[15] MIDTERM | INTRAPARTUM PART 3A (STAGES OF LABOR) Flashcards
- regular progression of uterine contractions
- effacement and progressive dilatation of the cervix
- progress in descent of the presenting part
NORMAL LABOR
1ST STAGE OF LABOR
- stage of ____
- begins with the onset of regular ____ and ends with complete ____
- Factors affecting the length of labor: ____, maternal & fetal position, ____, and level of ____
- stage of dilatation
- begins with the onset of regular uterine contractions and ends with complete dilation of the cervix
- Factors affecting the length of labor: analgesia, maternal & fetal position, woman’s body size, and level of physical fitness
1ST STAGE OF LABOR
LATENT PHASE
* Contractions are mild to moderate intensity and short, lasting ____ seconds.
- may start as mild contractions lasting ____ seconds with a frequency of ____ minutes and progress to moderate lasting ____ seconds with a frequency of ____ minutes
- w/ effacement & cervix dilates ____ cm
- Duration: Nullipara: ____ hrs. ; Multipara: ____ hours
- ____ contractions an hour is considered a meaningful signal that spontaneous birth is beginning or imminent.
- Prolonged latent phase: exceeding ____ hours in nullipara & ____ hours in multipara
LATENT PHASE
* Contractions are mild to moderate intensity and short, lasting 20 to 40 seconds.
- may start as mild contractions lasting 20 to 30 seconds with a frequency of 10 to 30 minutes and progress to moderate lasting 30 to 40 seconds with a frequency of 5 to 7 minutes
- w/ effacement & cervix dilates 0-3 cm
- Duration: Nullipara: 6 hours ; Multipara: 4.5 hours
- Twelve contractions an hour is considered a meaningful signal that spontaneous birth is beginning or imminent.
- Prolonged latent phase: exceeding 20 hours in nullipara & 14 hours in multipara
ACTIVE PHASE
* Cervical dilatation occurs more rapidly, increasing from ____ cm ( ____ cm/hr in nulliparas and ____ cm/hr in multiparas)
- Fetal descent is ____
- Contractions become more frequent (every ____ minutes) and longer in duration lasting ____ seconds, and are ____ intensity
ACTIVE PHASE
* Cervical dilatation occurs more rapidly, increasing from 4 to 7 cm (1.2 cm/hr in nulliparas and 1.5 cm/hr in multiparas)
- Fetal descent is progressive
- Contractions become more frequent (every 3-5 minutes) and longer in duration lasting 40 to 60 seconds, and are moderate to strong intensity
ACTIVE PHASE: WHO, 2018
* The duration of active first stage (from ____ cm until full cervical dilatation) usually does not extend beyond ____ hours in first labors, and usually does not extend beyond ____ hours in subsequent labors.
- A minimum cervical dilatation rate of ____ cm/hour throughout active first stage is unrealistically fast for some women and is therefore not recommended for identification of normal labor progression.
- A slower than ____ cm/hour cervical dilatation rate alone should not be a routine indication for obstetric intervention.
ACTIVE PHASE: WHO, 2018
* The duration of active first stage (from 5 cm until full cervical dilatation) usually does not extend beyond 12 hours in first labors, and usually does not extend beyond 10 hours in subsequent labors.
- A minimum cervical dilatation rate of 1 cm/hour throughout active first stage is unrealistically fast for some women and is therefore not recommended for identification of normal labor progression.
- A slower than 1-cm/hour cervical dilatation rate alone should not be a routine indication for obstetric intervention.
ACTIVE PHASE
* Duration: nulliparas ____ hrs and ____ hrs in multiparas
- Show and perhaps spontaneous ____ may occur
- By the end of the active phase, contractions have a frequency of ____ min, duration of ____ seconds, and ____ intensity
ACTIVE PHASE
* Duration: nulliparas 3 hrs and 2 hrs in multiparas
- Show and perhaps spontaneous rupture of the membranes may occur
- By the end of the active phase, contractions have a frequency of 2 -3 min, duration of 60 seconds, and strong intensity
TRANSITION PHASE
* contractions reach their peak of intensity which is ____, occurring every ____ min with duration of ____ seconds and causing maximum dilatation of ____ cm.
- By the end of this phase, both ____ and complete ____ have occurred
TRANSITION PHASE
* contractions reach their peak of intensity which is strong, occurring every 2-3 min with duration of 60-70 seconds and causing maximum dilatation of 8-10 cm.
- By the end of this phase, both full dilatation (10 cm) and complete cervical effacement (obliteration of the cervix) have occurred
TRANSITION PHASE
* Does not usually last longer than ____ for nulliparas or____; increased by approx. ____ if epidural anesthesia is used
- Does not usually last longer than 3 hours for nulliparas or longer than 1 hour for multiparas; increased by approx. 1 hour if epidural anesthesia is used
TRANSITION PHASE - Characteristics
* Increasing ____
* Hyperventilation
* Generalized discomfort, including ____
* Increased need for partner’s and/or nurse’s presence and support
* Restlessness
* Increased ____
* An inner focusing on her contractions
* A sense of bewilderment, frustration, and anger at the contractions
* Requests for ____
* Hiccupping, belching, nausea, or vomiting
* Beads of perspiration on the upper lip of brow
* Increasing ____
- Increasing bloody show
- Hyperventilation
- Generalized discomfort, including low backache, shaking and crampin in legs, and increased sensitivity to touch
- Increased need for partner’s and/or nurse’s presence and support
- Restlessness
- Increased apprehension and irritability
- An inner focusing on her contractions
- A sense of bewilderment, frustration, and anger at the contractions
- Requests for medications
- Hiccupping, belching, nausea, or vomiting
- Beads of perspiration on the upper lip of brow
- Increasing rectal pressure and feeling the urge to bear down
MATERNAL ASSESSMENT
INITIAL INTERVIEW AND PHYSICAL EXAMINATION
Obtain information about the following:
* Woman’s name and age
* ____
* Frequency, duration, and intensity of contractions
* Amount and character of show
* Whether ____ has occurred
* Vital signs (assessed between contractions)
* Time the woman last ate
* Any known drug allergies
* Past pregnancy and previous pregnancy history
* Her ____ or what ____
- Woman’s name and age
- LMP and expected date of birth
- Frequency, duration, and intensity of contractions
- Amount and character of show
- Whether rupture of membranes has occurred
- Vital signs (assessed between contractions)
- Time the woman last ate
- Any known drug allergies
- Past pregnancy and previous pregnancy history
- Her birth plan or what individualized measures she has planned
MATERNAL ASSESSMENT
HISTORY
* Physical and psychological events
* ____
* General health
* ____
* Note that all date are necessary to plan nursing care
- Physical and psychological events
- Review of past pregnancies
- General health
- Family medical information
- Note that all date are necessary to plan nursing care
MATERNAL ASSESSMENT
CURRENT PREGNANCY HISTORY
* ____
* A description of this pregnancy
* ____
* Future child care
- OB score
- A description of this pregnancy
- Plans for labor
- Future child care
MATERNAL ASSESSMENT
PAST PREGNANCY HISTORY
Document the following: (6)
- Number
- Dates
- Types of birth
- Any complications and outcomes
- Sex and birth weights of children
- Current health status of the children
MATERNAL ASSESSMENT
PAST HEALTH HISTORY
* Previous surgeries
* ____
* ____
* TB
* Kidney disease or hypertension
* ____
* Woman’s lifestyle
- Previous surgeries
- Heart disease or diabetes
- Anemia
- TB
- Kidney disease or hypertension
- STI such as Herpes
- Woman’s lifestyle
MATERNAL ASSESSMENT
FAMILY MEDICAL HISTORY
Ask if any family member is/has: (9)
- Cognitively challeneged
- Heart disease
- Blood dyscrasia
- DM
- Kidney disease
- Cancer
- Allergies
- Seizures
- Congenital disorder
MATERNAL ASSESSMENT
PHYSICAL EXAMINATION
* Thorough PE, including a pelvic examination, to confirm ____ and ____
* Include inspection, palpation, and auscultation
- Thorough PE, including a pelvic examination, to confirm the presentation and position of the fetus and the stage of cervical dilatation
- Include inspection, palpation, and auscultation
MATERNAL ASSESSMENT
VITAL SIGNS - Temperature
* Obtained ____
* ____ → infection on NPO, ____ → ____
* After rupture of the membranes, temperature should be taken ____
- Obtained q4h
- >37.2 C (99 F) → infection on NPO, ↑ temp → dehydration
- After rupture of the membranes, temperature should be taken q2h
MATERNAL ASSESSMENT
VITAL SIGNS - Pulse and Respiration
* ____
* PR: ____
* PR >100 bpm → tachycardia (dehydration/ hemorrhage)
* RR: 18-20 cpm
* Contractions = ____
- Q4h
- PR: 70-80bpm
- PR >100 bpm → tachycardia (dehydration/ hemorrhage)
- RR: 18-20 cpm
- Contractions = ↑RR
MATERNAL ASSESSMENT
VITAL SIGNS - Blood Pressure
* ____
* During contraction: BP rise ____
* ↑ BP = PIH
* ↓ BP/Pulse Pressure = ____
- Q4h
- During contraction: BP rise 5-15 mmHg
- ↑ BP = PIH
- ↓ BP/Pulse Pressure = hemorrhage
MATERNAL ASSESSMENT
ABDOMINAL ASSESSMENT
* Estimate ____
* Presentation and position
* Palpate and percuss ____
* Assess for ____
- Estimate fetal size (fundic height)
- Presentation and position
- Palpate and percuss the bladder area
- Assess for abdominal scars
MATERNAL ASSESSMENT
VAGINAL ASSESSMENT
* Determine the ____; confirm the ____, position, and ____
* Do not do vaginal exam in the presence of fresh → bleeding may indicate ____
- Determine the extent of cervical effacement and dilatation; confirm the fetal presentation, position, and degree of descent
- Do not do vaginal exam in the presence of fresh → bleeding may indicate placenta previa
MATERNAL ASSESSMENT
ASSESSING RUPTURE OF MEMBRANES
Sterile Vaginal Examination
* After vaginal secretions are obtained, test them with a strip of ____
* ____ - Acidic
* ____ - Alkaline
____ (Examination of Vaginal Secretions under a Microscope)
* Amniotic fluid will show a ____ when dried and examined in this way; urine will not
BOW Ruptured at Home - ask mother to describe the color of amniotic fluid
* Should be ____
* ____ - blood incompatibility between mother and fetus
* ____ - meconium staining (in vertex presentation, may indicate fetal anoxia; meconium aspiration)
Sterile Vaginal Examination
* After vaginal secretions are obtained, test them with a strip of Nitrazine paper
* Vaginal secretions - Acidic
* Amniotic fluid - Alkaline
Fern Test (Examination of Vaginal Secretions under a Microscope)
* Amniotic fluid will show a fern pattern when dried and examined in this way; urine will not
BOW Ruptured at Home - ask mother to describe the color of amniotic fluid
* Should be as clear as water
* Yellow-stained - blood incompatibility between mother and fetus
* Green Fluid - meconium staining (in vertex presentation, may indicate fetal anoxia; meconium aspiration)
MATERNAL ASSESSMENT
ASSESSMENT OF PELVIC ADEQUACY
* ____ - not to attempt a home birth
* ____ - to determine how readily the fetal head will born
* ____ to measure the pelvic outlet
- Cephalopelvic disproportion - not to attempt a home birth
- Estimate suprapubic angle - to determine how readily the fetal head will born
- Closed fist to measure the pelvic outlet
MATERNAL ASSESSMENT
ASSESSMENT OF UTERINE CONTRACTIONS (3)
- Length/duration
- Intensity
- Frequency
FETAL ASSESSMENT
FETAL POSITION
Determined thru:
* ____ - size and shape, lie: projects up and down (longitudinal lie) or left to right (transverse lie)
* Palpation - ____
* ____ - presenting part
* ____ - used when the fetal position cannot be determined by abdominal palpation
Determined thru:
* Inspection - size and shape, lie: projects up and down (longitudinal lie) or left to right (transverse lie)
* Palpation - Leopold’s manuever
* Vaginal Examination - presenting part
* Ultrasound - used when the fetal position cannot be determined by abdominal palpation
FETAL ASSESSMENT
FHR - Auscultation of Fetal Heart Sounds
* Transmitted best through the ____
* Use stethoscope or a ____
* ____ – best heard through the fetal back
* ____ – heard most clearly at the woman’s umbilicus or above
* ____ – heard loudest in lower abdomen - ROA – RLQ; LOA - LLQ
- Transmitted best through the convex portion of a fetus
- Use stethoscope or a fetoscope, doppler unit
- Vertex or Breech – best heard through the fetal back
- Breech – heard most clearly at the woman’s umbilicus or above
- Cephalic – heard loudest in lower abdomen - ROA – RLQ; LOA - LLQ
FETAL ASSESSMENT
FHR - Auscultation of Fetal Heart Sounds
____
* Latent Phase - q1h
* Active Phase - q30 minutes
* Second Stage - q15 minutes
Low Risk Women
* Latent Phase - q1h
* Active Phase - q30 minutes
* Second Stage - q15 minutes
FETAL ASSESSMENT
FHR - Auscultation of Fetal Heart Sounds
____
* Latent Phase - q30 minutes
* Active Phase - q15 minutes
* Second Stage - q5 minutes
High Risk Women
* Latent Phase - q30 minutes
* Active Phase - q15 minutes
* Second Stage - q5 minutes
FETAL ASSESSMENT
FHR - ____
The monitor is left in place for continuous monitoring on women who are categorized as high risk for any reason or who have oxytocin stimulation.
FHR - Electronic Monitoring
The monitor is left in place for continuous monitoring on women who are categorized as high risk for any reason or who have oxytocin stimulation.
NURSING DIAGNOSES (3)
- Fear/Anxiety r/t discomfort of labor and unknown labor outcome
- Acute Pain r/t uterine contractions, cervical dilatation, and fetal descent
- Deficient Knowledge r/t lack of information about normal labor process and comfort measures
PAIN MANAGEMENT
FACTORS THAT INFLUENCE LABOR PAIN
* ____ - pain perception, is the least amount of sensation that a person perceives as painful
* ____ - amount of pain one is willing to endure
* ____ - Occurs in the spinal cord; Pain sensations are transmitted from the periphery of the body along nerve pathways to the brain; Only limited number of sensations can travel these pathways at one time.
* ____ - neurmodulators; also called endorphins or endogenous opiates
- Pain Threshold - pain perception, is the least amount of sensation that a person perceives as painful
- Pain Tolerance - amount of pain one is willing to endure
- Gate Control Theory - Occurs in the spinal cord; Pain sensations are transmitted from the periphery of the body along nerve pathways to the brain; Only limited number of sensations can travel these pathways at one time.
- Chemical Factors - neurmodulators; also called endorphins or endogenous opiates
MANAGEMENT OF PAIN
NONPHARMACOLOGICAL PAIN MANAGEMENT (12)
- Cognitive Stimulation Methods
- Cutaneous Stimulation
- Thermal Stimulation
- Breathing Techniques
- Relaxation
- Hypnosis
- Therapeutic Touch
- Music
- Aromatherapy
- Acupressure
- Acupuncture
- Prayer
MANAGEMENT OF PAIN
NONPHARMACOLOGICAL PAIN MANAGEMENT
Cognitive Stimulation Methods
* Mental Stimulation: ____
* Using ____ or focusing on ____ or a ____ may help the woman block out painful sensations
- Mental Stimulation: Imagery
- Using focal point or focusing on breathing patterns or a spot on the wall may help the woman block out painful sensations
MANAGEMENT OF PAIN
NONPHARMACOLOGICAL PAIN MANAGEMENT
Cutaneous Stimulation
* Touching, rubbing or massaging (____)
* Counter pressure at the point of back pain (____)
- Touching, rubbing or massaging (rhythmic stroking/effleurage)
- Counter pressure at the point of back pain (sacral pressure)
MANAGEMENT OF PAIN
NONPHARMACOLOGICAL PAIN MANAGEMENT
Thermal Stimulation
* ____ - warm bath or shower
* ____ - cool, damp cloth applied to the forehead
* Hot or cold towels applied to the back to relieve mild back presure
- Early Labor - warm bath or shower
- Later Phases - cool, damp cloth applied to the forehead
- Hot or cold towels applied to the back to relieve mild back presure
MANAGEMENT OF PAIN
NONPHARMALOGICAL PAIN MANAGEMENT
* ____ - relaxation of voluntary muscles between contractions
* ____ - safe, without known side effects, and has positive physical and psychologic outcomes
- Relaxation - relaxation of voluntary muscles between contractions
- Hypnosis - safe, without known side effects, and has positive physical and psychologic outcomes
MANAGEMENT OF PAIN
NONPHARMACOLOGIC PAIN MANAGEMENT
Therapeutic Touch
* Use of touch to comfort and relieve pain (____)
* Distraction effleurage, the technique of gentle abdominal massage often taught with ____
- Use of touch to comfort and relieve pain (energy fields)
- Distraction effleurage, the technique of gentle abdominal massage often taught with Lamaze preparation
MANAGEMENT OF PAIN
NONPHARMACOLOGICAL PAIN MANAGEMENT
Music
* Decreased ____
* Comforting music promotes ____ (increasing oxygen intake)
- Decreased maternal anxiety
- Comforting music promotes maternal relaxation (increasing oxygen intake)
MANAGEMENT OF PAIN
NONPHARMALOGICAL PAIN MANAGEMENT
* ____ - fragrances of rose, lavender, frankincense, and bergamot oils are believed to promote comfort and relaxation and decrease pain
* ____ - Pressure Point (between the first and second metacarpal bones on the back of the hand)
* ____ - activation of the insertion points - release of endorphins
- Aromatherapy - fragrances of rose, lavender, frankincense, and bergamot oils are believed to promote comfort and relaxation and decrease pain
- Acupressure - Pressure Point (between the first and second metacarpal bones on the back of the hand)
- Acupuncture - activation of the insertion points - release of endorphins
MANAGEMENT OF PAIN
PHARMACOLOGICAL - Systemic Medications
Opioid Analgesics
* Analgesic effect; induces sedation
* Drugs: (4)
- Analgesic effect; induces sedation
- Drugs: Butorphanol tartrate (Stadol), Nalbuphine hydrochloride (Nubain), Meperidine (Demerol), and Fentanyl (sublimaze)
PHARMACOLOGICAL - Systemic Medications
Analgesic Potentiators
* Tranquilizer; decreases anxiety
* Potentiate the effects of opioid analgesics
* Side Effect: sedation
* Drugs: (3)
- Tranquilizer; decreases anxiety
- Potentiate the effects of opioid analgesics
- Side Effect: sedation
- Drugs: Promethazine (Phenergan), Hydroxyzine (Vistaril), and Promazine (Sparine)
MANAGEMENT OF PAIN
PHARMACOLOGICAL - Regional Anesthesia and Analgesia
* ____ - temporary loss of sensation of a body part
* ____: epidural, spinal, and combined epidural-spinal blocks
* ____ – used during labor and vaginal birth and CS
* ____ – alter the transmission of impulses to the bladder, ↓ UO; interfere with BP stability and leg movement; slowed descent of fetus; ↑risk of perineal lacerations
- Regional anesthesia - temporary loss of sensation of a body part
- Regional anesthetic blocks: epidural, spinal, and combined epidural-spinal blocks
- Epidural blocks – used during labor and vaginal birth and CS
- Anesthetic agents – alter the transmission of impulses to the bladder, ↓ UO; interfere with BP stability and leg movement; slowed descent of fetus; ↑risk of perineal lacerations
MANAGEMENT OF PAIN
PHARMACOLOGICAL - Regional Anesthesia and Analgesia
Nursing Care during Administration of Regional Anesthesia:
* ____ before administration
* Assisting her with positioning during and after the procedure
* Monitoring and assessing VS and respiratory status
* Monitoring ____
* Determine ____
- Helping the woman void before administration
- Assisting her with positioning during and after the procedure
- Monitoring and assessing VS and respiratory status
- Monitoring analgesic effect
- Determine fetal being
MANAGEMENT OF PAIN
PHARMACOLOGICAL - Regional Anesthesia and Analgesia
Types of Local Anesthetic Agents:
* ____ - procaine hydrochloride ( ____ ), chloroprocaine hydrochloride ( ____ )
* ____ – lidocaine hydrochloride ( ____ ), mepivacaine hydrochloride ( ____ )
- Ester - procaine hydrochloride (novocaine), chloroprocaine hydrochloride (nesacaine)
- Amide – lidocaine hydrochloride (xylocaine), mepivacaine hydrochloride (carbocaine)
MANAGEMENT OF PAIN
PHARMACOLOGICAL - Regional Anesthesia and Analgesia
Adverse Maternal Reactions to Anesthetic Agents:
* ____: palpitations, tinnitus, apprehension, confusion, and metallic taste in mouth.
* ____: more severe degrees of mild symptoms plus nausea and vomiting, hypotension, and muscle twitching, which may progress to convulsion.
* ____: sudden loss of consciousness, coma, severe hypotension, bradycardia, respiratory depression, and cardiac arrest.
- Mild reactions: palpitations, tinnitus, apprehension, confusion, and metallic taste in mouth.
- Moderate reactions: more severe degrees of mild symptoms plus nausea and vomiting, hypotension, and muscle twitching, which may progress to convulsion.
- Severe reactions: sudden loss of consciousness, coma, severe hypotension, bradycardia, respiratory depression, and cardiac arrest.
MANAGEMENT OF PAIN
PHARMACOLOGICAL - Regional Anesthesia and Analgesia
* ____ - injection of an anesthetic agent into the epidural space (between L4 and L5) provides pain relief from uterine contractions and vaginal or cesarean birth.
- Epidural Block - injection of an anesthetic agent into the epidural space (between L4 and L5) provides pain relief from uterine contractions and vaginal or cesarean birth.
MANAGEMENT OF PAIN
PHARMACOLOGICAL - Regional Anesthesia and Analgesia
Pudendal Block
* Administered by ____, intercepts signals to the pudendal nerve
* Provides ____ for the first stage of labor, second stage, birth, and episiotomy repair
* Relieves the pain of ____ and relieves pain in ____ but not for discomfort of uterine contractions
- Administered by transvaginal method, intercepts signals to the pudendal nerve
- Provides perineal anesthesia for the first stage of labor, second stage, birth, and episiotomy repair
- Relieves the pain of perineal distention and relieves pain in lower vagina, vulva, and perineum but not for discomfort of uterine contractions
MANAGEMENT OF PAIN
PHARMACOLOGICAL - Local Infiltration Anesthesia
* Injecting an anesthetic agent into the ____ areas of the perineum
* Use at the time of birth, both in preparation for an ____
* Local anesthetic agents: chloroprocaine hydrochloride ( ____ ), lidocaine hydrochloride ( ____ ), and tetracaine hydrochloride ( ____ )
- Injecting an anesthetic agent into the intracutaneous, subcutaneous, and intramuscular areas of the perineum
- Use at the time of birth, both in preparation for an episiotomy and for episiotomy repair
- Local anesthetic agents: chloroprocaine hydrochloride (nesacaine), lidocaine hydrochloride (xylocaine), and tetracaine hydrochloride (pontocaine)
