Chapter 8 Flashcards
how many stages of labor are there?
4
stage 1 of labor is subdivided into:
- latent: up to 5 cm dilated
- active: 6-7 cm dilated
- transition: 8-10 cm dilated
what happens during stage 1 of labor?
- ROM
- cervix dilates and causes pain
- assess vitals
- assess pain
- FHR & contractions
- cervical changes
- fetal decent & position
which stage of labor is the longest?
stage 1
nursing actions: stage 1
- limit PO fluids
- assist with comfort measures
- encourage frequent position changes
- help with bowel movements
- educate
- peri care
ROM means
rupture of membranes
SROM means
spontaneous rupture of membranes
how to assess ROM
- ferning: sample fluid from upper vaginal area is placed on a glass slide and assessed for a ferning pattern-ROM occurred
- nitrazine paper: turns blue when in contact with amniotic fluid-ROM occurred
nursing actions: ROM
- check for umbilical cord prolapse
- assess color of fluid: should be clear/cloudy without odor; report other colors
- educate regarding when to seek medical attention
ROM: non-risk patient education *when to go to hospital
- go to hospital when contractions are consistent for 1 hour, and are 5 minutes apart, lasting 60 seconds
ROM: immediate risk patient education
- SROM
- intense pain
- bloody show increases
(needs to go to hospital asap)
stage 2 of labor is
10 cm dilated to birth
how does the nurse assist with pushing?
- push for 6-8 seconds
- slight exhale
- repeat 3-4 times
what happens during stage 2 of labor?
- baby actively moves down the birth canal
- lasts about 50 minutes
- contractions intensify
- perineal stretching can help decrease tears
- mom feels urge to push
- perineum flattens
- rectum and vagina bulge
episiotomy
- surgical incision made to perineum to aid in delivery
- done by HCP
- can be midline (straight down)
- can be mediolateral (diagonal)
nursing actions: episiotomy
- inspection approximated
- free of foul smell drainage
laceration
- tear of perineum
- not done by HCP, happens naturally
- graded: 1st, 2nd, 3rd, 4th
nursing actions: laceration
- assess for slow, steady trickle of blood
stage 3 of labor
begins after birth and ends with the expulsion of the placenta
nursing interventions: stage 3 of labor
- watch for signs of placental separation:
-increase in cord length
-upward rising of uterus into a ball shape
-sudden gush of blood from the vagina - assist w/ delivery of placenta:
-encourage breathing and abdominal relaxation during delivery of the placenta - assess fundus continuously; palpate fundus
- possible need for admin of Pitocin if excess bleeding is noted * have med & IV fluids in room if hemorrhage occurs
- placenta out: assess for hemorrhage
- provide newborn care
- skin to skin
- monitor delivery of placenta
- admin oxytocin IM or IV if placenta takes > 30 min to deliver
- inspect placenta to make sure it is 100% (don’t want to leave any behind)
- obtain order for pain meds or uterotonics PRN
- assess vitals q15 min
- encourage bonding
- admin pain meds
- document
nursing interventions: stage 4 of labor
- palpate fundus q15 min x 1 hour: assessing for uterine involution and/or uterine atony
- assess vaginal bleeding
- encourage bonding & breastfeeding
- have Pitocin IV available, if needed, for hemorrhage
- assess perineum & provide perineal care: tears and lacerations
- heated blanket
- provide food
- encourage rest
stage 4 of labor
delivery of placenta to maternal recovery
pain management in labor: nonpharmacologic
- childbirth classes
- relaxation and breathing
- cutaneous stimulation- effleurage
- thermal stimulation
- mental stimulation
pain management in labor: pharmacologic
- local
- pudendal block
- epidural block
- spinal
- general
labor triggers: maternal factors
- stretching of uterine muscles
- estrogen/progesterone changes
- oxytocin release
- release of prostaglandins
labor triggers: fetal factors
- fetal cortisol changes
- placenta ages
- prostaglandins increase causing contractions
5 P’s: factors affecting labor
- Powers: contractions
- Passage: pelvis and birth canal
- Passenger: the fetus
- Psyche: the response of woman
- Position: maternal posture and the physical positions to facilitate birth
powers
uterine contractions
- rhythmic
- synchronized
- intermittent (not constant, come and go)
upper 2/3 contracts and pushes down
lower segment less active - becomes thin and pulls up
DIF of contractions
Duration: how long
Intensity: how strong
Frequent: how often
passage
includes pelvis and birth canal
pelvis types
- gynecoid: fat heart
- android: skinny heart
- anthropoid: narrow but tall (oval)
- platypelloid: wide but short (narrow)
parts of the pelvis
- ileum
- ischium
- pubis
- sacrum and coccyx
what plays the biggest role in determining a successful vaginal delivery?
the maternal pelvis
effacement
- shortening and thinning of the cervix
- expressed in percentages 0-100%
- starts out 2-3 cm long and 1 cm thick
female pelvis: ischial spines- station
- stations are measured as cm up or down the ischial spine
- -3 to 0 = above the ischial spine
- 0 = narrowest point & is at the ischial spine
- +1 to +3 = below the ischial spine
passenger vs passageway relationship
- relationship of fetus to passageway is a major factor in the birthing process
relationship includes: - size of fetal head/skull
- fetal lie
- fetal attitude
- fetal presentation
- fetal position
- fetal size
fetal skull
- head is biggest part of fetus
- head molds to allow the skull to fit through the birth canal
- sutures (listed anterior - posterior) : frontal |, coronal - , sagittal |, lambdoid -
- fontanels (squishy, soft patches): anterior, posterior
fetal attitude
relationship of the fetal parts to one another
- vertex presentation
- brow presentation
- face presentation
fetal attitude: general flexion
back of the fetus is rounded, chin to chest, thighs are flexed on abdomen, legs flexed at the knees
*deviations from normal/gen flex can cause difficulties with labor and birth (i.e. extended head)
vertex presentation
head is completely flexed onto the chest
occiput is the presenting part
brow presentation
forehead down
face presentation
face down
- bruising on baby’s face
fetal lie
- refers to the relation of the long axis of the fetus to the mom’s long axis
- longitudinal: vertical
- transverse: horizontal
frank breech
butt down, legs extended up by head
complete breech
butt down, legs crossed, head tucked chin to chest
footling breech
1 foot down, 1 foot out, head up
fetal position
- relationship of the reference point of the fetus to the mom’s pelvis
- examiner during internal vaginal exam feels for the presenting part and figure out what it is
- cephalic: occipital bone
- breech: sacrum
positions: right occiput
- ROA: occiput is on the right side of the maternal pelvis: anterior meaning closer to the front of the pelvis
- ROT: occiput is on the right side of the maternal pelvis: transverse meaning across the maternal pelvis
- ROP: occiput is on the right side of the maternal pelvis: posterior meaning to the back part of the pelvis
positions: left occiput
- LOA: occiput is on the left side of the maternal pelvis: anterior meaning closer to the front of the pelvis
- LOT: occiput is on the left side of the maternal pelvis: transverse meaning across the maternal pelvis
- LOP: occiput is on the left side of the maternal pelvis: posterior meaning to the back part of the pelvis
positions: breech
- LSA: sacrum is on the left side of the maternal pelvis with the sacrum sitting anterior (in the front) of the maternal pelvis
- LSL: sacrum is on the left side of the maternal pelvis with the sacrum sitting lateral of the maternal pelvis
- LSP: sacrum is on the left side of the maternal pelvis with the sacrum sitting posterior (behind) of the maternal pelvis
- RSP: sacrum is on the right side of the maternal pelvis with the sacrum sitting posterior (behind) of the maternal pelvis
- RSL: sacrum is on the right side of the maternal pelvis with the sacrum sitting lateral of the maternal pelvis
- RSA: sacrum is on the right side of the maternal pelvis with the sacrum sitting anterior (in the front) of the maternal pelvis
maternal psyche
refers to mother’s disposition during each stage of labor
psyche: coping mechanisms
- culture
- expectations
- support systems
- type of support during labor
maternal positions
- upright
- all fours
- lateral
maternal position: upright
- walking
- standing
- kneeling
- squatting
- sitting: improve abdominal muscles working in greater synchrony with contractions and bearing down effort
maternal position: all fours- purpose
relieves backache if fetus is occiput/posterior
the lateral maternal position is used to ____
help rotate fetus that is in a posterior position
intrapartum
onset of labor through the delivery of the placenta
lightening
fetus decsends into the pelvis
braxton hicks
practice contractions
does not change the cervix
prepares the body for labor
how does labor influence the cervix/what changes happen to the cervix?
soften and thin
nesting
moms organize, clean and prepare for baby
involuntary uterine contractions
effacement: thin out the cervix
voluntary expulsion of the infant
pushing
what are the two types of powers?
- involuntary uterine contractions
- voluntary expulsion of the infant
what is the most common pelvis shape?
gynecoid
- 50% of women have this shape
what is the optimal pelvis shape?
gynecoid
which pelvis type would have molding of the head?
android pelvis
which pelvis type is the least common?
platypelloid
which pelvis type typically has the longest labor?
anthropoid
dilation
the widening of the cervical opening from less than 1 cm to 10 cm (full dilation)
- fully dilated = 10 cm
do effacement and dilation both need to happen for delivery?
for vaginal- yes
do effacement and dilation happen at the same time or one before the other?
a nulligravida mom will have effacement before dilation; a multigravida mom may have effacement and dilation occur simultaneously
most common presentation
cephalic (head)
- vertex
- occiput is presenting part
- 95% of all deliveries
what are the ideal positions for a vaginal delivery?
ROA or LOA
what is the presenting part of a frank breech infant?
buttocks
shoulder presentation
- usually represents a transverse lie
- c section
false labor
- contractions but no change in cervix
- activity doesn’t change pattern
- hydration or sedation slows/stops ctxs
true labor
- regular contractions increase in frequency and intensity
- change in cervix
- causing effacement and dilation
active labor is defined as ___
6 cm
why is prolonged pushing (2 hr) good for baby?
- pushes all the mucous and fluids out of fetal chest/lungs
- baby comes out dry, ready to eat
1st degree laceration
involves the perineal skin and vaginal mucous membrane
2nd degree laceration
involves skin, mucous membrane, and fascia of the perineal body
3rd degree laceration
involves skin, mucous membrane, and muscle of the perineal body
4th degree laceration
extends into the rectal mucosa and exposes the lumen of the rectum
oxytocin (pitocin)
hormone -IV or IM
- stimulates uterine muscle that produces intermittent contractions
- has vasopressor and antidiuretic properties
methergine
oxytocic or ergot alkaloids
- increases the tone, rate and amplitude of contractions on the smooth muscles of the uterus, producing sustained contractions and reducing blood loss
hemabate/carboprost
prostaglandin F2a analog
increases contractions of the uterine smooth muscles
misoprostol (cytotec)
synthetic analog of prostaglandin E
- acts as a prostaglandin analogue causing uterine contractions
tranexamic acid/TXA
antifibronolytic
- inhibits fibrinolysis (stops the breakdown of clots)
1 g blood loss = __ mL blood loss
1 mL
retained placenta causes what ?
PPH (post partum hemorrhage)
oxytocin/pitocin: side effects
- hypotension
- tachycardia
- water retention
oxytocin/pitocin: indications
- control of postpartum bleeding after placental expulsion
methergine: indications
- prevent or treat PPH, uterine atony, or subinvoliution
- used as a second-line medication
what do we monitor with methergine use?
- BP
- CNS status
- vaginal bleeding
- may cause nausea
(patient may require antiemetic)
methergine is contraindicated in patients with __
- hypertension
- preeclampsia
- may cause severe vasoconstriction
hemabate/carboprost: indications
- uterine atony
- second-line medication
- carboprost is a treatment alternative to methylergonovine for patients with HTN disorders
- may be used in hemorrhage situations retractory to methylergonovine and oxytocin
hemabate/carboprost: side effects
- nasuea
- vomitting
- diarrhea
hemabate/carboprost is used with caution with patients with ___
asthma
- carboprost can stimulate vasospasm
misoprostol: side effects
- abdominal pain
- diarrhea
- fever
- chills
misoprostol: indications of use
- used to control PPH
- 1st line medication in low-resource areas where oxytocin is not available
tranexamic acid/TXA: side effects
- abdominal pain
- headache
- nausea
- vomiting
- diarrhea
tranexamic acid/TXA: route/dosage
1g IV over 10-20 minutes
what are the most common uterotonic medications?
- oxytocin/pitocin
- methergine
- hemabate/carboprost
- misoprostol (cytotec)
- tranexamic acid/TXA
