:11:22.110 become more effective, and utero placental blood 00:11:22.110 --> 00:11:24.570 flow actually increases. And the data on this 00:11:24.570 --> 00:11:26.809 isn't subtle. The sources we're looking at are 00:11:26.809 --> 00:11:29.350 incredibly explicit about the impact doulas have, 00:11:29.529 --> 00:11:32.169 especially on historically marginalized demographics. 00:11:32.370 --> 00:11:34.330 The statistics are staggering. In the United 00:11:34.330 --> 00:11:37.029 States, black maternal clients face a tragically 00:11:37.029 --> 00:11:39.590 disproportionate risk of severe morbidity and 00:11:39.590 --> 00:11:42.230 mortality from pregnancy related complications. 00:11:42.470 --> 00:11:45.409 It's awful. It is. But the evidence clearly shows 00:11:45.409 --> 00:11:48.169 that continuous support from a doula significantly 00:11:48.169 --> 00:11:50.929 reduces these risks for historically marginalized 00:11:50.929 --> 00:11:54.149 racial groups and clients with low socioeconomic 00:11:54.149 --> 00:11:56.830 status. They act as advocates, right? Yes, doulas 00:11:56.830 --> 00:11:58.970 act as vital advocates and liaisons, ensuring 00:11:58.970 --> 00:12:00.870 that the client's cultural beliefs are respected, 00:12:01.269 --> 00:12:03.570 their pain is taken seriously, and their voice 00:12:03.570 --> 00:12:06.029 is actually heard by the medical team. So a safe, 00:12:06.269 --> 00:12:08.549 effective nurse views the doula as a critical 00:12:08.549 --> 00:12:11.570 collaborator, not as someone in the way. Collaborative 00:12:11.570 --> 00:12:15.570 care improves outcomes, always. If an exam question 00:12:15.570 --> 00:12:17.830 asks about the best action regarding a doula, 00:12:18.409 --> 00:12:20.809 the answer is always to facilitate their involvement 00:12:20.809 --> 00:12:22.980 and incorporate them into the care plan. All 00:12:22.980 --> 00:12:25.480 right, let's organically synthesize this foundation 00:12:25.480 --> 00:12:27.919 for you. If you only remember a few things from 00:12:27.919 --> 00:12:30.539 this section, we know the first stage is all 00:12:30.539 --> 00:12:33.259 about getting to 10 centimeters. We know to change 00:12:33.259 --> 00:12:35.620 the patient's position every half hour to keep 00:12:35.620 --> 00:12:38.220 the pelvis open. Avoiding the supine position 00:12:38.220 --> 00:12:41.039 at all costs to protect that vena cava. Right. 00:12:41.289 --> 00:12:43.870 We know upright positions speed things up. And 00:12:43.870 --> 00:12:46.330 we know integrating continuous emotional support 00:12:46.330 --> 00:12:48.830 physiologically accelerates labor by dropping 00:12:48.830 --> 00:12:51.049 adrenaline. Perfect summary. OK, so she hits 00:12:51.049 --> 00:12:53.590 10 centimeters, the physical space is maximized, 00:12:53.669 --> 00:12:55.889 the cervix is completely out of the way. What 00:12:55.889 --> 00:12:58.750 happens next? The exact moment you confirm 10 00:12:58.750 --> 00:13:00.649 centimeters of dilation, you have officially 00:13:00.649 --> 00:13:02.649 crossed the boundary into the second stage of 00:13:02.649 --> 00:13:05.250 labor. Stage two. Yes. The second stage lasts 00:13:05.250 --> 00:13:08.429 from complete dilation until the final expulsion 00:13:08.429 --> 00:13:11.899 of the fetus. But This is where clinical judgment 00:13:11.899 --> 00:13:14.740 gets really muddy and where students make fatal 00:13:14.740 --> 00:13:17.419 errors on exams. The instinct is to think, oh, 00:13:17.539 --> 00:13:19.659 10 centimeters, the door is open. Let's get this 00:13:19.659 --> 00:13:22.639 baby out right now. Why on earth would a nurse 00:13:22.639 --> 00:13:25.179 ever tell a fully dilated patient to just sit 00:13:25.179 --> 00:13:28.539 there and not push? Because complete dilation 00:13:28.539 --> 00:13:32.100 is only one piece of the puzzle. To safely initiate 00:13:32.100 --> 00:13:34.440 active pushing, you need three physiological 00:13:34.440 --> 00:13:37.139 criteria to align perfectly. OK, what are they? 00:13:37.340 --> 00:13:40.340 First, yes, complete dilation at 10 centimeters. 00:13:40.509 --> 00:13:44.029 Second, the client must actually have an overwhelming, 00:13:44.250 --> 00:13:47.090 involuntary physiological urge to bear down. 00:13:47.570 --> 00:13:49.769 This is often referred to as the Ferguson reflex. 00:13:51.549 --> 00:13:54.610 And third, the fetal station needs to be low 00:13:54.610 --> 00:13:56.830 enough in the pelvis. We are looking for a station 00:13:56.830 --> 00:14:00.019 of zero or lower, meaning The widest part of 00:14:00.019 --> 00:14:02.240 the baby's head has engaged deeply into the maternal 00:14:02.240 --> 00:14:04.019 pelvis. But wait, what if the patient has an 00:14:04.019 --> 00:14:06.759 epidural? I imagine that completely numbs the 00:14:06.759 --> 00:14:09.039 Ferguson reflux, doesn't it? It absolutely can. 00:14:09.539 --> 00:14:11.899 A dense regional anesthetic might leave the client 00:14:11.899 --> 00:14:14.320 completely numb from the waist down. You check 00:14:14.320 --> 00:14:16.820 their cervix and they are 10 centimeters, but 00:14:16.820 --> 00:14:18.980 they feel absolutely zero pressure. They have 00:14:18.980 --> 00:14:22.070 no urge to push. So I'm confused. If the cervix 00:14:22.070 --> 00:14:25.049 is fully open, what is the actual harm in forcing 00:14:25.049 --> 00:14:27.929 them to push? Even if the baby is high up at 00:14:27.929 --> 00:14:30.830 a minus two station, wouldn't bearing down just 00:14:30.830 --> 00:14:33.789 manually force the baby down faster? It is incredibly 00:14:33.789 --> 00:14:36.809 harmful. If you demand that a client actively 00:14:36.809 --> 00:14:39.549 push when the fetus is still high up in the pelvic 00:14:39.549 --> 00:14:42.990 canal, you are demanding an immense agonizing 00:14:42.990 --> 00:14:45.850 expenditure of energy for almost zero movement. 00:14:46.000 --> 00:14:48.419 Because the baby still has so far to go. Exactly. 00:14:48.620 --> 00:14:50.860 Pushing is an athletic event. If you force them 00:14:50.860 --> 00:14:53.220 to push prematurely, they will suffer severe 00:14:53.220 --> 00:14:55.879 maternal exhaustion. By the time the baby actually 00:14:55.879 --> 00:14:58.120 gets low enough to require a massive push to 00:14:58.120 --> 00:15:00.259 crown, the mother will have nothing left in the 00:15:00.259 --> 00:15:02.220 tank. And what happens to the tissue? This is 00:15:02.220 --> 00:15:04.279 the critical safety issue. If you force pushing 00:15:04.279 --> 00:15:07.200 before the cervix is genuinely 100 % effaced 00:15:07.200 --> 00:15:09.460 and retracted out of the way, the immense force 00:15:09.460 --> 00:15:11.759 of the fetal head grinding against the remaining 00:15:11.759 --> 00:15:14.559 lip of the cervix causes severe trauma. Oh, that 00:15:14.559 --> 00:15:17.639 sounds bad. It is. That cervical tissue will 00:15:17.639 --> 00:15:20.320 bruise, swell massively, and can even result 00:15:20.320 --> 00:15:22.759 in cervical prolapse, where the swollen, bleeding 00:15:22.759 --> 00:15:25.519 cervix pushes outside the vagina. It also causes 00:15:25.519 --> 00:15:28.179 horrific fetal head compression, which leads 00:15:28.179 --> 00:15:31.080 to immediate fetal distress. So the expected 00:15:31.080 --> 00:15:33.179 safe practice is something completely different 00:15:33.179 --> 00:15:35.419 than what we see on TV. The gold standard expected 00:15:35.419 --> 00:15:37.759 practice is called laboring down, or passive 00:15:37.759 --> 00:15:40.679 fetal descent. If a client is 10 centimeters 00:15:40.679 --> 00:15:43.480 dilated but the baby is high or the urge is absent, 00:15:43.919 --> 00:15:46.419 we do absolutely nothing but wait. You just let 00:15:46.419 --> 00:15:49.100 them rest at 10 centimeters. For how long? For 00:15:49.100 --> 00:15:52.659 up to two hours. We allow the natural involuntary 00:15:52.659 --> 00:15:55.700 contractions of the uterus to slowly, gently 00:15:55.700 --> 00:15:58.179 act like an elevator, bringing the baby down 00:15:58.179 --> 00:15:59.940 through the pelvis over the course of one to 00:15:59.940 --> 00:16:02.940 two hours. That is wild. Up to two hours of just 00:16:02.940 --> 00:16:06.679 waiting. Yes. It conserves maternal energy. drastically 00:16:06.679 --> 00:16:09.120 decreases the incidence of severe perineal tears, 00:16:09.879 --> 00:16:11.820 and significantly reduces the need for the doctor 00:16:11.820 --> 00:16:14.620 to intervene with forceps or vacuums. So the 00:16:14.620 --> 00:16:16.600 concerning finding the red flag intervention 00:16:16.600 --> 00:16:19.080 is the nurse cheering like a football coach and 00:16:19.080 --> 00:16:21.240 forcing active pushing before the physiology 00:16:21.240 --> 00:16:23.879 is actually ready. Yes, do not be the cheerleader 00:16:23.879 --> 00:16:26.620 for premature pushing. But during those two hours 00:16:26.620 --> 00:16:29.440 of laboring down, or once active pushing finally 00:16:29.440 --> 00:16:32.580 begins, the nurse isn't just kicking back right, 00:16:32.740 --> 00:16:36.039 we are constantly monitoring. Frequent fetal 00:16:36.039 --> 00:16:38.539 monitoring during the second stage is paramount. 00:16:39.000 --> 00:16:40.779 The contractions are getting stronger, which 00:16:40.779 --> 00:16:42.799 means the placenta is getting squeezed tighter. 00:16:43.559 --> 00:16:46.500 This restricts blood flow to the baby with every 00:16:46.500 --> 00:16:48.620 single contraction. So how often are we checking 00:16:48.620 --> 00:16:51.460 the heart rate? If you are using intermittent 00:16:51.460 --> 00:16:54.080 monitoring, you must assess the fetal heart rate 00:16:54.080 --> 00:16:56.940 every 15 minutes during that passive laboring 00:16:56.940 --> 00:16:59.559 down phase. Yeah. Once the client begins active 00:16:59.559 --> 00:17:02.240 pushing, you are assessing that heart rate every 00:17:02.240 --> 00:17:04.480 five to 15 minutes. And what if we are dealing 00:17:04.480 --> 00:17:06.900 with a medical induction? What if they are on 00:17:06.900 --> 00:17:09.960 a continuous oxytocin drip? The stakes immediately 00:17:09.960 --> 00:17:12.940 skyrocket. Yeah. If synthetic oxytocin like pedosin 00:17:12.940 --> 00:17:15.259 is running, you must assess the fetal heart rate 00:17:15.259 --> 00:17:17.299 every five minutes during active pushing. No 00:17:17.299 --> 00:17:19.240 exceptions. Every five minutes, that's intense. 00:17:19.339 --> 00:17:22.579 Why so frequent? Because oxytocin stimulates 00:17:22.579 --> 00:17:26.380 incredibly powerful, smooth muscle contractions. 00:17:26.680 --> 00:17:30.119 High doses can cause tachycystally. That's when 00:17:30.119 --> 00:17:32.660 the uterus contracts too frequently, more than 00:17:32.660 --> 00:17:35.380 five contractions in 10 minutes, or the contractions 00:17:35.380 --> 00:17:38.039 last too long without a resting tone. And if 00:17:38.039 --> 00:17:40.799 the uterus never relaxes? The placenta never 00:17:40.799 --> 00:17:43.779 refills with oxygenated blood. You will cause 00:17:43.779 --> 00:17:46.650 severe fetal hypoxia. Which brings us to another 00:17:46.650 --> 00:17:49.210 massive exam trap regarding the actual technique 00:17:49.210 --> 00:17:52.490 of pushing. We briefly touched on the movie myth 00:17:52.490 --> 00:17:54.710 of holding your breath and pushing until your 00:17:54.710 --> 00:17:58.910 face turns purple. Why exactly is that so dangerous? 00:17:59.390 --> 00:18:01.930 That movie method is medically known as closed 00:18:01.930 --> 00:18:04.769 glottis pushing, or the Valsalva maneuver. The 00:18:04.769 --> 00:18:06.670 patient takes a deep breath, forcefully slams 00:18:06.670 --> 00:18:08.589 their glottis shut, and bears down as hard as 00:18:08.589 --> 00:18:10.329 they can for 10 seconds. Right, like they're 00:18:10.329 --> 00:18:12.230 lifting a heavy weight. Physiologically, this 00:18:12.230 --> 00:18:14.309 is a disaster. When you hold your breath and 00:18:14.309 --> 00:18:16.849 strain that intensely, you drastically spike 00:18:16.849 --> 00:18:19.190 the intra -thoracic pressure inside your chest 00:18:19.190 --> 00:18:21.029 cavity. And if the pressure in the chest is too 00:18:21.029 --> 00:18:22.990 high, blood from the body can't fight its way 00:18:22.990 --> 00:18:26.950 back into the heart. Exactly. Venous return plummets. 00:18:27.170 --> 00:18:29.670 Cardiac output drops. Maternal blood pressure 00:18:29.670 --> 00:18:32.170 bottoms out. And the moment maternal cardiac 00:18:32.170 --> 00:18:34.759 output drops... The profusion of blood to the 00:18:34.759 --> 00:18:37.400 placenta plummets. So not only is the mother 00:18:37.400 --> 00:18:39.299 exhausting herself and popping blood vessels 00:18:39.299 --> 00:18:41.859 in her eyes, but she is actively depriving the 00:18:41.859 --> 00:18:44.819 fetus of oxygen right at the most critical moment 00:18:44.819 --> 00:18:47.859 of descent. Exactly. So the alternative is open 00:18:47.859 --> 00:18:50.319 glottis pushing. Explain open glottis pushing 00:18:50.319 --> 00:18:52.720 for us. Open glottis pushing is spontaneous, 00:18:53.200 --> 00:18:56.160 physiological pushing. The client breathes deeply, 00:18:56.460 --> 00:18:58.299 and when they feel the peak of the urge, they 00:18:58.299 --> 00:19:01.279 bear down while exhaling. They might grunt, moan, 00:19:01.420 --> 00:19:03.559 or literally breathe out through the push. They 00:19:03.559 --> 00:19:05.660 do not hold their breath. And the outcomes are 00:19:05.660 --> 00:19:09.000 measurably better. Massly superior. Open glottis 00:19:09.000 --> 00:19:11.339 pushing decreases the total duration of the second 00:19:11.339 --> 00:19:14.240 stage. It lessens maternal fatigue because the 00:19:14.240 --> 00:19:16.079 muscles are continually oxygenated. That makes 00:19:16.079 --> 00:19:18.119 total sense. It prevents those sudden, dangerous 00:19:18.119 --> 00:19:20.299 drops in fetal heart rate, which yields much 00:19:20.299 --> 00:19:22.900 higher Apgar scores for the newborn. And because 00:19:22.900 --> 00:19:24.799 the stretching is more gradual, it decreases 00:19:24.799 --> 00:19:27.740 severe perineal lacerations. To remember this, 00:19:27.980 --> 00:19:31.240 keep it incredibly simple for the exam. Don't 00:19:31.240 --> 00:19:33.559 hold your breath to have a baby keep the glottis 00:19:33.559 --> 00:19:37.119 open. It sounds so obvious, but it completely 00:19:37.119 --> 00:19:39.880 contradicts decades of bad medical television. 00:19:40.059 --> 00:19:42.500 It really does. And just to tie up perineal trauma 00:19:42.500 --> 00:19:45.259 routine, episiotomies are a thing of the past. 00:19:45.599 --> 00:19:47.980 Cutting the perineum prophylactically is no longer 00:19:47.980 --> 00:19:50.099 the standard of care. So what's the expected 00:19:50.099 --> 00:19:52.920 intervention then? To prevent trauma as the fetal 00:19:52.920 --> 00:19:56.160 head crowns, the expected priority nursing interventions 00:19:56.160 --> 00:19:59.519 are perineal massage and applying warm compresses 00:19:59.519 --> 00:20:01.720 to the tissue to help it stretch naturally. OK, 00:20:01.759 --> 00:20:04.279 the tissue stretches, the head crowns, the shoulders 00:20:04.279 --> 00:20:07.240 pass, and the baby is born. The second stage 00:20:07.240 --> 00:20:09.980 is officially complete. You hear that first cry 00:20:09.980 --> 00:20:12.680 and the relief in the room is palpable. Everyone 00:20:12.680 --> 00:20:15.079 is so happy. Everyone is taking photos, looking 00:20:15.079 --> 00:20:17.799 at the newborn. But from a clinical nursing perspective, 00:20:17.960 --> 00:20:19.589 you're The maternal alarm bell should actually 00:20:19.589 --> 00:20:22.009 be ringing louder than ever because medically 00:20:22.009 --> 00:20:24.670 the danger to the mother is peaking at this exact 00:20:24.670 --> 00:20:27.250 second. This is the transition into the third 00:20:27.250 --> 00:20:30.710 stage of labor. And this is where SHRP clinical 00:20:30.710 --> 00:20:33.769 judgment prevents maternal death. The third stage 00:20:33.769 --> 00:20:36.069 begins the moment the newborn is delivered and 00:20:36.069 --> 00:20:38.210 ends the moment the placenta is expelled. It's 00:20:38.210 --> 00:20:40.589 a really short window, right? Terrifyingly short. 00:20:40.690 --> 00:20:43.130 It typically lasts only five to 30 minutes. Why 00:20:43.130 --> 00:20:45.849 is this specific window so incredibly dangerous? 00:20:46.029 --> 00:20:48.869 Because of the anatomy of the uterus. When the 00:20:48.869 --> 00:20:50.950 placenta is attached to the uterine wall during 00:20:50.950 --> 00:20:54.210 pregnancy, it is fed by a massive network of 00:20:54.210 --> 00:20:57.150 high flow spiral arteries. Okay, visualizing 00:20:57.150 --> 00:21:00.349 that. The moment the placenta detaches, it leaves 00:21:00.349 --> 00:21:03.269 behind a wound the size of a dinner plate inside 00:21:03.269 --> 00:21:06.430 the uterus with dozens of open pumping blood 00:21:06.430 --> 00:21:08.970 vessels. Wow, a dinner plate. If the uterine 00:21:08.970 --> 00:21:11.329 muscle does not immediately and violently cramp 00:21:11.329 --> 00:21:13.329 down to physically pinch those vessels shut, 00:21:13.710 --> 00:21:15.630 the mother can lose a catastrophic amount of 00:21:15.630 --> 00:21:18.710 blood in a matter of minutes. Yes, postpartum 00:21:18.710 --> 00:21:21.769 hemorrhage or PPH is one of the leading causes 00:21:21.769 --> 00:21:24.329 of maternal mortality worldwide. So what are 00:21:24.329 --> 00:21:26.970 we looking for? How do we know the placenta is 00:21:26.970 --> 00:21:29.789 actually detaching safely? You are watching for 00:21:29.789 --> 00:21:32.970 the three classic expected signs of placental 00:21:32.970 --> 00:21:36.289 separation. This is very testable. First, you'll 00:21:36.289 --> 00:21:38.450 see a sudden gush or surge of dark blood from 00:21:38.450 --> 00:21:40.410 the vagina as the placenta pulls away. Okay, 00:21:40.509 --> 00:21:43.509 a gush of blood. Second, the umbilical cord protruding 00:21:43.509 --> 00:21:46.089 from the vagina will visibly lengthen. And third, 00:21:46.410 --> 00:21:49.089 if you look at the maternal abdomen, the fundus, 00:21:49.210 --> 00:21:51.690 the top of the uterus, will change from a flat 00:21:51.690 --> 00:21:55.589 discoid shape to a firm globular shape as it 00:21:55.589 --> 00:21:58.730 rises upward in the abdomen. Cushive blood, long 00:21:58.730 --> 00:22:02.369 cord, globular fundus. Got it. Let's talk about 00:22:02.369 --> 00:22:04.269 the umbilical cord for a second, because before 00:22:04.269 --> 00:22:06.250 the placenta comes out, we have to cut the cord. 00:22:06.569 --> 00:22:09.170 Is that done immediately? No. The expected evidence 00:22:09.170 --> 00:22:11.970 -based practice is delayed cord clamping. We 00:22:11.970 --> 00:22:14.309 intentionally wait 30 to 60 seconds after the 00:22:14.309 --> 00:22:16.630 baby is born before clamping and cutting the 00:22:16.630 --> 00:22:19.109 cord. Why wait? Because in those first 60 seconds 00:22:19.109 --> 00:22:22.349 the placenta is still actively pulsing transfusing 00:22:22.349 --> 00:22:25.309 a massive amount of blood up to a third of the 00:22:25.309 --> 00:22:27.670 newborn's total blood volume into the baby. A 00:22:27.670 --> 00:22:31.160 third of their blood volume. Yes. This physiological 00:22:31.160 --> 00:22:34.200 boost significantly increases the newborn's hemoglobin 00:22:34.200 --> 00:22:36.519 levels, builds up their iron stores for the first 00:22:36.519 --> 00:22:39.099 several months of life, and is linked to improved 00:22:39.099 --> 00:22:41.000 cognitive and motor development. What is the 00:22:41.000 --> 00:22:43.079 concerning finding that would force a nurse to 00:22:43.079 --> 00:22:45.259 skip that weight and clamp immediately? Because 00:22:45.259 --> 00:22:47.859 there are always exceptions on the NCLEX. You 00:22:47.859 --> 00:22:50.680 only perform immediate cord clamping if the newborn 00:22:50.680 --> 00:22:53.180 is severely compromised, meaning they are not 00:22:53.180 --> 00:22:55.519 breathing, they are floppy, and they require 00:22:55.519 --> 00:22:59.039 urgent, immediate neonatal resuscitation away 00:22:59.039 --> 00:23:01.359 from the mother. Otherwise, you delay. OK, the 00:23:01.359 --> 00:23:04.640 cord is cut. The placenta is expelled. What is 00:23:04.640 --> 00:23:07.420 the absolute priority nursing action to stop 00:23:07.420 --> 00:23:09.640 the bleeding from those open spiral arteries? 00:23:10.099 --> 00:23:11.740 We don't just cross our fingers and hope the 00:23:11.740 --> 00:23:14.400 uterus cramps down on its own, right? No, we 00:23:14.400 --> 00:23:16.740 aggressively intervene. This is called active 00:23:16.740 --> 00:23:20.480 management of the third stage of labor, or AMTSL. 00:23:20.940 --> 00:23:23.880 And the cornerstone of AMTSL is immediately administering 00:23:23.880 --> 00:23:27.579 uterotonic medications. Uterotonics? Yes. Utero 00:23:27.579 --> 00:23:29.779 referring to the uterus and tonic referring to 00:23:29.779 --> 00:23:33.549 tone. These are incredibly powerful pharmacological 00:23:33.549 --> 00:23:36.410 agents that force the smooth muscle of the uterus 00:23:36.410 --> 00:23:39.150 to contract violently, clamping those bleeding 00:23:39.150 --> 00:23:41.349 vessels shut. Grab a pen, everyone listening, 00:23:41.450 --> 00:23:43.329 because this is where the pharmacology gets heavily 00:23:43.329 --> 00:23:46.470 tested. Nursing instructors absolutely love testing 00:23:46.470 --> 00:23:49.269 uterotonic contraindications. Because giving 00:23:49.269 --> 00:23:51.730 the wrong drug to the wrong patient here doesn't 00:23:51.730 --> 00:23:55.029 just fail to stop the bleeding, it actively causes 00:23:55.029 --> 00:23:58.049 a secondary life -threatening emergency. It really 00:23:58.049 --> 00:24:00.940 does. Let's break down the big four uterotonics. 00:24:01.019 --> 00:24:03.099 You must know these inside and out. First is 00:24:03.099 --> 00:24:06.539 oxytocin or pitocin. This is the universal first 00:24:06.539 --> 00:24:08.799 -line recommendation for postpartum hemorrhage 00:24:08.799 --> 00:24:11.519 prophylaxis. Think of uterotonics like bouncers 00:24:11.519 --> 00:24:14.740 clearing out a rowdy violent nightclub. The nightclub 00:24:14.740 --> 00:24:16.839 is the bleeding uterus and the bouncers are kicking 00:24:16.839 --> 00:24:18.960 the blood and the placenta out to shut the club 00:24:18.960 --> 00:24:21.380 down. They all get the job done. But they have 00:24:21.380 --> 00:24:24.140 very different styles. Oxytocin is your standard 00:24:24.140 --> 00:24:26.859 reliable head bouncer. Exactly. For the third 00:24:26.859 --> 00:24:29.700 stage of labor, giving oxytocin intramuscularly, 00:24:29.839 --> 00:24:33.400 or via a slow IV push, has the highest efficacy 00:24:33.400 --> 00:24:36.299 with the lowest severe side effects. But exams 00:24:36.299 --> 00:24:38.500 will set a trap here regarding the side effects 00:24:38.500 --> 00:24:41.420 of prolonged use. What's the trap? Oxytocin has 00:24:41.420 --> 00:24:44.599 a severe antidiuretic effect. If a patient is 00:24:44.599 --> 00:24:47.140 hemorrhaging and you run massive IV doses of 00:24:47.140 --> 00:24:50.299 oxytocin over a long period, their kidneys stop 00:24:50.299 --> 00:24:53.279 excreting urine. Oh, they hold on to water. They 00:24:53.279 --> 00:24:55.660 retain fluid to a dangerous degree, which can 00:24:55.660 --> 00:24:58.819 lead to water intoxication, cerebral edema, coma, 00:24:59.259 --> 00:25:02.140 and even fatal seizures. So oxytocin is reliable, 00:25:02.380 --> 00:25:04.480 but you have to watch out for fluid overload. 00:25:04.880 --> 00:25:07.299 What about the second bouncer, methylurganafine? 00:25:07.480 --> 00:25:10.599 also known as methylgene or ergot. Methylurganavine 00:25:10.599 --> 00:25:13.519 is the hyperaggressive bouncer. It forces a sustained 00:25:13.519 --> 00:25:15.940 tannic contraction of the uterus, which stops 00:25:15.940 --> 00:25:18.299 bleeding brilliantly, but it achieves this by 00:25:18.299 --> 00:25:21.480 causing intense systemic vasoconstriction. Systemic. 00:25:21.579 --> 00:25:24.180 As in everywhere? Everywhere. It clamps down 00:25:24.180 --> 00:25:26.200 blood vessels everywhere in the body. So if a 00:25:26.200 --> 00:25:28.180 patient already has high blood pressure and you 00:25:28.180 --> 00:25:30.059 give them a drug that aggressively constricts 00:25:30.059 --> 00:25:32.940 all their blood vessels. You will cause a catastrophic 00:25:32.940 --> 00:25:36.700 hypertensive crisis. The absolute never do it 00:25:36.700 --> 00:25:38.880 contraindication that you'll see on the NCLEX. 00:25:39.579 --> 00:25:42.140 Never give methylurganavine to a patient with 00:25:42.140 --> 00:25:45.400 chronic hypertension, preeclampsia, or cardiovascular 00:25:45.400 --> 00:25:48.079 disease. You'll cause a stroke, palpitations, 00:25:48.440 --> 00:25:51.470 or deadly arrhythmias. Okay, so methylarganavine 00:25:51.470 --> 00:25:54.369 wrecks the blood pressure. No methyl gene for 00:25:54.369 --> 00:25:58.069 high BP. What about the third bouncer? Carboprost, 00:25:58.269 --> 00:26:01.589 also known as hemidate. It's a synthetic prostaglandin. 00:26:01.829 --> 00:26:04.289 Carboprost is highly effective, but it severely 00:26:04.289 --> 00:26:06.589 irritates smooth muscle outside the uterus as 00:26:06.589 --> 00:26:08.450 well, specifically in the respiratory tract. 00:26:08.490 --> 00:26:11.710 It causes severe bronchospasm. Oh, asthma! Yes. 00:26:11.890 --> 00:26:14.509 The absolute contraindication trap here is, never 00:26:14.509 --> 00:26:16.430 give carbaprost to a patient with a history of 00:26:16.430 --> 00:26:18.750 pulmonary issues, specifically asthma. If an 00:26:18.750 --> 00:26:20.769 exam scenario describes a laboring client with 00:26:20.769 --> 00:26:23.329 asthma who is hemorrhaging, carbaprost is a lethal 00:26:23.329 --> 00:26:25.529 choice. It will shut their airway down. Wow. 00:26:25.650 --> 00:26:27.970 It is also contraindicated in patients with hepatic 00:26:27.970 --> 00:26:30.230 or renal disease. Let me summarize that. Methyl 00:26:30.230 --> 00:26:32.650 argonamine equals NO for high blood pressure. 00:26:33.069 --> 00:26:36.589 Carbaprost equals NO for asthma. Spot on. And 00:26:36.589 --> 00:26:39.170 the fourth common uteratonic is mesoprostal, 00:26:39.289 --> 00:26:43.190 or cytotech. This is also a prostaglandin. It 00:26:43.190 --> 00:26:46.049 is cheap, shelf -stable, and can be given orally, 00:26:46.390 --> 00:26:49.130 subliminally, or rectally, making it incredibly 00:26:49.130 --> 00:26:50.990 versatile. What's the catch with misoprostol? 00:26:51.009 --> 00:26:53.309 There's always a catch. The side effect profile. 00:26:53.890 --> 00:26:56.549 Because it's a prostaglandin, it causes intense 00:26:56.549 --> 00:26:59.430 gastrointestinal upset. We are talking about 00:26:59.430 --> 00:27:03.009 severe shivering, fever, abdominal pain, nausea, 00:27:03.190 --> 00:27:05.849 and explosive diarrhea. Having explosive diarrhea 00:27:05.849 --> 00:27:08.190 moments after delivering a baby sounds like an 00:27:08.190 --> 00:27:10.589 absolute nightmare, but it is infinitely better 00:27:10.589 --> 00:27:13.390 than bleeding to death. Exactly. It is a highly 00:27:13.390 --> 00:27:16.289 effective bouncer, but it leaves a mess. To survive 00:27:16.289 --> 00:27:18.750 the pharmacology section of your exam, simply 00:27:18.750 --> 00:27:21.170 remember the contraindications. High blood pressure 00:27:21.170 --> 00:27:24.430 means no methyl -argonamine. Bad lungs mean no 00:27:24.430 --> 00:27:26.859 carboprost. While one nurse is hyper -focused 00:27:26.859 --> 00:27:29.119 on the mother, aggressively managing the third 00:27:29.119 --> 00:27:31.480 stage, monitoring the bleeding, and pushing those 00:27:31.480 --> 00:27:34.039 uteratomics, there is an entirely different drama 00:27:34.039 --> 00:27:36.920 unfolding two feet away. The baby. Another nurse 00:27:36.920 --> 00:27:39.380 is entirely focused on the newly arrived passenger. 00:27:40.000 --> 00:27:41.960 This brings us to the golden hour, the critical 00:27:41.960 --> 00:27:44.359 transition of the newborn. The transition from 00:27:44.359 --> 00:27:47.299 intrader in life to extradorn life is the most 00:27:47.299 --> 00:27:50.539 precarious physiological leap a human being ever 00:27:50.539 --> 00:27:53.200 makes. It's crazy to think about. For nine months, 00:27:53.599 --> 00:27:56.440 this baby has lived in a warm, dark, wet environment, 00:27:56.980 --> 00:27:59.640 floating in amniotic fluid, getting 100 % of 00:27:59.640 --> 00:28:02.079 its oxygen passively from the placenta without 00:28:02.079 --> 00:28:04.660 ever having to take a single breath. And a boom. 00:28:05.059 --> 00:28:07.839 Suddenly, they are thrust into a cold, bright 00:28:07.839 --> 00:28:10.490 room. They have to inflate fluid -filled lungs, 00:28:10.950 --> 00:28:13.650 breathe room air, regulate their own core temperature, 00:28:14.109 --> 00:28:16.809 and completely reroute their cardiovascular system 00:28:16.809 --> 00:28:19.829 as the umbilical cord is clamped. The high -yield 00:28:19.829 --> 00:28:22.509 core metric for this transition is the Apgar 00:28:22.509 --> 00:28:25.029 score. It is the most famous medical assessment 00:28:25.029 --> 00:28:27.180 in the world. And you must know precisely how 00:28:27.180 --> 00:28:29.500 to calculate it. The ATGAR score is performed 00:28:29.500 --> 00:28:31.440 strictly at one minute and five minutes after 00:28:31.440 --> 00:28:33.720 birth. Why are there specific times? The one 00:28:33.720 --> 00:28:36.140 minute score is a snapshot of how well the baby 00:28:36.140 --> 00:28:38.779 tolerated the physical trauma of the birthing 00:28:38.779 --> 00:28:41.700 process itself. The five minute score tells you 00:28:41.700 --> 00:28:44.119 how well the baby is neurologically transitioning 00:28:44.119 --> 00:28:47.059 to extruder in life and how effectively they're 00:28:47.059 --> 00:28:49.380 responding to any resuscitation efforts. And 00:28:49.380 --> 00:28:51.740 if the score is low? If the score is less than 00:28:51.740 --> 00:28:54.460 seven, at the five minute mark, You must continue 00:28:54.460 --> 00:28:57.599 scoring every five minutes until 20 minutes post 00:28:57.599 --> 00:28:59.859 -birth. Let's break down the categories. It's 00:28:59.859 --> 00:29:03.079 conveniently an acronym. A, appearance, which 00:29:03.079 --> 00:29:05.819 assesses skin color. P, pulse, which assesses 00:29:05.819 --> 00:29:09.000 heart rate. G, grimace, which assesses reflex 00:29:09.000 --> 00:29:13.039 irritability in response to stimulation. A, activity, 00:29:13.359 --> 00:29:17.130 which assesses muscle tone. R, respiration. which 00:29:17.130 --> 00:29:19.329 assesses breathing effort. And each is scored 00:29:19.329 --> 00:29:22.670 0 to 2. Right. Each category is scored as a 0, 00:29:22.710 --> 00:29:26.450 1, or 2. So a perfect, robust baby scores a 10. 00:29:26.849 --> 00:29:29.569 I want to look closely at expected versus concerning 00:29:29.569 --> 00:29:32.289 findings here, especially for appearance. If 00:29:32.289 --> 00:29:34.009 I looked at a newborn and their hands and feet 00:29:34.009 --> 00:29:36.210 were entirely blue, my instinct would be to panic. 00:29:36.460 --> 00:29:39.480 Which is exactly why exams test this. An expected 00:29:39.480 --> 00:29:41.559 totally normal finding in a newborn is called 00:29:41.559 --> 00:29:44.420 acrocyanosis. This means the newborn has a pink, 00:29:44.599 --> 00:29:46.880 well -oxygenated core body, but their hands and 00:29:46.880 --> 00:29:49.140 feet remain somewhat blue. So blue hands are 00:29:49.140 --> 00:29:52.240 normal? Yes. This is a benign result of peripheral 00:29:52.240 --> 00:29:55.000 vasoconstriction, as their tiny circulatory system 00:29:55.000 --> 00:29:57.279 adjusts to pumping blood against gravity in the 00:29:57.279 --> 00:30:00.480 cold air. Because of expected acrocyanosis, almost 00:30:00.480 --> 00:30:03.400 every healthy baby scores a 1 for color, making 00:30:03.400 --> 00:30:05.980 an Avgar of 8 or 9 completely normal and expected. 00:30:06.140 --> 00:30:08.839 So blue hands and feet are fine. What is concerning? 00:30:09.099 --> 00:30:11.759 Central cyanosis. If the baby's central chest, 00:30:12.039 --> 00:30:15.059 lips, face, or mucus membranes are blue, that 00:30:15.059 --> 00:30:18.500 is a score of zero. That indicates systemic hypoxia 00:30:18.500 --> 00:30:21.119 and is a massive immediate red flag requiring 00:30:21.119 --> 00:30:23.640 oxygenation. What about the heart rate and respiratory 00:30:23.640 --> 00:30:25.640 parameters? A newborn heart beats incredibly 00:30:25.640 --> 00:30:28.779 fast. The expected normal heart rate is 110 to 00:30:28.779 --> 00:30:31.339 160 beats per minute. That earns a score of two. 00:30:31.539 --> 00:30:34.109 If it drops below 100, that's a one. Absent is 00:30:34.109 --> 00:30:36.670 zero. And breathing? For respirations, we want 00:30:36.670 --> 00:30:39.069 40 to 60 breaths per minute accompanied by a 00:30:39.069 --> 00:30:42.109 strong, vigorous, angry cry. That earns a two. 00:30:42.269 --> 00:30:44.190 And what concerning respiratory signs should 00:30:44.190 --> 00:30:46.509 a nurse immediately intervene for? You are looking 00:30:46.509 --> 00:30:49.089 for signs that the newborn is fighting for air, 00:30:49.769 --> 00:30:52.730 nasal flaring with every breath, an audible grunt 00:30:52.730 --> 00:30:55.450 on exhalation, and chest retractions where the 00:30:55.450 --> 00:30:57.750 skin aggressively sucks inward around the ribs 00:30:57.750 --> 00:31:00.829 and sternum. These indicate severe respiratory 00:31:00.829 --> 00:31:03.380 distress. So the timer hits one minute. What 00:31:03.380 --> 00:31:05.559 are we physically doing to the baby before we 00:31:05.559 --> 00:31:08.680 even calculate that score? The absolute first 00:31:08.680 --> 00:31:11.920 priority actions are to dry the baby vigorously 00:31:11.920 --> 00:31:15.299 with warm towels, stimulate them by rubbing their 00:31:15.299 --> 00:31:17.460 back or flicking the soles of their feet, clear 00:31:17.460 --> 00:31:19.779 their airway of any mucus, and immediately place 00:31:19.779 --> 00:31:22.059 them skin -to -skin on the mother's bare chest. 00:31:22.220 --> 00:31:24.299 And once they are stable on the chest, we have 00:31:24.299 --> 00:31:26.799 two mandatory pharmacological interventions. 00:31:27.140 --> 00:31:30.079 The eye goop and the shot. Yes. Erythromycin 00:31:30.079 --> 00:31:32.589 ophthalmic ointment. and the vitamin K injection. 00:31:33.190 --> 00:31:35.150 Exams will always ask you for the rationale behind 00:31:35.150 --> 00:31:36.910 these medications. Let's start with the eyes. 00:31:37.190 --> 00:31:39.609 Why are we smearing antibiotic ointment into 00:31:39.609 --> 00:31:43.049 a newborn's eyes? We use erythromycin 0 .5 % 00:31:43.049 --> 00:31:45.829 ointment to prevent a condition called ophthalmia 00:31:45.829 --> 00:31:48.750 neonitorum. When a baity descends through the 00:31:48.750 --> 00:31:51.109 vaginal canal, they are exposed to the mother's 00:31:51.109 --> 00:31:53.970 natural flora, but they are also exposed to undiagnosed 00:31:53.970 --> 00:31:56.390 sexually transmitted infections. Like gonorrhea 00:31:56.390 --> 00:31:58.549 and chlamydia. Exactly. Neisseria gonorrhea and 00:31:58.549 --> 00:32:01.750 chlamydia trachymitis. If those specific bacteria 00:32:01.750 --> 00:32:04.490 infect the newborn's eyes, the resulting infection 00:32:04.490 --> 00:32:06.630 is so aggressive it can cause permanent blindness 00:32:06.630 --> 00:32:10.029 within days. The ointment is a mandatory preventative 00:32:10.029 --> 00:32:12.750 prophylaxis. That makes perfect sense. Now, let's 00:32:12.750 --> 00:32:15.640 pause on the vitamin K. Why does a baby need 00:32:15.640 --> 00:32:17.859 a shot of vitamins immediately upon entering 00:32:17.859 --> 00:32:20.039 the world? Like, what's the urgency? Because 00:32:20.039 --> 00:32:22.660 it isn't just a nutritional vitamin. It is a 00:32:22.660 --> 00:32:26.400 critical life -saving clotting necessity. Phytonidione, 00:32:26.539 --> 00:32:28.960 or vitamin K, is required by the human liver 00:32:28.960 --> 00:32:31.859 to synthesize clotting factors 2, 7, I, X, and 00:32:31.859 --> 00:32:34.579 X. OK. Here is the fascinating physiological 00:32:34.579 --> 00:32:37.859 quirk. Humans do not produce vitamin K on our 00:32:37.859 --> 00:32:40.400 own. It is synthesized by the bacterial flora 00:32:40.400 --> 00:32:43.279 living in our gut. But when a newborn is delivered, 00:32:43.400 --> 00:32:46.019 their gastrointestinal tract is completely 100 00:32:46.019 --> 00:32:48.519 % sterile. Because they've never eaten anything. 00:32:48.680 --> 00:32:51.099 Right. They have no gut bacteria. Therefore, 00:32:51.220 --> 00:32:53.759 they cannot produce vitamin K, which means they 00:32:53.759 --> 00:32:56.759 cannot produce clotting factors. So every baby 00:32:56.759 --> 00:32:59.519 is born with a massive bleeding disorder. Exactly. 00:32:59.880 --> 00:33:01.980 They are at extreme risk for a condition called 00:33:01.980 --> 00:33:05.460 vitamin K deficiency bleeding. Without intervention, 00:33:05.940 --> 00:33:08.980 a minor bump could cause a spontaneous, fatal 00:33:08.980 --> 00:33:12.160 intracranial hemorrhage. Wow. You must give them 00:33:12.160 --> 00:33:14.720 an intramuscular injection of vitamin K into 00:33:14.720 --> 00:33:17.640 the vastus lateralis muscle of the thigh within 00:33:17.640 --> 00:33:20.619 the first hour of life to bridge the gap until 00:33:20.619 --> 00:33:22.980 their gut bacteria develops from feeding. That 00:33:22.980 --> 00:33:26.119 physiology is wild and it makes it very easy 00:33:26.119 --> 00:33:29.019 to understand why it's a priority. Now you mentioned 00:33:29.019 --> 00:33:31.519 earlier that the very first thing we do is dry 00:33:31.519 --> 00:33:34.519 the baby vigorously with warm towels. Let's dig 00:33:34.519 --> 00:33:36.980 into newborn thermoregulation because I know 00:33:36.980 --> 00:33:40.240 this is a massive NCLEX trap. Thermoregulation 00:33:40.240 --> 00:33:43.079 is arguably the most tested newborn concept. 00:33:43.640 --> 00:33:45.279 Newborns are terrible at keeping themselves warm. 00:33:45.559 --> 00:33:47.680 They have a massive body surface area relative 00:33:47.680 --> 00:33:50.619 to their body mass, a very thin epidermal layer, 00:33:51.180 --> 00:33:53.539 and almost zero subcutaneous insulating fat. 00:33:53.740 --> 00:33:56.099 So they just lose heat instantly. Incredibly 00:33:56.099 --> 00:33:58.920 rapidly. And they cannot shiver to generate warmth. 00:33:59.440 --> 00:34:02.319 Instead, they burn specialized brown fat, which 00:34:02.319 --> 00:34:04.740 rapidly depletes their blood sugar, leading to 00:34:04.740 --> 00:34:07.099 life -threatening hypoglycemia. So keeping them 00:34:07.099 --> 00:34:09.219 warm literally keeps their blood sugar stable. 00:34:09.659 --> 00:34:12.320 The exam trap here usually involves identifying 00:34:12.320 --> 00:34:15.559 the four specific mechanisms of heat loss. They 00:34:15.559 --> 00:34:17.960 will give you a scenario and ask which type of 00:34:17.960 --> 00:34:20.079 heat loss is occurring. Let's break down the 00:34:20.079 --> 00:34:22.340 four mechanisms so you never miss these questions. 00:34:22.840 --> 00:34:26.400 Number one, evaporation. This is heat lost when 00:34:26.400 --> 00:34:28.840 liquid moisture on the skin turns into a vapor, 00:34:29.440 --> 00:34:31.480 taking body heat with it. Give me a scenario 00:34:31.480 --> 00:34:34.880 for evaporation. The classic trap scenario. A 00:34:34.880 --> 00:34:37.340 baby is born covered in warm amniotic fluid, 00:34:37.500 --> 00:34:39.059 and the nurse leaves them red on the warmer, 00:34:39.519 --> 00:34:41.300 or the nurse gives the baby their first bath 00:34:41.300 --> 00:34:43.000 and doesn't dry them quickly enough. And the 00:34:43.000 --> 00:34:45.380 fix is just to dry them? Yes. Vigorously dry 00:34:45.380 --> 00:34:47.440 the baby immediately with warm blankets. Wet 00:34:47.440 --> 00:34:49.860 is evaporation. What's the second? Number two, 00:34:50.239 --> 00:34:52.989 conduction. This is heat lost through direct 00:34:52.989 --> 00:34:55.809 physical contact with a cold or solid surface. 00:34:56.349 --> 00:34:58.489 Heat transfers from the warm baby to the cold 00:34:58.489 --> 00:35:00.809 object. Okay, scenario for conduction. A nurse 00:35:00.809 --> 00:35:03.409 places a bare newborn directly onto a cold metal 00:35:03.409 --> 00:35:06.730 weighing scale or assesses their heart with a 00:35:06.730 --> 00:35:10.090 freezing cold stethoscope. The fix is to always 00:35:10.090 --> 00:35:12.469 place a warm blanket or paper pad on the scale 00:35:12.469 --> 00:35:15.230 first and warm your hands and instruments. Touch 00:35:15.230 --> 00:35:18.510 is conduction. Number three. Number three. Convection. 00:35:18.800 --> 00:35:21.579 This is heat lost to cooler ambient air currents 00:35:21.579 --> 00:35:24.039 actively moving across the body, stripping away 00:35:24.039 --> 00:35:26.280 the heat envelope. It's like a fan. Right. The 00:35:26.280 --> 00:35:28.500 trap scenario. The baby is placed under an air 00:35:28.500 --> 00:35:30.760 conditioning vent near an open window, or people 00:35:30.760 --> 00:35:32.920 are rapidly walking past the bassinet creating 00:35:32.920 --> 00:35:36.380 a draft. The fix. Keep the baby away from drafts 00:35:36.380 --> 00:35:38.599 and maintain a warm ambient room temperature. 00:35:38.840 --> 00:35:41.340 Drafts are convection. And the last one. Number 00:35:41.340 --> 00:35:44.989 four. Radiation. This one is tricky. This is 00:35:44.989 --> 00:35:47.530 heat lost to a colder solid surface that the 00:35:47.530 --> 00:35:49.789 baby is not physically touching but is in close 00:35:49.789 --> 00:35:52.730 proximity to. Heat radiates through the air toward 00:35:52.730 --> 00:35:55.170 the cold object. Proximity. Okay, what's the 00:35:55.170 --> 00:35:57.329 scenario? The baby's crib is placed right next 00:35:57.329 --> 00:35:59.750 to a cold, uninsulated exterior window in the 00:35:59.750 --> 00:36:01.550 middle of winter, even though the room air is 00:36:01.550 --> 00:36:04.730 warm. The fix. Move bassinets away from cold 00:36:04.730 --> 00:36:07.690 exterior walls or windows. Okay, to cement that 00:36:07.690 --> 00:36:11.199 into your brain, what is evaporation? Touch is 00:36:11.199 --> 00:36:14.539 conduction. Drafts are convection. Proximity 00:36:14.539 --> 00:36:17.199 is radiation. Memorize those scenarios because 00:36:17.199 --> 00:36:19.300 they appear on almost every OB exam. All right. 00:36:19.320 --> 00:36:22.500 The baby is stable, dry, and resting on the mother's 00:36:22.500 --> 00:36:25.179 chest. The bleeding is temporarily controlled. 00:36:25.619 --> 00:36:28.079 We are now entering the final phase of our deep 00:36:28.079 --> 00:36:31.219 dive, the fourth stage of labor focusing on maternal 00:36:31.219 --> 00:36:34.659 recovery. We are in that critical one to two 00:36:34.659 --> 00:36:37.139 hour post -birth window. The fourth stage is 00:36:37.139 --> 00:36:40.420 defined by one primary nursing objective. aggressive, 00:36:40.659 --> 00:36:43.019 continuous surveillance for postpartum hemorrhage. 00:36:43.260 --> 00:36:45.340 The danger does not end when the placenta delivers. 00:36:45.519 --> 00:36:47.880 Because the uterus can still relax. Exactly. 00:36:48.239 --> 00:36:50.320 The uterus must maintain its contracted state. 00:36:50.679 --> 00:36:52.559 To ensure this, you are constantly assessing 00:36:52.559 --> 00:36:55.860 three interdependent things. The fundus, the 00:36:55.860 --> 00:36:57.940 bladder, and the lochia. Let's start with the 00:36:57.940 --> 00:36:59.900 fundus. We touched on this earlier, but what 00:36:59.900 --> 00:37:02.440 is the fundus actually doing during this recovery 00:37:02.440 --> 00:37:06.239 phase? The fundus is the rounded, thickest, top 00:37:06.239 --> 00:37:08.949 portion of the uterine muscle. Now that it is 00:37:08.949 --> 00:37:12.250 empty, it must undergo a process called involution. 00:37:12.630 --> 00:37:14.909 It has a forcefully contract, shrinking down 00:37:14.909 --> 00:37:17.849 into a tight, hard ball in the pelvis to keep 00:37:17.849 --> 00:37:19.949 those placental blood vessels clamped shut. And 00:37:19.949 --> 00:37:22.349 if it doesn't? If the muscle gets exhausted and 00:37:22.349 --> 00:37:25.369 relaxes, if it loses its tone, that is called 00:37:25.369 --> 00:37:28.530 uterine anthony. The vessels pop open and the 00:37:28.530 --> 00:37:31.010 mother will silently hemorrhage. So when a nurse 00:37:31.010 --> 00:37:33.550 presses deeply into a postpartum patient's abdomen, 00:37:33.949 --> 00:37:36.829 what are the expected reassuring findings? The 00:37:36.829 --> 00:37:39.250 expected finding is that the fundus feels incredibly 00:37:39.250 --> 00:37:41.789 firm, almost like a hard grapefruit beneath the 00:37:41.789 --> 00:37:44.769 skin. Location -wise, it must be perfectly midline 00:37:44.769 --> 00:37:46.849 in the abdomen, located somewhere between the 00:37:46.849 --> 00:37:48.730 umbilicus, the belly button, and the symphysis 00:37:48.730 --> 00:37:51.309 pubis bone. Where is it usually right after birth? 00:37:51.449 --> 00:37:53.309 In the immediate hours after birth, it is usually 00:37:53.309 --> 00:37:55.829 right at or slightly below the level of the umbilicus. 00:37:56.369 --> 00:37:58.349 Yeah. Expected progress is that it drops about 00:37:58.349 --> 00:38:01.269 one finger width or one centimeter lower into 00:38:01.269 --> 00:38:03.550 the pelvis every single day. And the lochia. 00:38:03.840 --> 00:38:07.800 the expected vaginal bleeding. Expected is lochirubra, 00:38:08.079 --> 00:38:11.159 which is dark or bright red blood. It should 00:38:11.159 --> 00:38:13.360 be a moderate amount, perhaps soaking one pad 00:38:13.360 --> 00:38:15.860 every two to three hours. And this stage of lochia 00:38:15.860 --> 00:38:18.099 typically lasts for the first three to four days 00:38:18.099 --> 00:38:20.239 before transitioning to a lighter color. Now, 00:38:20.380 --> 00:38:22.920 what are the concerning findings, the red flags 00:38:22.920 --> 00:38:26.139 that require immediate intervention? First and 00:38:26.139 --> 00:38:29.420 foremost, a boggy fundus. If you press into the 00:38:29.420 --> 00:38:33.000 abdomen and the uterus feels soft, mushy or spongy 00:38:33.000 --> 00:38:36.039 like dough, it means the muscle has relaxed. 00:38:36.679 --> 00:38:39.519 Uterine ethyny. The vessels are open and bleeding. 00:38:40.079 --> 00:38:42.340 If I walk into a room, assess the patient, and 00:38:42.340 --> 00:38:44.880 feel a mushy, boggy fundus, my immediate instinct 00:38:44.880 --> 00:38:46.960 is to hit the call light and yell for the doctor. 00:38:47.159 --> 00:38:49.489 Is that the right move? No. And if you choose 00:38:49.489 --> 00:38:51.809 that on an exam, you will fail the question. 00:38:52.309 --> 00:38:54.909 Your absolute immediate priority nursing action 00:38:54.909 --> 00:38:57.489 for a body fundus is to massage it. Don't leave 00:38:57.489 --> 00:38:59.389 the room. You do not leave the patient. You do 00:38:59.389 --> 00:39:01.590 not wait for orders. You place one hand firmly 00:39:01.590 --> 00:39:04.369 just above the pubic bone to support the lower 00:39:04.369 --> 00:39:06.809 uterine segment. This prevents you from accidentally 00:39:06.809 --> 00:39:08.869 pushing the uterus inside out and prolapsing 00:39:08.869 --> 00:39:12.730 it. And you use your dominant hand to deeply 00:39:13.320 --> 00:39:15.880 forcefully massage the top of the fundus in a 00:39:15.880 --> 00:39:19.039 circular motion. The physical mechanical stimulation 00:39:19.039 --> 00:39:22.260 forces the muscle fibers to wake up and contract. 00:39:22.780 --> 00:39:25.500 Massage is the immediate fix for a boggy fundus. 00:39:25.820 --> 00:39:28.300 But what if I assess the abdomen and the fundus 00:39:28.300 --> 00:39:31.559 feels perfectly firm but it's way up high and 00:39:31.559 --> 00:39:33.340 pushed all the way over to the right side of 00:39:33.340 --> 00:39:36.300 the belly? A displaced fundus is the second major 00:39:36.300 --> 00:39:39.119 concerning finding and it introduces a massive 00:39:39.119 --> 00:39:43.360 NCLEX trap. Why is it pushed to the side? Because 00:39:43.360 --> 00:39:45.940 of the bladder. I think of it this way. The contracting 00:39:45.940 --> 00:39:48.539 uterus is like a tightly clenched fist, acting 00:39:48.539 --> 00:39:51.719 as pressure to stop a severe bloody nose. But 00:39:51.719 --> 00:39:54.179 anatomically, the maternal bladder sits right 00:39:54.179 --> 00:39:56.000 underneath and slightly in front of the lower 00:39:56.000 --> 00:39:58.559 uterus. Exactly. During labor, IV fluids are 00:39:58.559 --> 00:40:00.380 pumping and the mother can't usually feel when 00:40:00.380 --> 00:40:02.260 her bladder is full. So that bladder fills up 00:40:02.260 --> 00:40:04.320 with urine and expands like a massive water balloon. 00:40:04.400 --> 00:40:06.500 Yes. And because the bladder is fixed to the 00:40:06.500 --> 00:40:09.539 pelvic floor, as it expands upward, it physically 00:40:09.539 --> 00:40:11.900 pushes the entire uterus up and shoves it over 00:40:11.900 --> 00:40:14.510 to the side. Usually the right side. And when 00:40:14.510 --> 00:40:17.269 that fist is being stretched and balanced precariously 00:40:17.269 --> 00:40:20.750 over a giant water balloon, it can't clench properly. 00:40:21.389 --> 00:40:23.610 The pressure is lost and the bleeding from the 00:40:23.610 --> 00:40:26.250 placental site resumes. That is precisely the 00:40:26.250 --> 00:40:29.170 mechanism. And here is the trap, which is the 00:40:29.170 --> 00:40:31.750 number one missed concept by nursing students. 00:40:32.329 --> 00:40:34.760 The exam will give you this scenario. The nurse 00:40:34.760 --> 00:40:37.539 assesses a postpartum client and notes a firm 00:40:37.539 --> 00:40:39.920 fundus displaced to the right, slightly above 00:40:39.920 --> 00:40:42.679 the umbilicus, with moderate to heavy lochia. 00:40:43.260 --> 00:40:46.219 What is the priority intervention? Students choose 00:40:46.219 --> 00:40:47.940 massage the fundus because they've been drilled 00:40:47.940 --> 00:40:50.760 that bleeding means massage. Exactly. But read 00:40:50.760 --> 00:40:54.519 the serial. The fundus is already firm. Massaging 00:40:54.519 --> 00:40:56.840 a firm displaced fundus does nothing but cause 00:40:56.840 --> 00:40:59.480 severe pain. The uterus doesn't need massage. 00:40:59.820 --> 00:41:02.079 It needs anatomical room to sit back down deep 00:41:02.079 --> 00:41:04.119 into the pelvis so it can do its job. So what's 00:41:04.119 --> 00:41:06.260 the intervention? Your priority intervention 00:41:06.260 --> 00:41:08.500 is to empty the bladder. You assist the client 00:41:08.500 --> 00:41:10.440 to the bathroom, or if they have an epidural 00:41:10.440 --> 00:41:13.159 and cannot walk, you perform a straight catheterization 00:41:13.159 --> 00:41:15.619 to drain the urine. The moment the bladder empties, 00:41:15.760 --> 00:41:17.840 the uterus drops back to midline and the bleeding 00:41:17.840 --> 00:41:24.019 stops. drain the bladder. It's a critical distinction. 00:41:24.539 --> 00:41:26.199 Now the third concerning finding you mentioned 00:41:26.199 --> 00:41:29.199 earlier was lochia exceeding 1 ,000 milliliters. 00:41:29.500 --> 00:41:32.039 How are we accurately measuring that? Because 00:41:32.039 --> 00:41:35.539 looking at a soaked pad and guessing seems incredibly 00:41:35.539 --> 00:41:38.579 subjective and dangerous. Visual estimation is 00:41:38.579 --> 00:41:41.829 notoriously dangerously inaccurate. A nurse might 00:41:41.829 --> 00:41:44.150 look at a pad and guess 200 milliliters, when 00:41:44.150 --> 00:41:46.909 in reality it's 600 milliliters. The absolute 00:41:46.909 --> 00:41:50.690 gold standard priority action is QBL, quantitative 00:41:50.690 --> 00:41:55.610 blood loss. How does QBL actually work? You meticulously 00:41:55.610 --> 00:41:57.789 weigh everything. You take every single blood 00:41:57.789 --> 00:42:00.250 -soaked pad, chuck or sponge, and you weigh them 00:42:00.250 --> 00:42:02.650 on a gram scale. You then subtract the known 00:42:02.650 --> 00:42:04.409 dry weight of those items. So you need to know 00:42:04.409 --> 00:42:07.130 the dry weight beforehand. Yes. The medical conversion 00:42:07.130 --> 00:42:09.630 you must memorize is exactly one to one. One 00:42:09.630 --> 00:42:12.090 gram of measured weight equals exactly one milliliter 00:42:12.090 --> 00:42:14.849 of blood loss. One gram equals one ml. If that 00:42:14.849 --> 00:42:17.030 calculated number crosses 1 ,000 milliliters, 00:42:17.110 --> 00:42:18.849 regardless of whether it's a vaginal birth or 00:42:18.849 --> 00:42:21.690 a cesarean, you are officially diagnosing a postpartum 00:42:21.690 --> 00:42:23.929 hemorrhage and initiating emergency protocol. 00:42:23.789 --> 00:42:26.730 It takes the guesswork completely out of the 00:42:26.730 --> 00:42:29.489 equation. And it saves lives by catching hemorrhages 00:42:29.489 --> 00:42:32.070 before the mother ever shows signs of hypovolemic 00:42:32.070 --> 00:42:35.329 shock, like a dropping blood pressure or a spiking 00:42:35.329 --> 00:42:37.489 heart rate. Because their vital signs compensate 00:42:37.489 --> 00:42:39.750 for a long time, right? Exactly. By the time 00:42:39.750 --> 00:42:42.070 a young, healthy pregnant woman shows vital sign 00:42:42.070 --> 00:42:44.650 changes from blood loss, she has already lost 00:42:44.650 --> 00:42:47.949 a catastrophic amount of blood. QBL catches it 00:42:47.949 --> 00:42:50.829 early. And just like that, we have navigated 00:42:50.829 --> 00:42:54.019 an incredible clinical journey. We started with 00:42:54.019 --> 00:42:56.039 the physical space of the contracting pelvis, 00:42:56.679 --> 00:42:58.340 worked through the physiological requirements 00:42:58.340 --> 00:43:01.639 for safe pushing, managed the precarious pharmacology 00:43:01.639 --> 00:43:04.500 of the third stage, protected the fragile transition 00:43:04.500 --> 00:43:07.119 of the newborn, and locked down the recovery 00:43:07.119 --> 00:43:09.619 of the postpartum uterus. It is an immense amount 00:43:09.619 --> 00:43:11.619 of material, but notice how it all connects. 00:43:11.760 --> 00:43:14.659 It's all rooted in the physiological why. Exactly. 00:43:14.940 --> 00:43:17.239 And I want to emphasize to you, the listener, 00:43:17.739 --> 00:43:20.639 the sheer value of thinking this way. Leaning 00:43:20.639 --> 00:43:23.139 into this level of clinical detail isn't just 00:43:23.139 --> 00:43:25.619 an academic exercise to help you guess the right 00:43:25.619 --> 00:43:28.260 multiple -choice letter on an exam. No, not at 00:43:28.260 --> 00:43:31.460 all. When you truly understand the cascade of 00:43:31.460 --> 00:43:34.840 aortic oval compression, or why forcing a push 00:43:34.840 --> 00:43:37.980 against an unready cervix causes trauma, or exactly 00:43:37.980 --> 00:43:40.699 why you are massaging that specific fundus instead 00:43:40.699 --> 00:43:43.500 of running for help, you are building the mental 00:43:43.500 --> 00:43:46.420 reflexes of an elite nurse. You aren't just going 00:43:46.420 --> 00:43:48.539 to pass a test. You are going to literally save 00:43:48.539 --> 00:43:51.500 lives on the floor. You absolutely will and as 00:43:51.500 --> 00:43:53.199 we conclude this deep dive. I want to leave you 00:43:53.199 --> 00:43:55.440 with one final broader perspective to reflect 00:43:55.440 --> 00:43:57.630 on well I like this go ahead Throughout all of 00:43:57.630 --> 00:44:00.170 these complex labor stages, we rely so heavily 00:44:00.170 --> 00:44:02.889 on advanced pharmacology, quantitative measurements, 00:44:03.070 --> 00:44:05.829 and continuous monitoring. But think about the 00:44:05.829 --> 00:44:08.550 sheer undeniable power of simple skin -to -skin 00:44:08.550 --> 00:44:11.210 contact during that golden hour. It's easy to 00:44:11.210 --> 00:44:13.449 overlook because it isn't a drug or a machine. 00:44:13.769 --> 00:44:15.869 Exactly. We have millions of dollars of advanced 00:44:15.869 --> 00:44:18.090 medical technology packed into a single labor 00:44:18.090 --> 00:44:20.489 and delivery room. We have specialized radiant 00:44:20.489 --> 00:44:23.969 warmers, complex neonatal cardiac monitors, and 00:44:23.969 --> 00:44:26.969 synthesized oxytocin drips. Yet... simply placing 00:44:26.969 --> 00:44:29.610 a bare, wet newborn directly onto their mother's 00:44:29.610 --> 00:44:32.650 bare chest regulates that infant's body temperature 00:44:32.650 --> 00:44:34.750 more efficiently than our most expensive warming 00:44:34.750 --> 00:44:37.630 beds. It physically stabilizes their erratic 00:44:37.630 --> 00:44:39.909 newborn breathing. It prevents their blood sugar 00:44:39.909 --> 00:44:41.690 from crashing. And it helps the mother, too. 00:44:42.070 --> 00:44:45.039 Miraculously. The sensation of the infant on 00:44:45.039 --> 00:44:47.500 the chest triggers the mother's brain to release 00:44:47.500 --> 00:44:50.599 massive waves of natural endogenous oxytocin, 00:44:50.840 --> 00:44:52.780 which violently clamps down her uterus and saves 00:44:52.780 --> 00:44:55.199 her from bleeding to death. In a medical world 00:44:55.199 --> 00:44:57.559 that is completely obsessed with expensive high 00:44:57.559 --> 00:44:59.920 -tech interventions, isn't it absolutely fascinating 00:44:59.920 --> 00:45:02.639 that the most powerful multi -system life -saving 00:45:02.639 --> 00:45:05.539 tool in the entire hospital is entirely biological 00:45:05.539 --> 00:45:06.739 and completely free?