Assessment/Care in Labour Flashcards
When should primiparous and multiparous come in for labour?
P- contractions 5-7 minutes apart for an hour
M- contractions 7-10 minutes apart
Labour usually progresses slower in first time moms
Other reasons to come in for labour?
Membranes have ruptured, experience vaginal bleeding, logistical issues (like living rural), and decrease/change in baby’s movements
What do you need to know for admission for a client?
What pregnancy this is for you, when is baby’s EDD, any contractions, is baby active, and bleeding/ruptured membranes, complications in pregnancy, allergies, and anything else I need to know. Nurses do this by just having a friendly conversation with the client
When should you complete the admission for the cleint?
After assessing the fetus
Parts of the initial assessment and lab findings?
Baseline- FHR, VS, contractions, cervix, membranes, bleeding, edema, abnormalities, weight change, assess urine for glucose, ketones, protein, possible UTI
Know LMP and EDD
Lab findings- evaluate CBC, infection or coagulation problems, evaluate serologic testing results (blood type, Rh, antibodies, HIV, Hep B, STBBI)
Other tests- ultrasounds, group B strep, diabetes screening
What is resting tone?
Uterus is soft between contractions for minimum of 3o seconds
What is tachystole and characteristics?
Means excessive uterine activity/contractions.
Frequency: >5 in 10 minutes
Duration: lasts longer than 90 seconds
Resting tone: resting period of <30 seconds or remains firm to palpation between contractions
How do we assess contractions?
Non electronically- duration, frequency, intensity
Electronically- intrauterine pressure catheter- invasive, or tocometer- placed on fundus of the uterus
Vaginal exam?
Use sterile hands to stick fingers to find cervix/palpate. Provides info about dilation/effacement, membrane status, amniotic fluid, fetal position and station.
What is effacement?
Thinning of cervix from 4 cm to 1 mm or less. Muscles of upper uterine segment will shorten and cause the cervix to flatten/thin out. This can occur before labour, or during labor (for multiparous)
What is bishops scoring system?
Looks at dilation, effacement, length of cervix, consistency of cervix, position of cervix, station of fetus. If score is over 7 then there’s a good chance labour will progress
What to assess for after ROM?
Fluid, FHR, cord prolapse, and infection
Amount/colour/odour of amniotic fluid?
Amount- 800-1000 mL at term, can be huge gush or trickle
Colour- should be clear with white flecks (green means meconium which is bad, bright red is bad)
Odour- earthy smell not foul (foul means infection)
How to confirm ROM?
Ferning- collect sample of fluid/let dry/put in on slide under microscope and it looks like ferns
Nitrzine swab- test to make sure its amniotic fluid, take sample of fluid from vagina to determine pH, blue means positive, yellow means negative
How to assess fetal heart? 2 methods
- Intermittent auscultation using a doppler- for low risk women, allows client to be mobile at will, can’t detect variability or decels, FHR heard clearly at back
- Electronic fetal monitoring- for women at risk of adverse outcomes/high risk, can be external (attach to abdomen) or internal (equipment attach to fetus)
Normal FHR?
110-160 bpm, regular rhythm, accelerations present (not required), some decelerations (absent, early or variable), and moderate variability
Electronic fetal monitoring?
Do leopolds first to find out where to place stuff. It provides continuous data and used for high risk clients. Reduces/restricts mobility (have to be in bed). Internal scalp electrode can be placed on fetus head but client needs to have ROM, dilation of at least 2, and presenting part low enough to allow placement of electrode.
Tachycardia and bradycardia for FHR?
T- rate above 160 for >10 minutes
B- rate below 110 for >10 minutes
Care in 1st stage of labour?
Provide privacy, void q2h, encourage position changes, provide comfort, monitor labour process, test urine for ketones/glucose/protein
Care 2nd stage of labour?
Help client find effective pushing pattern, take FHR q5 min when pushing, note contractions, help client rest between pushes, get help from delivery person, set of delivery (infant warmer, O2 equipment), administer syntocinon as ordered, note time of actual birth
3rd stage care?
VS, promote bonding, assess placenta for intactness, look for sign of separation of placenta, register birth, for baby (maintain respirations, promote warmth, prevent infection, clamp cord, apgar score), inspect cord
4th stage care?
Up to 4 hrs after placenta delivery, stabilize before transfer to postpartum, assess VS, fundus, bleeding, and perineum q15 minutes for an hour. Help with nutrition, showers, elimination, breastfeeding, and bonding
What is FHR variability? and types
When there is fluctuations in baseline FHR in a minute. Excludes access or decels. Absent means undetectable, minimal variability (<5 bpm, not normal), moderate (6-25 bpm, normal and healthy), marked variability (>25 bpm, not normal)
What can reduce FHR variability over short term?
Fetal sleep periods, reposition client to see if patient wakes up
What is sinusoidal FHR?
FHR is smooth and repetitive. Persists for >20 min, amplitude of 5-15 bpm, and frequency 3-5 cycles/minute.
What is accelerations?
Abrupt increase in FHR at least 15 bpm above baselines for at least 15 sec and <2 min. They are normal/healthy, but not necessary during labour. Can be caused by/c of contractions or when they’re active.
Decelerations?
Decrease in FHR that’s abrupt or gradual. Can be variable, early or late.
What are variable decelerations?
Caused by cord compression and looks like a sharp V. Come out of it once cord isn’t squished. Abrupt FHR decrease >15 bpm below baseline for >15 seconds. Can be periodic or episodic (irregular). 2 types- uncomplicated and complicated (hypoxia).
What are early decelerations?
Caused by head compression during contractions. Gradual decrease in FHR associated with uterine contractions, no depth criteria. Onset, nadir, recovery coincide with onset, acme, and end of contractions. Uniform in shape (U). Usually doesn’t require intervention. Starts with start of contraction.
What is late decelerations?
Caused by uteroplacental insufficiency (poor oxygenation from placenta). Causes gradual decrease in FHR associated with uterine contractions. Onset/nadir/recovery occur after beginning of the contraction. They are ominous and never normal. Indicate fetal distress
What are prolonged decels?
decrease in FHR below baseline lasting >2 min but <10 min (after 10 min it would be bradycardia). Indicates profound change in fetal environment and increased likelihood of fetal hypoxia
What does VEAL CHOP stand for?
V- variable decelerations. C- cord compressions
E- early decelerations H- head compression
A- accelerations. O- okay!
L- late decelerations P- placental insufficiency
Nursing interventions for abnormal/atypical FHR?
Reposition client, decrease/discontinue oxytocin, check maternal VS, correct hypotension if present w/ IV fluids, pause pushing efforts, vaginal exam (rule out prolapse), consider meds to relax uterus or nitro for tachystole, initiate continuous EFM monitoring, and oxygenate if hypoxia,
