2 Nursing Care During Labor & Birth Flashcards
When should the pt come to the hospital 4
ROM
Contractions 5 min apart, lasting 45-60seconds
Any vaginal bleeding
Any danger signals (⬇️ FM, swelling, s/s preclampsia)
Labor admission assessment
Priority
Mother Vs:
BP <140/90
Temp <100.4
Fetal status:
FHR 110-160
Moderate variability
Additional data needed for labor admission
Contractions
Membrane
Pelvic exam
Prenatal hx
Contraction: freq, duration, intensity
Status of membranes: time, amount, color, monitor FHR x1 minute post rupture (if ruptured worried about infection)
Pelvic exam: cerical dilation/effacement and station
Prenatal hx: EDD/EDB
Addiritional data needed upon admission
Birthplan
Leopolds maneuver
Collection of what
Types of labs
Birthplan
Leopolds maneuver: vertex(cephalic)
Collect urine specimen
Labs:
CBC (h&h, plt, wbcs)
Type and screen
GBS status ( if unknown or + = give PCN)
Leopolds maneuver
1: palpate fundus: what part is up there (tells us fetal lie)
2: palpate sides: find fetal back for monitoring
3: find what i presenting in pelvis
4: find if baby is flexed or extended
Membrane status
Ruptured membranes
ROM/SROM/ AROM (amniotomy/artificial)
PROM(prelabor ROM)/ PPROM (preterm premture ROM)
Sterile procedure (nitrazine paper(alkaline (blue) or fen test
Presence of fluid in vagina
Membrane status
Assessment
FHR tracing (#1 priority with ROM=check on baby)
Fluid color (clear/straw colored, meconium stained)
Odor (odorless)
Time of rupture (important for infection)
1 issue with ruptures
Cord compression
Cord prolapse
Vaginal examination
Sterile
Hips flexed and abducted
Perform exam between uterine contractions
Assess: cervical dilation/effacement/station/presentation of fetus
What stage and phase does epidurals happen?
Stage one
Active phase
Stages of labor 1st stage (latent phase)
(how often, and increase in cm)
Vs
Temp
Contractions
Vag exam
BP,P,R q30-60min
Temp q4 unless ROM then q2
Contractions and FHR 30-60min
Vag exxam ass needed:
Progress once at 6cm
Primip: 1cm/hr
Multip: 1.5cm/hr
Stages of labor 1st stage (active phase)
Vs
Temp
Contractions
Meds
Want them to be doing if no epidural
Can intake what
Void how often
Vag exam
Support
BP,P,R q30min
Temp q4h unless ROM then q2
Contractions and FHR q15-30
Epidural and analgesics
Ambulation/positioning
Ice chips/clear liquids
Void q2h if no folely catheter (inhibits fetal descent)
Vag exam as needed
Emotional support
First stage of labor transition phase
Nursing measures
Lots of encouragement
Dont leave alone
Monitory cervix (may feel like they need to have a bowel)
Assess for urge to push,pressure, perineal, building/crowning
VS: 15-30min
Contractions 10-15min
FHR 15-30min
Preparation for delivery
For the first stage phases we just need to know what about VS and contractions and FHR
That the later phases will need to be monitored more frequently
Second stage of labor: pushing
Begins with complete cervical dilation and ends with birth of neonate
Ecourage pushing with contractions, wait for urge
Vitals q 15
FHR q5-15
Coaching with pushing/open glottis, discourage holding breath
Position upright/squatting
Perineal cleansing/stretching
Second stage of labor
Lengths
Lengths:
Nullipara:
Without epidural: 3hrs
With epidural: 4hrs
Multipara:
Without epidural:2hrs
With epidural:3hrs
Second stage of labor
signs of impending birth
Increased bloody show
Burning/stretching/bulging/crowning of perineum
Uncontrollable urge to push
Second stage of labor: birth
Dont do what
Support what
Check for what
Rotate how and what comes out first
How to cut cord
Dont leave pt alone
Support head
Check for nuchal cord
External rotation/delivery of anterior should first
Cord is clamped twice and cut between the clamps
Immediate newborn care
(5 things)
Can be delayed after what
Mucus removed by bulb syringe
Record time of birth
Inspect cord for 2A and 1V
Apgar scoring at 1min and 5 min includes vitals
Vit k and erythromycin
Measurements can be delayed until after skin to skin/breast feeding if stable
Third stage of labor
What is it
Length
Signs of placental dettachment (3)
Inspect what 2 things
Administer what
Start with birth of neonate and ends with delivery of placenta
Approx: 5-15min
VS 15min
Signs of placental detachment:
Lengthening of cord, breif gush of dark blood, fundus firmly contracting
Inspect placenta and perineal (may need repair)
Aminister oxytocin (helps with hemorrhage)
EFM monitoring
Labor does what to fetus (how)
EFM provides what info
Labor creates stress to fetus:
Compression of spiral arteries
EFM provides info on:
Fetal oxygenation and contaction patterns
EFM types for FHR and contractions
FHR:
External: ultrasound transducer(goes on back)
Internal: fetal scalp electrode (FSE) need ROM
Contractions:
External: Toco transducer (goes on fundus)
Internal: intrauterine pressure catheter (IUPC) tells us intensity and needs ROM
When can internal EFM be placed
Can toco monitor intensity?
With ROM
NO, you have to palpate for that
Uterine activity UA assessment
Frequency
Number present in a 10min window, but avg over 30 mins
Normal: 5 or fewer contractions in 10min avg over 30mins
Tachysystole: more than 5 contractions in 10min avg over 30mins (uterus not relaxing-at risk of rupture)
Uterine activity UA assessment
Duration
45-90 seconds
Uterine activity UA assessment
Intensity
Palpate: mild/moderate/strong
IUPC:
Good: 50-80mmhg
Resting tone: 10-20 mmhg
Relaxation time: time between contractions
FHR with electronic fetal monitoring
Evaluated over how long
Excludes what
Normal range
10mins
Excluding:
Accels, decels, periods of marked variability
Normal range: 110-160 bpm
Tachycardia
Cause
160 bpm + for 10 +mins
Cause:
Maternal fever, infection, chorioamnionitis
Fetal infection/anemia
Maternal use of cocaine/methamphetamines
Bradycardia
Causes
110 bpm or less for 10mins
Causes:
Placental insufficiency
Cord prolapse
Prolonged cord compression
Mother in supine position/HOTN
Hypoxia
FHR variability
Flucuations in bpm over how long
Indicates well what
10 minutes
Indicates well:
-oxygenation
-neurological system
(We want variability)
Which variability is what we want
Moderate
VEAL CHOP
V: variabile decels = C: cord compression
E: early decels = H: head compression
A: accels = O: oxygenation/OK
L: Late decels = P: placental insufficiency
Early decels
Causes
What we see
Head compression
Gradual decrease of FHR starts with/ contraction and ends with/ contraction
Mirror image of UC
REASSURING PATTERNS (baby is tolerating contractions)
Intervention not required
GOOD to be what
BAD to be what
GOOD to be EARLY
BAD to be LATE
Late decels
Cause
What we see
Decreased placental blood flow:
-Uterine tachysystole
-maternal HOTN/HTN
-epi/spinal anesthesia
-postmaturity
-IUGR
gradual decrease of FHR after contraction starts
non-reassuring
Late decels interventions
Repositioning
Correct maternal HOTN: IV fluids/meds
O2 @ 10L non rebreather mask
Tocolysis: (stopping contractions)
positioning, D/C oxytocin, meds
Notify MD
Plan for expedited delivery
Variable decels
Causes
What we see
Causes: cord compression
-position
-nuchal cord
-true knot in cord
-prolapsed cord
Abrupt FHR decrease from onset to nadir <30secs
Drop in FHR at least 15 bpm for at least 15 secs
Rapid return to baseline
`
Variable decels
Frequently below what
Shape
Below 100 bpm
U,V,W
No relation to contraction
Variable decels
Interventions
Position
Vag exam (find prolapse)
O2 @ 10L
D/C oxytocin
Notify MD
Tocolysis (stop contractions)
Amnioinfusion (route: thru IUPC)
Prolonged decels
What it looks like
Depth of 15 bpm lasting >2minutes up to 10 min
After 10 min = change in baseline
W/without contractions
Associated with loss of FHR variablilty
Prolonged decels
Causes
Prolapse of cord
Maternal HOTN (epi/spinal)
Tachysystole
Seizures
Prolonged decels
Interventions
Position
Vag ecam to r/o prolapse
O2 @ 10L
Correct maternal HOTN (LR)
D/C oxytocin
Notify MD
Plan for expediated delivery
Complications of labor
(Contraction)
Intrauterine pressure over 80
Resting tone greater than 20
Contraction duration equal to or greater than 90secs
(Want 45-90secs)
Contractions more freq than q2minutes
Complications of labor
(Others)
Absent variability
Fetal tachy/bradycardia
Late and variable decels
Meconium-stained fluid
Foul smelling discharge/fever (infection)
Persistent bleeding
Nonpharmacologic treatment
Relaxtion:
-music, meditation, aromatherapy
Paced breathing
Cutaneous stimulation:
-thermal(hot pad), accupressure/sacral pressure
Hydrotherapy
Analgesics in labor
Opioid analgesics
Primary action in CNS
Given IV during early part of active labor (4-7cm)
Fetal and maternal resp depression(EXAM)
Opiate antagonist (Narcan)
Barbituates/benzos
Traquilizing an sedative effects
Promote relaxation but dont take away pain
Used during early/ latent phase
Antiemetics
Potentiate effects of opioids (makes it work better)
Decreases nausea and vomiting
Increase sedation
metoclopramide, promethazine
Nitrous oxide inhalation
Reduces anxiety, mild analgesia
Mother control the administration
Minimal/no effect on fetus
Pudendal nerve block
Transvaginal
Relief in lower vagina, vulva, perineum, and rectum
Second(pushing)/third(placenta removal or repair) stages of labor
Epidural block
Does what
Blocks what
During what phase
Makes what difficult
Produces a loss of sensation or with opioid use pain control
Entire pelvis by blocking impulses from T12-S5
During active labor (at least 4cm)
Make pushing difficult in second stage of labor (prolong)
Epidural block contraindications
maternal HOTN
Coagulation disorders
Local infection
Drug allergies
Uncorrected loss of blood
Mom refuses
Epidural nursing care
Give what
Get what
IV if
Monitor what
500-1000ml IV fluid bolus recommended to prevent HOTN
Consent, positioning, local anesthetic, catheter inserted
Intravascular if: numbness in tongue/lips, tinnitus, dizziness
Monitor
Mom VS(BP)
FHR
Adverse effects
Epidural Adverse effects
Mom HOTN
Fetal bradycardia
Prolonged second stage of labor (difficult to push)
Bladder distantion (catheter placed)
Mom HOTN tx
Place mother in left lateral position
Bolus/increase rate of IVF per protocol
IV Vasopressor(ephedrine)
O2 administered via non-rebreather
IF SEVERE: mother in trandelenburg position
Spinal block
Done quickly for c-section
Local anesthetic injected into subarachnoid space into CSF
Spinal block
AE
High incidences of what
Monitor for what (TX) only relief with what
AE: similar to epidural (HOTN, fetal bradycardia, prolonged second stage of birth, bladdr distention)
Higher incedences of bladder and uterine atony
Monitor: for spinal HA (caused by dural puncture)
-Epidural blood patch (with moms blood)
only get relief from lying down
General anesthesia
Emergency what
Concerns
Emergency c-section (no time for spinal or epi)
CONCERNS:
All agents cross placental barrier
So fetal depression is a concern
Concern of maternal aspirations
TX: (NPO, famotidine, metoclopramide)
Urterine atony, res depression
