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OB > 6.1a First Stage of Labor > Flashcards

6.1a First Stage of Labor Flashcards

1
Q

First Stage of Labor

A
  • Begins with onset of contractions and ends with complete dilation and effacement
Latent
- Regular, painful uterine contractions causing cervical change
- 0-6 cm dilation
Active
- Greatest rate of cervical dilation
- Begins at 6 cm
- Ends at 10 cm
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2
Q

Assessment

A
  • Begins at first contact with patient
  • Minimize anxiety by explaining terms commonly used in labor

Relevant Data to Document

  • Prenatal record
  • Initial interview
  • Physical exam to establish baseline (vitals)
  • Lab and diagnostic results
  • Psychosocial and Cultural factors
  • Evaluation of labor status
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3
Q

True Labor

A

Contractions

  • Occur regularly and become stronger, last longer, occur closer together
  • Become more intense when walking
  • Felt in lower back radiating to lower abdomen
  • Continue despite comfort measures
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4
Q

False Labor

A
  • Irregular and only regular temporarily
  • Often stop when walking or changing position
  • Felt in back “or” abdomen above umbilicus
  • Can be stopped with use of comfort measures
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5
Q

Prenatal Data

A
  • Identifies needs and risks
  • Usually done during 3rd trimester
  • If there are no records, nurse will need to obtain baseline information
  • Ask questions between contractions if patient is in discomfort
  • Partner/Support person can be a secondary source of information
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6
Q

Emergency Medical Treatment and Active Labor Act (EMTALA)

A
  • Patients who are having contractions or may be in labor are considered unstable.
  • They must be assessed, stabilized, and treated at the hospital where they are present regardless of insurance or ability to pay.

The Nurses Role
- Providing services to patients when they experience pregnancy problem
(labor, decreased fetal movement, rupture of membranes)
- Document all information
(Assessment, interventions implemented, client response to care)

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7
Q

Prenatal Factors to Tailor Care

A
  • Age
  • Height and Weight
  • General Health Status
  • Current Medical Conditions
  • Allergies
  • Respiratory Status
  • Previous Surgical Procedures
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8
Q

Prenatal Records

A
  • Should always occur upon admittance to the facility
    HISTORY
  • Gravidity (Number of Pregnancies)
  • Parity (Number given birth above 20 weeks whether alive or not)
  • Problems (bleeding, hypertension, gestational diabetes, infection, EDB)
  • Patterns of weight gain
  • VS, fundal height, Baseline FHR, Lab/Test results
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9
Q

Common Diagnostic and Fetal Assessments

A
  • Amniocentesis (testing sample of amniotic fluid)
  • Non-stress test (NST) - Assess fetal heart rate and oxygen supply (overall baby health)
  • Biophysical Profile (BPP) - Measures fetal heart rate in response to movement. Combines nonstress test with ultrasound
  • Ultrasound Examination
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10
Q

Assessment

A

If patient had previous births the below must be noted

  • Characteristics of previous labor
  • Types of pain relief used
  • Type of birth (c-section, vacuum assisted, forceps assisted, vaginal)
  • Condition of newborn
  • Patients perception of previous labor and birth
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11
Q

Interview

A
  • Determine primary reason for coming to hospital
  • Auscultate and assess respiratory status (asthma which may affect general anesthesia)
  • Allergies including latex and tape
  • Routinely used medications in OB
  • Time and type of most recent solid/liquid intake
  • Birth plan
  • Type of pain management
  • Choice of infant feeding method
  • Name of pediatric provider
  • Preparations made for childbirth
  • Support person or family member who will be available
  • Cultural needs
  • Alcohol/Tobacco use
  • Plans for preserving memories such as photos and videotaping
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12
Q

Triage

A
  • Determine status of amniotic membrane
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13
Q

Sterile Speculum Examination and Nitrazine (pH)

A
  • Cotton tip swab to test pH of fluid.
  • Amniotic fluid is alkaline
  • Urine/purulent material is acidic
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14
Q

Fern Test

A
  • Determines if membranes have ruptured by getting a sample of cervical mucus smears
  • When estrogen is elevated smears form a fern like pattern
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15
Q

Bloody Show

A
  • Pink and sticky discharge
  • Sign of labor

Brownish/bloody discharge may be caused by vaginal examination or coitus

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16
Q

MATERNAL TRIAGE CLASSIFICATIONS

A
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17
Q

STAT/Priority 1

A
  • > 130 or <40 HR, SPO2 <93%, BP 150+/110+, <60HR, No FHR, FHR <110
  • Cardiac compromise
  • Severe respiratory distress
  • Seizing/Hemorrhaging
  • Placental Abruption/Uterine Rupture
  • Mental status change/Cannot follow verbal commands
  • Prolapsed cord
  • Active bearing down
  • Fetal parts visible on perineum
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18
Q

Urgent/Priority 2

A 
HR >120 or <50, Temperature >101.0, RR >26 or <12, SPO2 <95, BP 140+/90+ symptomatic, FHR 160+ for 60+ seconds
- Severe pain greater or equal to 7 
- High risk medical condition
- Difficulty breathing
- Altered Mental Status
- Suicidal/Homicidal
- <34 week SROM leaking or spotting 
- Active vaginal bleeding (not spotting or show) 
- Decreased fetal movement
- Recent Trauma
- SROM Leakage including
(HIV, Breech, Multiple gestation, Placental Previa)
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19
Q

Prompt/Priority 3

A
  • Temp >100.4, BP 140+/90+ asymptomatic
  • Signs of active labor >34 weeks
  • Early signs of labor
  • Woman is not coping
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20
Q

Non-Urgent/Priority 4

A
  • Common discomfort
  • Vaginal discharge
  • Constipation
  • Ligament pain
  • Nausea
  • Anxiety
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21
Q

Scheduled/Priority 5

A
  • Prescription refills

- Missed outpatient services

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22
Q

Postural Management (Position)

A
  • Non-cephalic positions are risky (breech, transverse)

- Should be corrected before engagement but close enough to term where position will be maintained

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23
Q

External Cephalic Version (ECV)

A
  • Ultrasound guided hands on procedure to manipulate fetus into cephalic lie
  • Done at 36-37 weeks of gestation
  • If preformed at 34-36 weeks, it can significantly increase chances of baby being born in cephalic presentation.
  • Beta stimulants are used to relax the uterus
  • Most successful is multiparous women with adequate amniotic fluid
  • Small risks for ECV
  • All women with breech position should be offered this
  • Positioning women with pelvis elevated is not shown to work
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24
Q

Early Phase of Labor

A
  • 0-5cm dilation
  • Nulliparous and Multiparous progress at similar rates
  • Mild to moderate contractions
  • 2-30 minutes apart
  • 30-40 seconds duration
  • No descension
  • Brown discharge of mucus plug (scant)
  • Patient is excited, able to walk
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25
Q

Active Phase of Labor

A
  • 6-10 cm dilation
  • Multiparous women progress quicker than nulliparous
  • Moderate to strong contractions
  • Pink/bloody mucus (moderate)
  • Becomes serious and doubtful to pain response
26
Q

Sexual Abuse

A
  • Labor can trigger memories especially during intrusive procedures
  • Ask permission to touch patient
  • Limit number of people interacting with patient
  • Explain all procedures
  • Avoid words such as “open your legs” or “relax it wont hut”
  • Limit invasive procedures
  • Have patient choose a person to be with her during labor
27
Q

Stress of Labor

A
  • Related to how well they prepared for childbearing
  • Dysfunctional relationships can cause feeling of guilt or failure
  • Encourage patient to express their feelings and fears related to labor (especially important for primigravida patients who have not attended birth classes and attainted information on the internet)
  • Multiparous women who have had negative experiences in the past also should discuss feelings
  • Concerns include maternal/fetal well-being and actions/attitude of healthcare staff
28
Q

Cultural Factors

A
  • Encourage patients to request specific practices important to her
29
Q

Non-English speaking Women

A
  • Anxiety increases when she does not understand what is going on
  • Family members are prohibited from being a translator
  • Bilingual nurses and interpreters can be used
30
Q

Physical Examination

A
  • General Systems
  • Fetal Status
  • Uterine Contractions
  • Vaginal Examination
  • These serve as a baseline
31
Q

Early Labor Examination

A
  • Temperature every 4 hours until membrane rupture. Then every 2 hours
  • BP, Pulse, RR, UA, FHR, Bloody show every 30-60 minutes
  • Changes in maternal appearance, mood, energy, involvement every 30 minutes
32
Q

Active Labor Examination

A
  • BP, Pulse, RR, UA, FHR, Bloody show every 15 minutes

- Maternal appearance, mood, energy, involvement of partner every 5-15 minutes

33
Q

General Systems Assessment

A
  • Heart
  • Lung
  • Skin
  • Edema in Face/Hands/Sacrum/Legs
  • DTR
  • Clonus (involuntary contractions)
  • Weight
34
Q

Vitals

A
  • BP every 30 minutes if elevated between contractions

- Body temperature to identify infection or fluid deficit

35
Q

Leopold Maneuvar

A
  • Used to see fetal presentation/lie and fetal size
36
Q

Fundus Assessment

A
  • Head feels round, firm, freely moveable
  • Breech is irregular and softer
  • Identifies fetal lie (longitudinal or transverse) and presentation (cephalic or breech)
37
Q

Abdominal Sides Assessment

A
  • Identify where the fetal back and arms are

- This identifies fetal presentation (Left, Anterior, Cephalic)

38
Q

FHR Pattern Assessment

A
  • Point of Maximum Intensity (PMI)
  • Usually directly over the fetus’s back
    VERTEX POSITION
  • Heard below the umbilicus
    BREECH POSITION
  • Heard above the umbilicus
  • Important to measure FHR after rupture of membranes due to umbilical cord prolapse
  • Prolapse can also occur during changes in contraction pattern, maternal status, or before/after patient receives medication, or when procedure is preformed.
39
Q

Uterine Contraction Assessment

A
  • UA is not directly related to labor progress
  • Primary force to expel fetus (involuntary)

Frequency - How often contractions occur
Intensity - Strength of contraction
Duration - Time between onset and end
Resting Tone - Relaxation of uterus (tension between contractions)

40
Q

Intensity

A

Mild - Easy to indent with fingertips (Pressing finger against nose)
Moderate - Firm fundus, difficult to indent (Pressing finger against chin)
Strong - Board like fundus (Pressing finger to forehead)

  • IUPC most accurate way of assessing intensity
  • Upon admission, monitored for 20-30 min to establish baseline
41
Q

Vaginal Examination

A
  • Determine true labor and rupture of membranes
  • Should be done as infrequently as possible
  • On admission
  • Prior to medication administration
  • Significant change in uterine activity
  • Maternal request (perineal pressure or urge to bear down)
  • Ruptured membranes
  • Decelerations in FHR are noted
42
Q

Examination of Laboring Patient (Vaginal)

A
  • Sterile gloves
  • Position to prevent supine hypotension
  • Drape to ensure privacy
  • Cleanse area if needed (perineum, vulva)
  • Permission from patient (insert index and middle finger)

Determine

  • Dilation, effacement, position
  • Presenting part, position, station, molding of head
  • Status of membranes (intact, bulging, ruptured)
  • Amniotic Fluid (color, clarity, odor)
43
Q

Amniotic Fluid Membrane and Fluid Assessment

A
  • Occurs most commonly at active phase of 1st stage of labor
  • AROM (Artificial Rupture of Membranes) is called Amniotomy
  • Umbilical cord prolapse is a complication of membrane rupture (monitor FHR closely for a few minutes)
44
Q

Infection

A
  • Chorioamnionitis and Placentitis
  • Rupture of membranes allows microorganisms to ascend amniotic sac
  • Monitor maternal temperature every 2 hours to assess infection
45
Q

Complications of Labor

A
  • Intrauterine pressure >80mmHg or Resting Tone >20mmHg
  • Contraction lasing over 90 seconds
  • More than 5 contractions in 10 minutes
  • Relaxation between contractions longer than 30 seconds
  • Irregular FHR
  • Meconium stained fluid or blood from vagina
  • Maternal temperature over 100.4
  • Foul smelling vaginal discharge
  • Persistent bright or dark red vaginal bleeding
46
Q

Urinalysis

A
  • Hydration status (specific gravity, color, amount)
  • Nutritional status (ketones)
  • Infection status (leukocytes)
  • Preeclampsia (proteinuria)
47
Q

Blood Tests

A
  • CBC to measure hematocrit, WBC, RBC, hemoglobin and platelets
  • Rapid HIV test for those who are undetermined

“Type and Screen” or “Clot to Hold” determine blood type, rH, and antibodies

  • GBS can also be tested
48
Q

Interventions for Anxiety

A
  • Assess knowledge of labor
  • Teach expected progression and what to expect
  • Involve patient in decision making and share information of the progress of labor.
49
Q

Acute Pain from frequency/intensity of Contractions

A
  • Assess pain and teach coping methods
  • Teach non-pharmacological pain relief such as conscious relaxation, breathing, imagery and touch
  • Administer analgesics
50
Q

Urinary Retention

A
  • Patient should empty bladder every 2 hours (voiding or catheter)
  • Palpate bladder every 2 hours
  • Help patient to bathroom or catheterize
  • Teach voiding techniques such as listening to running water
51
Q

Eliminiation

A
  • Every 2 hours to avoid impeding descent of fetus and injuy
52
Q

Ambulation

A
  • Allow ambulation per orders if
  • Presenting part is engaged
  • Membranes are not ruptured (protect against prolapse)
  • Patient is not medicated (protects against injury)
53
Q

Bed Rest

A
  • Offer bedpan to prevent bladder distension
  • Encourage upright position on bedpan, allow tap water to run, place patients hand in warm water, pour warm water over vulva to encourage voiding
  • Privacy
  • Side rails up
  • Call bell and telephone within reach
  • Offer wash cloth for cleansing
  • Cleanse vulvar area
  • Catheterization if needed (insert in between contractions) (avoid force if there is resistance)
  • Rectal pressure from presenting part may cause sensation of bowel elimination
  • Help ambulation to bathroom if they do need to eliminate
  • Cleanse perineum after passage of stool
54
Q

Ambulation/Position

A
  • Upright position may be more pleasant. Associated with..
  • Improved contraction intensity
  • Shorter labor
  • Reduced operative birth
  • Less pain medication needed
  • Increased maternal autonomy and control
  • Distraction
  • Allows close interaction with partner
  • Change position every 30-60 minutes
  • Side lying position is best
55
Q

Semi-Recumbant

A
  • Upper body elevated 30 degrees
  • Wedge under hip
  • The greater the angle the more gravity is exerted for fetal descent
  • Convenient for providing care and external fetal monitoring
56
Q

Hands and Knees

A
  • Knees and hands on bed
  • Relieves back ache
  • Facilitates Internal Rotation
57
Q

Upright

A
  • Gravity enhances contraction cycle
  • More oxytocin is secreted
  • (Ambulation or sitting up)
58
Q

Lateral

A
  • Alternate between left and right
  • Removes pressure from vena cava and back
  • Easier for back massage or counterpressure
  • Less frequent but more intense contractions
  • Difficult to get good quality fetal monitor tracings
  • Can be used as birthing position
  • Takes pressure off perineum
  • Reduced risk of perineal trauma
  • Facilitates internal rotation
59
Q

Partner Support

A
  • Orient partner to the labor room, cafeteria, waiting room, bathroom
  • Inform partner about sights and smells they may encounter
  • Respect their decision on how they would like to be involved
  • Tell them their presence is helpful
  • Offer to teach them comfort measures
  • Inform them on progress and patient needs
  • Prepare partner for changes in behavior and physical appearance of partner
  • Remind them to eat
  • Offer blankets and area to sleep
  • Eliminate unsettling stimuli such as extra lights, create calm environment
60
Q

Doulas

A
  • Professional labor support person

- Role is to provide physical and emotional support through encouragement, touching, stroking, and hugging.

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