ch. 19 care of patient labor Flashcards
first stage of labor: 2 stages
Onset -> 10cm
1) latent phase (0-5cm):
- extends from onset of labor
- characterized by regular, painful uterine contractions that cause cervical change to the beginning of the active phase
- cervical dilation occurs more rapidly
2) active phase (6-10cm):
- period during which the greatest rate of cervical dilation occurs, which begins at 6cm
- ends with complete cervical dilation at 10cm
first stage of labor: determination of whether the woman is in true or false labor (3)
1) contractions:
- intermittent: false
- regular: true (Q2-3min)
2) cervix: effacement?
3) fetus
Obstetric traige and EMTALA: pregnant women presenting to an obstetric triage area is presumed to be in “true” labor until a qualified HCP certifies that she is not
- will be assessed, stabilized, and treated
first stage of labor: care mgmt (hx) (5)
1) admission to labor unit
2) admission data:
- prenatal data
- interview:
(a) spontaneous rupture of membrane (SROM): water break
(b) blood/pink show: thick cervical coating that protects cervix
3) psychosocial factors:
- women w/ history of sexual abuse (be thoughtful of body)
4) stress in labor: how is mother coping?
5) cultural factors:
- many women have idea of “right” way to behave in labor and react to the pain experienced in that way
- culture and father participation
- non speaking english women in labor
other: feel baby move, contractions?
first stage of labor: care mgmt physical exam (6)
1) general systems assessment
2) vital signs
3) Leopolds maneuver (abdominal palpation)
4) assessment of FHR and pattern
5) assessment of uterine contractions
- frequency: beginning of one contraction to beginning of next contraction
- intensity: per palpation: mild (nose), mod (chin), strong (forehead)
- duration: beginning and end of one contraction
- resting tone: mom getting rest?
6) vaginal examination:
- reveals true labor or if SROM occured
- stressful and uncomfortable
- cervical effacement, dilation, fetal descent
TIP:
- if mom wants to defecate during birth, perform vaginal exam
first stage of labor: care mgmt lab/diagnostic tests (5)
1) urinalysis: look for protein, ketones, no evidence of infection
2) blood tests:
- CBC: PLT
- human immunodeficiency virus (HIV) -> consent
- type and screen: Rh
3) assessment of amniotic membranes and fluid
4) other tests:
- if GBS unknown, RAPID TEST PERFORMED around 36-38 weeks
5) assessment of infection
first stage of labor: nursing interventions (7)
mgmt of care based on EBP (evidenced based practice)
- general hygiene
- nutrient and fluid intake (oral/IV)
- elimination (void Q2H, catheterization, bowel elimination)
- ambulation/positioning (encourage ambulation w/ wt ball)
- supportive care during labor and birth: emotional support, physical care/comfort measures, advice/information
- labor supports: nurse, father/partner, doulas, grandparents, siblings during labor and birth
- emergency interventions
determination of ruptured amniotic sac (3)
1) positive nitrazine tape (blue color)
2) ferning (snowflake upon microscope)
3) pooling of amniotic fluid in posterior vagina
second stage of labor (5)
10cm -> birth baby
- infant is born
- begins w/ full cervical dilation (10cm)
- complete effacement
- “pushing” stage -> expulsion
- ends with infant birth
second stages of labor: 2 stages
1) latent:
- AKA “delayed pushing, laboring down, passive descent”
- relatively calm with passive descent of baby through birth canal (let body continue to contract)
2) active:
- pushing and urge to bear down
- ferguson reflex: activated when the presenting part (fetus) presses on the stretch receptors of the pelvic floor (perineum/vaginal wall)
women will verbalize “feeling pressure” down there
second stage of labor: care mgmt (6)
1) assessment
2) preparing for birth:
- maternal position: supine, semirecumbent, lithotomy, upright (most desirable for short labor - squat, on a chair, on all fours)
- bearing down efforts (valsalva maneuver will decrease BP, HR)
- FHR and pattern
- support of partner
- supples, instruments, and equipmentop
3) birth in a delivery room/birthing room:
- lithotomy position vs. other positions
4) mechanism of birth vertex presentation:
- crowning
- episiotomy
- nuchal cord: release/loosen cord
5) get baby on warmer, dry baby, suction nose and mouth
6) immediate assessment and care of newborn
- skin to skin care (mom and dad)
- lotus birth “placental birth”
open glottis (2) vs closed glottis (2)
1) open glottis: spontaneous breathing or breathing down
- exhaling slowly and steadily while pushing during contractions
2) closed glottis: valsalva maneuver
- holding breath and pushing for an extended period of time creating high abdominal pressure
perineal trauma r/t birth (4)
1) first degree: laceration that is confined to the skin (can heal naturally, vaginal foreshay)
2) second degree: laceration that extends into the perineal body (episiotomy, tear 1/2 way through perineal muscle)
3) third degree: laceration that involves injury to the external and sphincter muscle (skin, muscle, rectal tissue)
4) fourth degree: laceration that extends completely through the anal sphincter and the rectal mucosa (right through rectum, vaginal rectal fistula, can take 4-6 months to heal)
other:
- vaginal/urethral lacerations
- cervical injuries (bleed, presipitous)
- episiotomy
episiotomy (2)
an incision in the perineum used to enlarge the vaginal outlet
- has steadily declined in recent years d/t lack of sound, rigorous research to support its benefits
third stage of labor (5)
baby -> placenta
birth of baby until placenta is expelled
- SHORTEST STAGE OF LABOR
- active vs. passive mgmt: placenta is expelled within 15 minutes after birth of the baby (uterus rises, gush of blood)
- placental separation concerns
- vaginal fullness
- placental examination/disposal (culture preferences)
signs of placental separation (2)
- lengthening of the umbilical cord
- gush of blood from the vagina (uterus rises, becomes globular)
