1229 Exam 3: Intrapartal Care Flashcards by Elizabeth Durham

beginning with irregular uterine contractions (Braxton Hicks) that eventually progress in strength and regularity

Contractions

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2-3 cm long and 1 cm thick all you fill is the rim. Not considered in labor till 4 cm.

Effacement (Chapter 15 pg 27)

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Measurement of fetal decent in centimeters.

Station (with station 0 being at the level an imaginary line at the level of the ischial spines, minus stations superior to ischial spines, and plus stations inferior to the ischial spines.)

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The condition of being dilated or stretched beyond normal dimensions. The act of dilating or stretching

Dilatation

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Occurs when the presenting part, passes the pelvic inlet at the level of the ischial spines. Referred to as station 0.

Engagement

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Brownish or blood-tinged mucus discharge caused by expulsion of the cervical mucus plug resulting from the onset of cervical dilation and effacement.

Bloody Show

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Surgical rupture of the membranes to induce labor.

Amniotomy

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Introduction of solutions into the Amnion.

Amnioinfusion

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Tests pH of the fluid and will turn deep blue indicating the alkalinity of the amniotic fluid and will remain yellow indicating slight acidity if the fluid is urine.

Nitrazine Test

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Long, difficult, or abnormal labor caused by various conditions associated with the five factors affecting labor.

Dystocia

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Dome-shaped top of the uterus and is the site at which the uterine tubes enter the uterus.

Fundus

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Surgical incision made in the area between the vagina and anus (perineum).

Episiotomy

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Occurs when the widest part of the head (the biparietal diameter) distends the vulva just before birth.

Crowning

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An obstetric procedure use to control delivery of the fetal head. It involves applying upward pressure from the coccygeal region to extend the head during actual delivery, thereby protecting the musculature of the perineum.

Ritgen Maneuver

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Determined at 1 and 5 minutes, provides information that must be considered in the context of data from the total assessment.

Apgar Score

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Begins after the contraction has started, and the lowest point of the deceleration occurs after the peak of the contraction. Usually doesn’t return to baseline until after contraction is over

Late Deceleration

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Defined as visually apparent, abrupt increase in FHR above the baseline rate

Acceleration

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Generally onset, nadir, and recovery of the deceleration correspond to the beginning, peak, and end of the contraction. “Mirror Image” of a contraction

Early Deceleration

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The degree of divergence or ability of an object to vary from a given standard or average

Variability

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Factors that Affect Labor

Passenger
Passageway
Powers
Position
Psychological

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Consists of the fetus and the placenta. The size of the fetal head, fetal presentation, lie, position, and attitude affect the ability of the fetus to navigate the birth canal. The placenta can be considered a passenger because it must also pass through the canal.

Passenger

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The relationship of the maternal longitudinal axis (spine) to the fetal longitudinal axis (spine).

Lie

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Relationship of fetal body parts to one another

Attitude

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The part of the fetus that is entering the pelvic inlet first. It can be the back of the head (occiput), chin (mentum), shoulder (scapula), or breech (sacrum).

Presentation

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Relationship of the presenting part of the fetus (sacrum, mentum, or occiput) preferably the occiput, in reference to its directional position as it relates to one of the four maternal pelvic quadrants.

Fetopelvic or Fetal Position

Uterine contractions cause effacement and dilation of the cervix and descent of the fetus. Involuntary urge to push and voluntary bearing down in the second stage helps in the expulsion of the fetus.

Powers

"The Birth Canal" which is composed of the bony pelvis, cervix, pelvic floor, vagina, and introitus (vaginal opening). The size and shape of the bony pelvis must be adequate to allow the fetus to pass through it. The cervix must dilate and efface in response to contractions and fetal descent.

Passageway

The client should engage in frequent position changes during labor to increase comfort, relieve fatigue, and promote circulation. Position during second stage is determined by maternal preference, primary care provider preference, the condition of the mother and the fetus.

Position of Laboring Woman

Maternal stress, tension, and anxiety can produce changes that impair the progress of labor.

Psychological Response

Bony Pelvis

Page 380

Involuntary uterine contractions that signal the beginning of labor

Primary Powers

Once the cervix has dilated voluntary bearing-down efforts by the woman that augment the force of the involuntary contractions

Secondary Powers

Two contractions without returning to the baseline. This is an ominous sign.

Coupling

Measured from the beginning of one contraction to the beginning of the next or from the peak of one to the peak of the next

Frequency

The beginning of one contraction to the end of the same contraction

Duration

Strength of the contraction

Intensity

The end of one contraction to the beginning of the next

Interval

Signs of Preceding Labor

Lightening (baby dropped) Bloody show Maternal weight loss Surge of Energy

May be spontaneous or by amnotomy

Rupture of Membranes (ROM) | ****Assess FHT immediately after ROM

Indications of Imminent Delivery

Bulging of perineum Uncontrollable urge to bear down Sudden increase in bloody show - May accompany urge to bear down

Phases of Stage 1 of Delivery

Latent Active Transitional

Cervical Dilation 0 to 3-4 cm Effacement - Beginning to 50% Contractions - regular, q 15-30 min, mild-moderate intensity lasting 15-30 sec Presenting part -3 to 0 station Bloody show may be present Mother may feel anticipation, excitement and be talkative and able to cope

Latent Phase

Cervical dilation - 4 to 7-8 cm Effacement 50 to 100% Contractions regular q 3-5 min x 30-60 sec with moderate intensity Presenting part +1 to +3 station Increased bloody show Mother becomes serious, concerned about progress of labor, and may ask for pain meds

Active Phase

Cervical dilation - 8 to 10 cm Effacement - 100% Presenting part continues descent Heavy bloody show Spontaneous rupture of membranes (SROM) - monitor FHR after ROM*** Mother less able to cope, may become angry, may lose control, thrash about in bed, groan or cry, may develop n/v, leg tremors

Transitional Phase

From complete cervical dilation through delivery of infant. Maternal behavior changes to actively pushing but may become exhausted In order to assist the client with pushing tell the client to take 2 cleansing breaths and push When the client is crowning the doctor is called and delivery is accomplished The nurse is responsible for prepping the perineum for the delivery

Stage 2

From delivery of infant through delivery of placenta. May experience due to uterine contractions before expulsion of placenta The doctor will deliver the placenta and examine the client for retained placenta The sign of release of the placenta -Lengthening of the umbilical cord in the vagina -Gush of dark blood -Globular shaped uterus Usually within 5-7 minutes after birth of baby

Stage 3

``` 1-4 hours following delivery Uterus should remain firm and positioned at midline, 1-2 finger breadths below umbilicus. Mother usually excited and tired, may be hungry or drowsy Assess -VS -Lochia (Bloody discharge after delivery) -Apply ice to episiotomy -Massage fundus -Check bladder Prevent hemorrhage -Massage fundus -Administer oxytocin -Keep bladder empty -Monitor VS ```

Stage 4

7 Cardinal Movements

``` Engagement Descent Flexion Internal Rotation Extension External Rotation Birth by Expulsion ```

Occurs when the presenting part passes the pelvis inlet at the level of the ischial spines. Referred to as station 0

Engagement

The progress of the presenting part through the pelvis

Descent

When the fetal head meets resistance of the cervix, pelvic wall, or pelvic floor, THe head flexes bringing the chin close to the chest, presenting a smaller diameter to pass through the pelvis

Flexion

The fetal occiput ideally rotates to a lateral anterior position as it progresses from the ischial spines to the lower pelvis in a corkscrew motion to pass through the pelvis

Internal Rotation

The fetal occiput passes under the symphysis pubis and then the head is deflected anteriorly and is born by extension of the chin away from the fetal chest

Extension

After the head is born it rotates to the position it occupied as it entered the pelvic inlet in alignment with the fetal body and completes a quarter turn to face transverse as the anterior shoulder passes under the symphysis

External Rotation

After birth of the head and shoulder the trunk of the infant is born by flexing it toward the symphysis pubis

Birth by Expulsion

Fetal Adaptation to Labor

Heart Rate (Accelerates and Decelerates) Circulation Respiration (Pg. 390)

Maternal Adaptation to Labor

Every system is affected (look at diagram of women)

Assessment of the laboring patient

``` Birth Plan: -Childbirth techniques; attended classes? -Support -Analgesia; Anesthesia Prenatal History: -EDC -Lab -Previous Experiences -Risk Factors ```

Assessment

``` Urine VS Connect to Monitor Uterine Contractions FHR-rate, variability, periodic changes Vaginal Exam (must be done sterile) Temp q2h if ROM ```

Vital Signs

Epidural: -BP q min x 5 min, then q5min, then q15min until stable as ordered Active Labor: - q 15-30 min -q 15 min during transition Take the temp q2hr - if PROM be vigilant in checking the VS and for signs of infections

Induction of Labor

Pitocin (Oxytocin) - used to induce labor (Protocol when membranes intact): - Pitocin 30 units in 500 ml NS for induction - IVPB into primary IV - Begin at 3 milliunits/minute via infusion pump - May increase to 5 milliunits/minute after 15 minutes - Never exceed 20 milliunits unless MD orders * **ALWAYS ON PUMP***

From cervical changes, distention of lower uterine segment, and uterine ischemia Located over the lower portion of abdomen Referred pain: originates in uterus, radiates to abdominal wall, lumbosacral area of back, iliac crests, gluteal area, and down the thighs

Visceral Pain

Pain described as intense, sharp, burning, and well localized Stretching and distention of perineal tissues and pelvic floor to allow passage of fetus, from distention and traction on peritoneum and uterocervical supports during contractions, and from lacerations of soft tissue

Somatic Pain

Threshold remarkably similar in all, regardless of gender, social, ethnic, or cultural differences Differences play definite role in person's perception of and behavioral responses to pain

Perception of Pain

Pain results in physiologic effects and sensory and emotional (affective) responses Emotional expressions of suffering often seen

Expression of Pain

Nonpharmacologic Management of Discomfort

Relaxing and breathing techniques: - Relaxation - Imagery and visualization - Music - Touch and massage - Breathing techniques - Effleurage and counter pressure - Water therapy (hydrotherapy)

Medications for Pain (Analgesia)

Demerol/Fentanyl Stadol/Nubain (IVP) -Push at the beginning of the contraction*** -May be used because these do not depress respirations or cause fetal depression -If given to a drug addicted client may cause narcotic withdrawal

Epidural Anesthesia

Put in at about 4 cm The nurse is responsible for vital signs -BP (Monitor drop in BP immediately following epidural), R, FHT's, etc.. *For Epidural/Spinal Anesthesia the client is given a bolus of IV fluid to offset the fluid volume deficit**

If the BP drops...

Open plain IV fluid Turn client to the side Apply oxygen by tight face mask at 10-12 L/min Elevate feet (don't put head down below 35 degrees) *If FHT's go down may need to turn off Pitocin*

An abnormal, dysfunctional, or difficult process of labor resulting primarily from ineffective uterine contractions, fetal problems or pelvic inadequacy

Dystocia

Thin, Watery (light brown)--no treatment Thick peas soup like--Indicates that the fetus has been stressed or in distress -Delee suction @ birth before first breath -Suction through ET tube with meconium aspirator

Meconium Stained Amniotic Fluid