ATI Maternal Newborn Study Guide
Chapter 1- contraception
• Contraception refers to strategies or device used to reduce the risk of
... [Show More] fertilization or implantation in an attempt to prevent pregnancy
• Natural family planning: behavioral methods
o Abstinence – no gentialia contact o Withdrawal (coitus interruptus)
Choice for monogamous couple
Least effective methods
Risk for pregnancy o Calendar methods
ovulation occurs about 14 days before the onset of her next menstrual cycle, and avoid intercourse during that period
count at least 6 cycles o basal body temperature
body temperature can drop slightly at the time of ovulation
measure oral temperature prior to getting out of bed each morning to monitor ovulation
inexpensive, convenient, and no adverse effects
Basal body temperature and the symptothermal method are fertility awareness methods.
o Lactational amenorrhea method
• Barrier o Condoms
Only water-soluble lubricants should be used with latex condoms to avoid condom breakage o Diaphragm
Dome-shaped cup with a flexible rim made of silicon that fits snugly over the cervix with spermicidal cream or gel placed into the dome and around the rim
Client should be properly fitted with a diaphragm by a provider
Replaced every 2 years and refitted for a 20% weight fluctuation, after abdominal or pelvic surgery and after every pregnancy
Prior to coitus, the diaphragm is inserted vaginally over the cervix with spermicidal jelly or cream that is applied to the cervical side of the dome and around the rim
The diaphragm can be inserted up to 6 hours before intercourse and must stay in place 6 hour after intercourse but for no more than 24 hrs.
Spermicide must be reapplied with each act of coitus
Patient should empty bladder before insertion
Wash with soap and water after use o Cervical cap o Contraceptive sponge o Question
Which method would the nurse identify as a barrier method of contraception?
a. Basal body temperature
b. Transdermal patch
c. Diaphragm
d. Symptothermal method
• Hormonal o Oral contraceptives
Adverse effect
• Chest pain, shortness of breath, leg pain from a possible clot, headache, eye problems form a stroke, and hypertensive, breast tenderness, nausea, breakthrough bleeding
(common adverse effects of estrogen component and progestin component)
Can increase the risk of thromboembolism, stroke, heart attack, hypertension, gallbladder disease, liver tumor
Effectiveness decrease when taking medications that affect liver enzymes, such as anticonvulsants and some antibiotics
o Injectable contraceptives
Medroxyprogesterone is an IM or SQ injection given to a female client every 11 to 13 weeks
• First injection should be during the first 5 days of period
• In postpartum, 5 days after delivery
Maintain adequate intake of calcium and vitamin D
Very effective and require only 4 injections per year
Adverse effects
• Decrease in bone mineral density, weight gain, increase depression and irregular vaginal spotting or bleeding
Contraindicated for osteoporosis patient
Return to fertility can be a long as 18 months after discontinuation o Transdermal patches o Vaginal rings o Implantable progestin
Minor surgical procedure to subdermally implant and remove a single rod contain etonogestrel on the inner side of the upper arm
Disadvantage
• Etonogestrel can cause irregular menstrual bleeding
Adverse effects
• Irregular and unpredictable menstruation (most common)
• Mood changes, headache, acne, depression, decreased bone density and weight gain
o Intrauterine contraceptives (IUD)
A chemically active T-shaped device that is inserted through the cervix and placed in the uterus by the provider
Device must be monitored monthly by clients after menstruation to ensure the presence of small string that hangs form the device into the upper part of the vagina to rule out migration or expulsion of the device
IUD can maintain effectiveness for 1 to 10 years
Contraception can be reversed
Can increase the risk of pelvic inflammatory disease, uterine perforation, or ectopic pregnancy and can be expelled
A client should report to the provider later or abnormal spotting or bleeding, abdominal pain or pain with intercourse, abnormal of foul-smelling vaginal discharge, fever, chills, a change in string length or if IUD cannot be located
IUD can cause irregular menstrual bleeding
Must be removed in the event of pregnancy o Emergency contraception
Morning-after pill that prevents fertilization from taking place
Pill is taken within 72 hr after unprotected coitus
• Surgical methods o Tubal ligation
Sterilization for women
A laprascope is inserted; fallopian tubes are grasped and sealed
o Vasectomy
Sterilization for men
Usually performed under local anesthesia
Involves cutting the vas deferens, which carries the sperm
Chapter 3 – Expected physiological changes during pregnancy
• Signs of pregnancy o Presumptive, probable, positive
• Presumptive: those changes felt by the woman o e.g., breast changes (darkened areolae, enlarged Montgomery’s glands), uterine enlarged, quickening
(slight fluttering movements of the fetus feld by a woman, usually between 16 to 20 seeks of gestation) o Skipping period is not reliable sign of pregnancy by itself but if it accompanied by nausea, fatigue, breast tenderness, and urinary frequency, pregnancy would see very likely
• Probable: those changes observed by an examiner o Hegar’s sign – softening and compressibility of lower uterine segment or isthmus o Ballottement
examiner pushes against the women's cervix during a pelvic exam and feels a rebound from the floating fetus
rebound of unengaged fetus o abdominal enlargement o Chadwick’s sign – deepened violet-bluish color of cervix and vaginal mucosa o Broxton Hicks contractions – falls contractions that are painless, irregular, and usually relieved by walking o Positive pregnancy test
Human chorionic gonadotropin (HcG) is earliest biochemical marker for pregnancy
Production begins as early as day of implantation
Can be detected in maternal serum or urine as soon as 7 to 8 days before the expected menses
Urine sample should be first-voided morning specimens and follow the direction for accuracy o Fetal outline felt by examiner
• Positive: those signs attributed only to the presence of the fetus o Confirm that fetus is growing in the uterus o Fetal heart sound - hearing fetal heart tones (via Doppler) o visualizing the fetus by ultrasound o palpating fetal movements (20 weeks) by examiner o Pulse sock on mom to get mom’s HR to ensure it’s not baby’s heart sound
• Calculating delivery date and determine number of pregnancies for pregnant client o Nagele’s rule
Date of last menstrual period (LMP)
Calculation of estimated or expected date of birth (EDB) or delivery (EDD)
• Nagele’s rule
• Use first day of LNMP 11/21/07
• Subtract 3 months 8/21/07
• Add 7 days 8/28/07
• Adjust year 8/28/08 = EDB
Ultrasound is the best method of dating a pregnancy o Kathy’s rule
Add 9 months and 7 days o Measurement of fundal height
In centimeters form the symphysis pubis to the top of the uterine fundus (between 18 and 32 weeks of gestation)
Approximates the gestational age o Gravidity – number of pregnancies
Nulligravid – never been pregnant
Primigravida – first pregnant
Multigravida – two or more pregnant o Parity – number of pregnancies in which the fetus or fetuses reach 20 weeks of pregnancy
Nullipara – no pregnancy beyond the stage of viability
Primipara – has completed one pregnancy to stage of viability
Multi para o Viability – infant has capacity to survive outside of uterus (22 to 25 weeks) o GTPAL acronym
Gravidity
Term birth (38 weeks or more)
Preterm birth (from viability up to 37 weeks)
Abortions/miscarriages (prior to viability)
Living children
• Blood pressure o Position of pregnant woman affect blood pressure o In Supine position, blood pressure might appear to be lower due to the weight and pressure of the gravid uterus on the vena cava, which pressures venous blood flow to the heart
o Maternal hypotension and fetal hypoxia might occur, which is referred to as supine hypotensive syndrome or supine vena cava syndrome
o Signs and symptoms include
Dizziness, lightheadness, and pale, clammy skin o Encourage client to engage in maternal positioning on the left-lateral side, semi-fowler’s position o if supine, with a wedge placed under one hip to alleviate pressure of the vena cava
• fetal heart tone o 110 to 160/min with reassuring FHR accelerations noted, which indicates an intact fetal CNS
• By 36 weeks gestation, the top of uterus and the fundus will reach the xiphoid process o This cause pregnant woman to experience shortness of breath as the uterus pushes against the diaphragm
• Skin changes o Chloasma – increase of pigmentation on the face o Linea nigra – dark line of pigmentation from the umbilicus extending to the pubic area o Striae gravidarum – stretch marks most notably found on the abdomen and thighs
• Client is encouraged to keep all follow-up appointments and to contact the provider immediately if there is any bleeding, leakage of fluid, or contractions at any time during the pregnancy
Chapter 5
• Recommended weight gain during pregnancy o Healthy weight BMI: 25 to 35 lb
First trimester: 3.5 to 5 lb
Second and third trimesters: 1 lb/wk o BMI <19.8: 28 to 40 lb
First trimester: 5 lb
Second and third trimesters: 1+ lb/wk o BMI >25: 15 to 25 lb
First trimester: 2 lb
Second and third trimesters: 2/3 lb/wk
• Client education o Increase calories
Second trimester – increase 340 cal/day
Third trimester – increase to 450 cal/day
During breastfeeding women should well nourished should be added 450 to 500 cal/day to a balanced diet
o Increasing protein intake
High in folic acid is important for neurological development and prevent fetal neural tube defects
Foods – green leafy vegetables, dried peas and beans, seeds, orange juice
Women who wish to become pregnant of childbearing age take 400 mcg of folic acid
Women who become pregnant take 600 mcg of folic acid to prevent fetal neural tube defects o Iron supplements
Best absorbed between meals and when given with a source of vitamin C (orange juice) Foods – beef liver, red meat, fish, poultry, dried peas and beans and fortified cereals
Stool softener might need to be added to decrease constipation with iron supplement o Calcium
Foods – milk, nuts, legumes and dark green leafy vegetables
Postpartum women who are breastfeeding should continue taking calcium supplement during lactation
o Fluid
8 to 10 glasses (2.3 L) of fluids are recommended daily o Limit caffeine
Recommend daily intake of no more than 200 mg of caffeine
It is recommended that women abstain form alcohol consumption during pregnancy
Chapter 6 – Assessment of fetal well-being
• Ultrasound o client should have full bladder for the procedure o fetal and maternal structures can be pointed out to the client as the US procedure is performed
• Biophysical profile o Uses a real-time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli
o Client presentation
Premature rupture of membranes
Maternal infection
Decreased fetal movement
Intrauterine growth restriction o Variables
FHR
Fetal breathing movements
Gross body movements
Fetal tone
Qualitative amniotic fluid volume o Total score findings
8 to 10 is normal – low risk of chronic fetal asphyxia
4 to 6 is abnormal – suspect chronic fetal asphyxia
Less than 4 is abnormal – strongly suspect chronic fetal asphyxia
• Nonstress test o Most widely used technique for antepartum evaluation of fetal well-being performed during the 3rd trimester
o Noninvasive procedure that monitors response of the FHR to fetal movement o Disadvantage of an NST include a high rate of false nonreactive results with the fetal movement response blunted by sleep cycles of the fetus, fetal immaturity, maternal medications and nicotine use disorder
The acoustic vibration device is activated for 3 seconds on the maternal abdomen over the fetal head to awaken a sleeping fetus
• Contraction stress test
o Nipple-stimulated contraction test
Consists of a woman lightly brushing her palm across her nipple for 2 min, which cause the pituitary gland to release endogenous oxytocin, and then stopping the nipple stimulation when a contraction begins
o Oxytocin-stimulated contraction test
IV administration of oxytocin to induce uterine contractions
Oxytocin is used to induce uterine contraction
Contraindicated for placenta previa, vasa previa, preterm labor, multiple gestations, previous classic incisions for C-section, reduced cervical competence
Can be difficult to stop and may lead to preterm labor
Negative results are a normal finding
Positive result is an abnormal finding o Indication for contraction stress test (CST)
Decreased fetal movement
Intrauterine growth restriction (IUGR)
Postmaturity
• Amniocentesis o Aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into a client’s uterus and amniotic sac under ultrasound guidance locating the placenta and determining the position of the fetus
o It may be performed after 14 weeks of gestation o Indications
Prenatal diagnosis of genetic disorder or congenital anomaly of the fetus
Alpha-fetoprotein (AFP) level for fetal abnormalities
• High AFP – neural tube defect
• Low AFP – down syndrome
Lung maturity assessment o Instruct the client to empty her bladder prior to the procedure to reduce its size and reduce the risk of inadvertent puncture
o Post procedure
Administer Rho(D) immune globulin to the client if she is Rh-negative (standing practice after an amniocentesis for all women who are Rh-negative to protect against Rh isoimmunization)
RhoGAM is giving to Rh- moms at 28 weeks gestation after amniocentesis and after delivery to protect mon against baby’s blood of bay is Rh+
o Complications
Amniotic fluid emboli
Maternal or fetal hemorrhage
Maternal or fetal infection
Miscarriage or preterm labor
Premature rupture of membrane
Leakage of amniotic fluid o A test of the L/S ratio is done as part of amniocentesis to determine fetal lung maturity
• High-risk pregnancy; chorionic villus sampling o CVS is ideally performed at 10 to 23 weeks of gestation o Indications
Risk for giving birth to a neonate who has a genetic chromosomal abnormality
• Monitoring for adverse effects of substance use disorders o Substance use is a risk factor that can leads to spontaneous abortion and abruptio placentae o Teach patient to watch for
Vaginal bleeding uterine craping, partial/complete expulsion of products of conception sharp abdominal pain, and tender rigid uterus
Chapter 7 – Bleeding During Pregnancy
• Ectopic pregnancy
o Ectopic pregnancy is abnormal implantation of a fertilization ovum outside of the uterine cavity usually in the fallopian tube, which can result in a tubal rupture causing a fetal hemorrhage
o Unilateral stabbing pain and tenderness in the lower-abdominal quadrant o Instruct client who is taking methotrexate to avoid alcohol consumption and vitamins containing folic acid to prevent a toxic response to the medication
• Molar growth o Bleeding is often dark brown resembling prune juice o Bright red that is either scant or profuse and continues for few days or intermittently for a few weeks and can be accompanied by passage of vesicles
• Placenta previa o Placenta a previa occurs when the placenta abnormally implants in the lower segment of the uterus near of over the cervical os instead of attaching to the fundus
Complete or total – cervical os is completely covered by the placental attachment
Incomplete or partial – cervical os is only partially covered by the placental attachment o Painless, bright red vaginal bleeding during the 2nd and 3rd trimester o Refrain from performing vaginal exams – can exacerbate bleeding o Administer IV fluids blood products, and medications as prescribed
Corticosteroids, such as betamethasone, promote fetal lung maturation if early delivery is anticipated (cesarean birth)
• Abruptio placentae o Abruptio placentae is the premature separation of the placenta from the uterus o It has significant material and fetal morbidity and mortality and is a leading cause of maternal death o Sudden onset of intense localized uterine pain with dark red vaginal bleeding o Risk factors
Blunt external abdominal trauma (motor-vehicle crash, maternal battering)
Cocaine use resulting in vasoconstriction
Smoking cigarette
Maternal hypertension (chronic or gestational)
Previous incidence of abruptio placentae
Premature rupture of membrane
Multifetal pregnancy
Chapter 9 – Medical conditions
• Cervical insufficiency (premature cervical dilation) o The client can require cervical cerclage (indicated for women who have singleton pregnancy) o Often placed at 12 to 14 weeks gestation and removed at 37 weeks gestation o Provide education about clinical findings to report to the provider for preterm labor rupture of membranes, infection, strong contractions less than 5 min apart, severe perineal pressure, and an urge to push
• Hyperemesis gravidarum o hyperemesis gravidarum is excessive nausea and vomiting (possibly related to elevated hCG levels) that is prolonged past 12 weeks gestation and results in 5% weight loss from pre-pregnancy weight, electrolyte imbalance, acetonuria and ketosis
o Risk factors
maternal age younger than 30, history or migraines, obesity, first pregnancy, diabetes, multigestation, GI disorders, or family history of hyperemesis monitor patient I&O, assess skin turgor, weight and vital signs
o laboratory test
Urinalysis for ketones and acetones (breakdown of PR and fat) is the most important lab test
- Elevated urine specific gravity, urine ketone present
Chemistry profile
Thyroid test – indicate hyperthyroidism
CBC (complete blood count) – elevated Hct
o Nursing care
Monitor I&O
Assess skin turgor and mucous membranes
Monitor vital signs
Monitor weight
Have the client remain NPO for 24 to 48 hours
Clear liquid after 24 if no vomiting and increase diet if tolerated o Medications
Give the client IV lactated ringer’s for hydration
Give pyridoxine (vitamin B6) and another vitamin supplement s as tolerated
Use antiemetic medications (ondansetron, metoclopramide) cautiously for uncontrollable nausea and vomiting
Use corticosteroid to treat refractory hyperemesis gravidarum o Advance the client’s diet as tolerated, with frequent small meals – start with dry toast, crackers, or cereal; then move to a soft diet; and finally, to a normal diet as tolerated
• Iron-deficiency anemia o Occurs during pregnancy due to inadequacy in maternal iron stores and consuming insufficient amounts of dietary iron
o Foods – legumes, fruits, green leafy veggies, and meat o Medications
Ferrous sulfate iron supplements
• Instruct the client to take the supplement on an empty stomach and take with orange juice to increase absorption
• Encourage a diet rich in vitamin C- containing foods to increase absorption
• Gestational diabetes mellitus o Gestational diabetes mellitus (GDM) is an impaired tolerance to glucose with the first onset or recognition during pregnancy
Normal glucose during pregnancy – 70 to 110 mg/dL
Women will develop type II diabetes mellitus within 5 years of delivery o Laboratory tests
Glucola screening test/1-hr glucose tolerance test
• 50 g oral glucose load, followed by plasma glucose analysis 1 hour later perforated 24 to 28 weeks of gestation
• Fasting is not necessary
• Positive blood glucose screening is 130 to 140 mg/dL or greater
• Additional testing with a 3-hr oral glucose tolerance test (OGTT) is indicated
Oral glucose tolerance test (OGTT)
• Following overnight fasting
• Avoid caffeine and abstinence from smoking for 12 hr prior to testing
• Fasting glucose is obtained, a 100g glucose load is given and serum glucose levels are determined at 1,2, and 3 hr following glucose ingestion
o Diagnostic procedures
Biophysical profile to ascertain fetal well-being
Nonstress test to assess fetal well-being o Medication
Oral hypoglycemic therapy is an alternation to insulin in women who have GDM who require medication in addition to diet for blood glucose control
Most oral hypoglycemic agents are contraindicated for gestational diabetes mellitus, but there is limited use of glyburide.
• Gestational hypertension o Vasospasm contributing to poor tissue perfusion is the underlying mechanism for the manifestations of pregnancy hyper tensive disorders o Gestational hypertension (GH)
After 20th weeks of pregnancy
Elevated BP at 140/90 mmHg or greater recorded on 2 different occasions at least 4 hr apart
Not proteinuria o Mild preeclampsia
GH with addition of
Proteinuria of greater than or equal to 1+ o Severe preeclampsia
Bp 160/110 mmHg or greater
Proteinuria greater than 3+
Elevated serum creatinine greater than 1.1 gm/dL
Cerebral visual disturbances (headache and blurred vision)
Hyperreflexia with possible ankle clonus
Pulmonary or cardiac involvement
Extensive peripheral edema
Hepatic dysfunction
Epigastric and right upper-quadrant pain and thrombocytopenia o Eclampsia
Severe preeclampsia manifestation with the onset of seizure activity or coma o Help syndrome
H: Hemolysis – resulting in anemia and jaundice
EL: Elevated liver enzyme – ALT, AST
LP: Low platelet (less than 100,000) o Laboratory
Liver enzyme – elevated AST, LDH
Serum creatinine, BUN, uric acid, magnesium increases as renal function decreases
CBC
Clotting studies – thrombocytopenia
Chemistry profile – decreased Hgb, hyperbilirubinemia o Medication
Anti-hypertensive medication
• Methyldopa
• Nifedipine
• Hydralazine
• Labetalol
Avoid ACE inhibitors and angiotensin II receptor blockers
Anticonvulsant
• Magnesium sulfate
• Medication of choice for prophylaxis or treatment to lower blood pressure and depress the CNS
• Monitor for signs of magnesium sulfate toxicity o Absence of patella deep tendon reflexes o Urine output less than 30 mg/hr o RR less than 12/min o Decrease level of consciousness o Cardiac dysrhythmias
• Antidote – calcium gluconate or calcium chloride
o Client education
Maintain bed rest and encourage side-lying position
Promote diversional activities (TV, visits form family or friends, gentle exercise)
Avoid foods that are high in sodium
Avoid tobacco and alcohol and limit caffeine intake
Drink 6 to 8 oz glasses of water a day
Maintain dark, quiet environment to avoid inducing a seizure
Maintain a patent airway in the event of seizure
Administer antihypertensive medications as prescribed
Chapter 10 – Early Onset of Labor
• Preterm labor o Preterm labor is uterine contraction and cervical changes that occur between 20 and 37 weeks of gestation
o Assessment of preterm labor
Previous preterm birth
Multifetal pregnancy
Substance use
History of multiple miscarriages or abortions
Diabetes mellitus
Chronic hypertension
Second trimester bleeding
History of UTI
o
o Expected findings – uterine contraction o Diagnostic procedures
Obtain swab of vaginal secretions for fetal fibronectin between 24 and 34 weeks of gestation
This protein can be found in vaginal secretions and can be related to inflammation of the placenta and that can lead to preterm birth
This test is used to determine preterm labor o Nursing care
Focusing on stopping uterine contraction
Activity restriction
• Strict bed rest can have adverse effects
• Encourage the client to rest in the left lateral position to increase blood flow to the uterus and decrease uterine activity
Ensuring hydration
• Dehydration stimulate the pituitary gland to secret and antidiuretic hormone and oxytocin
o Medication
Nifedipine
• Calcium channel blocker
• Used to suppress contractions by in habiting calcium form entering smooth muscles
• Nursing consideration o Monitor for headache, flushing, dizziness and nausea o These usually are related to orthostatic hypotension that occurs with administration
Magnesium sulfate
• Commonly used tocolytic that relaxes the smooth muscle of the uterus and thus inhibits uterine activity by suppressing contraction
• Nursing consideration o Contraindications for tocolysis include active vaginal bleeding, dilation of the cervix greater than 6 cm, chorioamnionitis, greater then 34 weeks gestation and acute fetal distress
o Monitor for client for magnesium toxicity and discontinue for any of the following adverse effects
Loss of deep tendon reflexes
Urinary output less than 30 ml/hr
Respiratory depression (less than 12/min)
Pulmonary edema and chest pain
o Administer gluconate of calcium chloride as and antidote for magnesium sulfate toxicity
• Notify provider – blurred vision, headache, nausea, vomiting, or difficulty breathing
Indomethacin
• Non-steroidal anti-inflammation drug (NSAID)
• Suppress preterm labor by blocking the production of prostaglandins
• This inhibition of the prostaglandins suppresses uterine contraction
Betamethasone
• Enhance fetal lung maturity and surfactant production in fetuses between 24 to 34 weeks gestation • Premature rupture of membranes
o Client reports a gush or leakage of clear fluids from the vagina
Temperature elevation
Increased maternal hear rate or FHR
Foul-smelling fluid or vaginal discharge
Abdominal tenderness o Positive nitrazine paper test (blue, pH 6.5 to 7.5) or positive forming test is conducted on amniotic fluid to verify rupture of membranes
o Medications
Ampicillin is an antibiotic uses to treat infection
Betamethasone
• Glucocorticoid administered IM in 2 injections • Enhance fetal lung maturity and surfactant production
o Tell the client to record daily kick counts for fetal movement
Chapter 11 – Labor and Delivery Process
• Stages of labor o First stage (onset of labor to complete dilation)
Latent phase (0 to 3 cm)
• Onset of labor – contractions irregular and mild to moderate
• Woman is talkative and eager
Active phase (4 cm to 7 cm)
• Contractions – regular moderate to strong
• Woman feeling of helplessness
• Anxiety and restlessness increase as contraction become stronger
Transition phase (8cm to 10 cm)
• Complete dilation
• Feeling out of control, client often states “cannot continue”
• Urge to push increased rectal pressure and feelings of needing to have a bowel movement
o Second stage
Full dilation to birth o Third stage
Delivery of the neonate to delivery of placenta o Fourth stage
Delivery of placenta to maternal stabilization of vital signs
• Physiologic changes preceding labor (premonitoring sign) o Backache, weight loss o Lightening
fetal head descends into true pelvis about 14 days before labor
feeling that the fetus has “dropped”
easier breathing but more pressure on bladder resulting urinary frequency o contraction – begin with irregular uterine contractions (Braxton Hicks)
o increased vaginal discharge or bloody show o energy burst o gastrointestinal changes – nausea, vomiting and indigestion o Cervical ripening- cervix become soft (opens) and partially effaced and can begin to dilate o Rupture of membrane
Immediately following the rupture of membranes, a nurse should assess the FHR for abrupt decelerations, which are indicative of fetal distress to rule out umbilical cord prolapse
o Assessment of amniotic fluid [Show Less]