Chapter 14 Nursing Mgmt During Labor And Birth

Question 1

Vaginal examination

Answer 1

Assess the amount of cervical dilation, percentage of cervical effacement, fetal membrane status, gather info on presentation, position, station, degree of fetal head flexion, and presence of fetal skull swelling or molding.

Question 2

Rupture of membranes

Answer 2

If they are not ruptured they will be felt as a soft bulge that is more noticeable during contraction. When membranes rupture the priority focus is to assess fetal heart rate. Hey deceleration might indicate cord compression. Signs of infection include maternal fever, fetal and maternal tachycardia, Foul odor, and increased WBC. To confirm rupture the fluid is tested with the nitrazine swab to determine the pH. Vaginal fluid is acidic but amniotic fluid is alkaline. The test can give a false positive if there is large amounts of blood. PH should be from 6.5 to 7.5. If this test is inconclusive you can use a fern test which examines it under the microscope

Question 3

Uterine contractions

Answer 3

The power of labor and in voluntary. They increase intrauterine pressure leading to cervical dilation and thinning which in turn forces the fetus through the birth canal. Increment, Acme/peak, decrement.

Question 4

Leopold’s maneuvers

Answer 4

1. Place woman in supine position
2. Using both hands on the abdomen determine fetal position in the fundus. Feel for the Butt or the head
3. Move hands down the lateral sides of the abdomen to palpate which side the back is on and which side the limbs are on
4. Place thumb and fingers just above symphysis pubis. Feel for the presenting part either the head or the butt
5. Facing the client’s feet, move fingers down applying pressure in the direction of the symphysis pubis. You palpate a hard area on the opposite side of the back, the fetus is in flexion because you found the chin. If The hard area is on the same side as the back, the fetus is an extension because you found the occipital

Question 5

Amniotic fluid

Answer 5

Clear is normal, cloudy or foul-smelling indicates infection, green indicates the fetus passed meconium, prolonged pregnancy, maternal hypertension, diabetes. Green is normal is fetus is in breech position. If Stool was passed you must use suction to help prevent meconium aspiration syndrome.

Question 6

Intermittent FHR Monitoring

Answer 6

Auscultation via fetoscope or Doppler. Allows mobility, determines a baseline by assessing for full minute after contraction. FHR most clear at fetal back. Palpate maternal pulse while listening to fetal so you make sure you have the right one.

Question 7

Frequency of FHR

Answer 7

Initial 10-20 minute continuous monitor

Complete prenatal and labor risk assessment

Intermittent every 30 minutes during active labor for low risk, every 15 minutes for high risk

2nd stage of labor q 15 min for low risk, q 5 min for high risk

Question 8

Continuous electronic fetal monitoring

Answer 8

Provide info about oxygenation, detect fetal heart rate changes early on. Hypoxia is demonstrated in a rate pattern.

Question 9

Continuous external monitoring

Answer 9

Two ultrasound devices attached to belt around abdomen. One detects uterine pressure and is placed on part of fundus that contracts most. The other one detects FHR, placed in between umbilicus and symphysis pubis

Question 10

Artifact

Answer 10

Irregular variations or absence of the FHR on monitor from mechanical limitations or interference.

Question 11

Continuous internal monitoring

Answer 11

For high risk such as multiples, decreased fetal movement, abnormal FHR, IUGR, maternal fever, preeclampsia, dysfunctional labor, preterm birth, diabetes, HTN. Electrode attached to fetus presenting part for FHR, and uterus for contractions

Question 12

Criteria for internal monitoring.

Answer 12

Ruptured membranes, cervical dilation at least 2cm, presenting part low enough, skilled person available.

Question 13

FHR patterns

Answer 13

They include baseline fetal heart rate variability, presence of accelerations, periodic or episodic deceleration, and changes or trends of fetal heart rate patterns

Question 14

Category one: Normal

Answer 14

Predictive abnormal fetal acid/base status

Baseline rate 110 to 160
Baseline variability moderate
 Present or absent accelerations
Present or absent early deceleration
No late or variable deceleration

Question 15

Category two: indeterminate

Answer 15

Not predictive of abnormal fetal acid-base status

Tachycardia greater than 160
Bradycardia less than 110 not accompanied by absent baseline variability
Absent baseline variability not accompanied by recurrent
decelerations
Minimal or marked variability
Recurrent late decelerations with moderate baseline variability
Recruit variable deceleration accompanied by minimal or moderate baseline variability; overshoots, or shoulders
Prolonged deceleration’s greater than two minutes but less than 10 minutes

Question 16

Category three: abnormal

Answer 16

Predictive of abnormal fetus acid-base status

Bradycardia less than 110
Recurrent late decelerations
Recurrent variable deceleration
Sinusoidal pattern (smooth, undulating baseline)

Question 17

Fetal bradycardia

Answer 17

When below 110 and last 10 minutes or longer. It can indicate asphyxia. Indicate hypoxia, prolonged maternal hypoglycemia, fetal acidosis, administration of analgesics to mom, hypothermia, anesthetic agents, maternal hypotension, fetal hypothermia, prolonged umbilical cord compression, and fetal congenital heart block

Question 18

Fetal tachycardia

Answer 18

Greater than one 6410 minutes or longer
Causes include fetal hypoxia, maternal fever, maternal dehydration, amnionitis, drugs, maternal hyperthyroidism, maternal anxiety, fetal anemia, prematurity, fetal infection, chronic hypoxemia, congenital anomalies, fetal heart failure, and fetal arrhythmias

Question 19

Baseline variability

Answer 19

Irregular fluctuations in baseline fetal heart rate. Clinical indicator predictive of fetal acid-base balance in cerebral tissue perfusion. Influenced by fetal oxygenation status, cardiac output, and drug effects

Absent: fluctuation range undetectable
Minimal: fluctuation range observed less than five BPM
Moderate/normal: fluctuation range from 6 to 25 BPM
Marked: fluctuation range greater than 25 BPM

Question 20

Absent or minimal variability

Answer 20

Interventions include lateral positioning of mother, increasing IV fluid rate, oxygen at 8 to 10 L per minute by mask, possible internal fetal monitoring, document findings, report to doc

Question 21

Marked variability

Answer 21

Interventions include lateral positioning, increasing IV fluids, oxygen at 8 to 10 by mask, discontinue oxytocin, observe changes in tracing, consider internal fetal monitoring, let Dr. know

Question 22

Periodic baseline changes

Answer 22

Temporary, recurrent changes made in response to stimulus such as a contraction. Accelerations or decelerations

Question 23

Acceleration

Answer 23

Increases in fetal heart rate above the baseline that last less than 30 seconds from onsets to peak. Their duration is greater than 15 seconds but less than two minutes. They are usually normal. Caused by sympathetic nervous stimulation

Question 24

Deceleration

Answer 24

Fall in fetal heart rate caused by stimulation of parasympathetic nervous syndrome.

Question 25

Early deceleration

Answer 25

Decrease in FHR in which the Nadir occurs at the peak of the contraction. Most often seen during pushing, crowning, vacuum extraction, and the active stage of labor. They are from fetal head compression of the vagal nerve. Do not require intervention

Question 26

Late deceleration

Answer 26

Occur after the peak of the contraction, FHR does not return to baseline level until after the contraction has ended. Most often from placental insufficiency or decreased blood flow

Question 27

Variable deceleration

Answer 27

Decreases in FHR are below baseline, unpredictable shape usually U, V, or W, not consistent related to uterine contractions. Usually from cord compression

Question 28

Prolonged deceleration

Answer 28

Decrease of 15 BPM that lasts longer than two minutes but less than 10 minutes. The rate usually drops below 90. Caused from cord compression, abruptio placenta, cord prolapse, supine position, vaginal exam, fetal blood sample, maternal seizures, regional anesthesia, or uterine rupture

Question 29

Umbilical cord analysis

Answer 29

Most reliable indicator of fetal oxygenation and acid-base condition at birth. Cerebral palsy is often attributed to fetal acidosis which is a low cord pH at birth. The normal is 7.2- 7.3. This is used when a newborn has a low Apgar score or category two and three pattern during labor

Question 30

Fetal scalp stimulation

Answer 30

Used to evaluate fetal oxygenation and acid-base balance. It can be stimulated by acoustic stimulator on the abdomen and turned on to produce sound and vibration or By placing a finger on the fetal scalp and applying pressure. A well oxygenated fetus will respond when stimulated. Do not perform if Fetus is preterm, intrauterine infection, placenta previa, or fever

Question 31

Hydrotherapy

Answer 31

The woman should be in active labor and more than 5 cm dilated to prevent the slowing of labor contractions because of muscular relaxation if in warm water.

Question 32

Neuraxial analgesia/anesthesia

Answer 32

Administration of analgesic or anesthetic either continuously or intermittently into the epidural or intrathecal space to relieve pain. Low-dose and ultralow dose epidural, spinal, and spinal/epidural analgesia. There is no need to withhold until the active stage of labor.

Question 33

Systemic analgesia

Answer 33

Must have Narcan available to give to baby if he has CNS depression. Can use opioids, antiemetics, or benzodiazepines.

Question 34

Opioids

Answer 34

Demerol is the most commonly given. Birth should happen within one hour or after four hours of administration to prevent fetus from receiving the peak concentration. They can cause a decrease in FHR, nausea vomiting pruritis delayed gastric emptying drowsiness hypoventilation and newborn depression

Question 35

Antiemetics

Answer 35

Used to decrease nausea and vomiting, and lessen anxiety. Be used to increase sedation. Can cause a decrease in FHR variability and newborn depression

Question 36

Benzodiazepines

Answer 36

Used for minor tranquilizing and sedative effects. Given IV to stop seizures resulting from eclampsia. Can calm woman who is out of control so she can relax. Can cause CNS depression for both women and Newporn

Question 37

Epidural

Answer 37

Increases duration of the second stage of labor and may increase the rate of instrument assisted deliveries as well as that of oxytocin administration. Vaginal and cesarean births. You must avoid the supine position to minimize hypotension

Question 38

Combined spinal/epidural analgesia

Answer 38

Rapid relief within 3 to 5 minutes up to three hours. Allows the women to remain active and be able to bear down. It allows the woman to ambulate.

Question 39

Spinal analgesia

Answer 39

Pain relief during labor or cesarean births. It may only last a few hours

Question 40

Laboratory tests on admission

Answer 40

Urinalysis and CBC. Can also include blood typing and Rh factor, syphilis screening, hepatitis B, group B Streptococcus, HIV if the woman gives consent, and possible drug screening if history is positive

Question 41

Group B streptococcus

Answer 41

Gram-positive organism that colonizes the female genital tract and rectum. They are asymptomatic. If positive the women need antibiotics. Neonatal manifestations include pneumonia and sepsis. The mother receives IV antibiotics at the onset of labor or ruptured membranes

Question 42

A woman with HIV

Answer 42

Given zidovudine IV. The newborn is giving it Oral and continued for six weeks. Should not use a scalp electrode or do blood sampling. Encourage formula feeding and avoid invasive procedures.

Question 43

Vital signs during labor

Answer 43

BP, pulse, and respirations are assessed every hour of labor. During the active and transition phases they are assessed every 30 minutes. Temperature is taken every four hours in the first stage, and every two hours after membranes have ruptured. Contractions are monitored every 30 to 60 minutes during latencies every 15 to 30 minutes during the active phase, and every 15 minute during transition.

Question 44

Perineal lacerations

Answer 44

First-degree extends through skin. Second-degree extends thru muscles of the perennial body. Third-degree continues to anal sphincter and muscle. Fourth degree involves anterior rectal wall.

Question 45

Episiotomy

Answer 45

Incision in the perineum to enlarge the vaginal outlet. Midline is the most common, you can also do right and left mediolateral

Question 46

Apgar score

Answer 46

Heart rate/absent, slow, or fast
Respiratory effort/absent, weak cry, or good strong yell
Muscle tone/limp, or lively and active
Response to irritation stimulus
Color/evaluate cardiorespiratory adaptation afterbirth

Question 47

Third stage of labor

Answer 47

Is done when the placenta is delivered. Three hormones: oxytocin, endorphins rise, while adrenaline decreases. To help with this, there should be skin to skin contact between the mother and newborn, provide warm blankets to prevent shivering, and allow breast-feeding.

Question 48

Signs the placenta is ready to deliver

Answer 48

Firmly contracting uterus, uterine shape changes to globular, gush of dark blood, lengthening of the umbilical cord.