Chapter 14 Nursing Mgmt During Labor And Birth Flashcards
Vaginal examination
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.
Rupture of membranes
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
Uterine contractions
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.
Leopold’s maneuvers
- Place woman in supine position
- Using both hands on the abdomen determine fetal position in the fundus. Feel for the Butt or the head
- Move hands down the lateral sides of the abdomen to palpate which side the back is on and which side the limbs are on
- Place thumb and fingers just above symphysis pubis. Feel for the presenting part either the head or the butt
- 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
Amniotic fluid
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.
Intermittent FHR Monitoring
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.
Frequency of FHR
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
Continuous electronic fetal monitoring
Provide info about oxygenation, detect fetal heart rate changes early on. Hypoxia is demonstrated in a rate pattern.
Continuous external monitoring
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
Artifact
Irregular variations or absence of the FHR on monitor from mechanical limitations or interference.
Continuous internal monitoring
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
Criteria for internal monitoring.
Ruptured membranes, cervical dilation at least 2cm, presenting part low enough, skilled person available.
FHR patterns
They include baseline fetal heart rate variability, presence of accelerations, periodic or episodic deceleration, and changes or trends of fetal heart rate patterns
Category one: Normal
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
Category two: indeterminate
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
Category three: abnormal
Predictive of abnormal fetus acid-base status
Bradycardia less than 110
Recurrent late decelerations
Recurrent variable deceleration
Sinusoidal pattern (smooth, undulating baseline)
Fetal bradycardia
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
Fetal tachycardia
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
Baseline variability
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
Absent or minimal variability
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
Marked variability
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
Periodic baseline changes
Temporary, recurrent changes made in response to stimulus such as a contraction. Accelerations or decelerations
Acceleration
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
Deceleration
Fall in fetal heart rate caused by stimulation of parasympathetic nervous syndrome.
Early deceleration
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
Late deceleration
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
Variable deceleration
Decreases in FHR are below baseline, unpredictable shape usually U, V, or W, not consistent related to uterine contractions. Usually from cord compression
Prolonged deceleration
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
Umbilical cord analysis
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
Fetal scalp stimulation
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
Hydrotherapy
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.
Neuraxial analgesia/anesthesia
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.
Systemic analgesia
Must have Narcan available to give to baby if he has CNS depression. Can use opioids, antiemetics, or benzodiazepines.
Opioids
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
Antiemetics
Used to decrease nausea and vomiting, and lessen anxiety. Be used to increase sedation. Can cause a decrease in FHR variability and newborn depression
Benzodiazepines
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
Epidural
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
Combined spinal/epidural analgesia
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.
Spinal analgesia
Pain relief during labor or cesarean births. It may only last a few hours
Laboratory tests on admission
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
Group B streptococcus
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
A woman with HIV
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.
Vital signs during labor
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.
Perineal lacerations
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.
Episiotomy
Incision in the perineum to enlarge the vaginal outlet. Midline is the most common, you can also do right and left mediolateral
Apgar score
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
Third stage of labor
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.
Signs the placenta is ready to deliver
Firmly contracting uterus, uterine shape changes to globular, gush of dark blood, lengthening of the umbilical cord.
