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NURS 4500: Midterm Material > Class 4: Uncomplicated Labour and Birth Part 1 > Flashcards

Class 4: Uncomplicated Labour and Birth Part 1 Flashcards

1
Q

what is considered pretern

A

<37 weeks gestations

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2
Q

what is considered postterm

A

equal to or >42 weeks gestation

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3
Q

define: labour

A
  • the process of moving the fetus, placenta, and membranes out of the uterus and thru the birth canal
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4
Q

what influences duration of labour (7)

A
  • parity
  • maternal emotions
  • position
  • lvl of activity
  • fetal size
  • presentation
  • position
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5
Q

what is parity? how does this impact labour?

A
  • number of pregnancies
  • labor process is faster if have had more than one vaginal birth
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6
Q

how might maternal emotions impact labor

A
  • stress, anxiety, and fear cause tightness = labor may take longer
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7
Q

labour includes.. (3)

A
  • regular progression of uterine contractions
  • effacement and progressive dilation of the cervix
  • descent of the presenting part
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8
Q

what is the most important factor in labor management

A
  • diagnoses of the active phase of 1st stage of labor
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9
Q

what change occurs to the cervix in the days/weeks prior to labor to prepare for birth? why?

A
  • cervix begins to soften = cervical ripening
  • associated w number of hormonal shifts which are imp instigators of the labour process
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10
Q

what changes occur r/t bleeding in the days/weeks prior to labor to prepare for birth?

A
  • as the cervix changes, the mucus plug loosens and may be expelled fro the vagina
  • this is normal, not considered antepartum bleeding
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11
Q

what changes occur to the presenting part in the days/weeks prior to labor to prepare for birth?

A
  • lightening = presenting part descends into true pelvis
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12
Q

what contractions occur in the days/weeks prior to labor to prepare for birth?

A
  • braxton hicks contractions
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13
Q

what are braxton hick contractions

A
  • tightening, very uncomfortable contractions in your abdomen that comes and goes
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14
Q

what impact do braxton hicks contractions have on the cervix

A
  • do not dilate the cervix, just part of the preparation process
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15
Q

what changes occur to energy occur in the days/weeks prior to labor to prepare for birth?

A
  • nesting –> surge in energy
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16
Q

the onset of labor is likely due to a combo of (3)

A
  • fetal hormones
  • birther hormones
  • progressive uterine distension and increased uterine pressure = irritability of muscle layer
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17
Q

what is the hormone of labor

A
  • oxytocin
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18
Q

what is oxytocin produced by

A
  • the posterior pituitary gland
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19
Q

what role does oxytocin have in labour (3)

A
  • supports the onset of labour contractions
  • stimulates uterine contracions
  • aids in milk let-down
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20
Q

synthetic oxytocin (syntocinon) may be administered for a variety of indications such as (3)

A
  • to induce labour contractions
  • to augment labour contractions
  • to support uterine contractions to control post partum bleeding from the placental site
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21
Q

how does oxytocin play a role in supporting uterine contractions to control postpartum bleeding from the placental site

A
  • stops hemorrhage by pinching blood vessels which are open after birth of placenta
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22
Q

dosage of syntocinon depends on.. the dosage for induction/augmentation is greater or less than for postpartum bleeding?

A
  • the timing and purpose of admin
    ex. dosing for induction/augmentation is FAR less then for postpartum bleeding
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23
Q

what route is used for admin of syntocinon? what determines this?

A
  • IM or IV
  • depends on timing, purpose
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24
Q

is IV or IM syntocinon used for induction/augmentation? postpoartum bleeding?

A
  • induction/augmenation = IV
  • post partum bleeding = IM or IV
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25
Q

what is important to note w syntocinon

A
  • syntocinon for induction/augmentation of labour is considered a hazardous med
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26
Q

why is synthetic oxytocin considered a hazardous med for induction/augmentation of labour

A
  • do not want contractions increased too much d/t risk of decreased gas exchange to fetus
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27
Q

describe contractions in true labour (5)

A
  • occur regularly
  • increasing in strength, length, and freq
  • become more intense w walking
  • lower back –> radiating to lower abdomen
  • continue despite walking/activity/comfort measures
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28
Q

describe contractions in pre-labour (3)

A
  • irregularly or occur only temporary
  • often cease w walking/activity/position changes/other comfort measures (may help w pain but they wont stop)
  • contraction experienced in back and upper abdomen
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29
Q

describe the cervic in true labour (3)

A
  • progressive change is evident –> softens, effaces, dilates
  • often results in bloody show
  • moves anteriorly
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30
Q

describe the cervix in pre-labour (2)

A
  • might be soft, but no significant change in effacement or dilation or bloody show
  • likely in more posterior position
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31
Q

what is important if it pre-labor and not in true labor?

A
  • can be very discouraging –> imp to validate feelings
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32
Q

describe what discharge teaching can be given if comes in w pre-labour (6)

A

when to return to hospital:
- contractions every 5 min for at least 1 hr
- contractions increasing regularity, freq, duration, and intensity
- a gush of fluid from the vagina –> rupture of membranes
- vaginal bleeding
- decreased fetal mvmt
- other concerns/feeling unwell

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33
Q

how many stages of labor are there

A
  • 4
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34
Q

when does the 1st stage of labour and birth start and end?

A
  • start of regular uterine contractions (start of true labour) until complete cervical effacement and dilation
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35
Q

describe the length of the 1st stage of L&D

A
  • typically the longest stage
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36
Q

the 1st stage of L&D typically includes 2 phases, what are they?

A
  1. latent/early phase
  2. active phase
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37
Q

when does the 2nd stage of L&D start and end?

A
  • start with complete cervical effacement & dilation
  • ends w birth of newborn
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38
Q

when does the 3rd stage of L&D start and end

A
  • start: from birth of newborn
  • end: when placenta is expelled
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39
Q

when does the 4th stage of L&D occur

A

first 1-2 hrs after placenta is expelled (due to risk of bleeding)

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40
Q

what factors affect L&D (5)

A
  • passageway (birth canal)
  • passenger (primarily fetus, also placenta)
  • powers (primary and secondary)
  • position (birther)
  • psychological response
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41
Q

what 3 parts of the passenger affect L&D

A
  • presentation
  • position
  • station
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42
Q

what does nulliparous mean

A
  • a person who has never given birth
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43
Q

what does multiparous mean

A
  • Having given birth two or more times
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44
Q

the passageway includes: (5)

A
  • bony pelvis
  • soft tissues of the cervix of pregnant person
  • pelvic floor
  • vagina
  • introitus (external opening of vagina)
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45
Q

what is imp to note regarding the passenger?

A
  • the fetus relationship to the passageway is the major factor in the birthing process
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46
Q

what terms are used to describe the relationship of the fetus to the passageway? (5)

A
  • fetal lie
  • fetal presentation
  • fetal attitude
  • fetal position
  • fetal station
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47
Q

define: fetal lie

A
  • relationship between the long axis (spine) of the fetus w respect to the long axis of the mother
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48
Q

what 3 terms can be used to describe fetal lie

A
  • longitudinal
  • transverse (perpendicular)
  • oblique (diagonal)
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49
Q

define: fetal presentation

A
  • part of fetus that enters pelvis first (typically cephalic/head)
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50
Q

define: fetal attitude

A
  • relationship of fetal body parts to each other (typically flexed)
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51
Q

define: fetal position

A
  • relationship of the fetal presenting part (usually head) to a specific quadrant of a pregnant person’s pelvis
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52
Q

what are the 4 quadrants of the pregnant person’s pelvis

A
  • right anterior
  • left anterior
  • right posterios
  • lef tposterior
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53
Q

what are the 4 fetal landmarks for fetal position

A
  • occiput
  • mentum
  • sacrum
  • acromion
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54
Q

what is occiput

A
  • vertex presentation = head presenting first
  • ‘O’
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55
Q

what is the fetal position “mentum”

A
  • aka chin
  • face presentation
  • ‘M’
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56
Q

what is the sacrum fetal position

A
  • breech presentation (bum first)
  • ‘S’
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57
Q

what is the acromion fetal position

A
  • aka scapula
  • shoulder presentation
  • ‘Sc’
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58
Q

define: fetal station

A
  • position of the presenting part relative to the lower bone of pelvis called the ischial spines
  • how far the fetus has descended into the pelvis
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59
Q

fetal position is abbreviated by 3 letters. what does each stand for?

A
  1. indicates whether the landmark is facing the mother’s left or right –> R for right or L for left
  2. indicates fetal landmark –> ex. S for sacrum
  3. indicates whether the landmark points anteriorly, posteriorly, or transverse –> A, P, or T
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60
Q

what are powers?

A
  • include both the involuntary and voluntary powers which together expel the fetus and placenta from the uterus
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61
Q

what are primary powers

A
  • involuntary uterine contractions
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62
Q

primary powers are discussed in terms of: (4)

A
  • frequency (in min)
  • duration (in sec)
  • intensity (weak, mod, strong)
  • resting tone
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63
Q

primary powers are responsible for: (3)

A
  • dilation of the cervix
  • effacement of the cervix
  • descent of the fetus
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64
Q

what are secondary powers

A
  • bearing down efforts
  • pushing down by the birther
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65
Q
  • what are secondary powers responsible for
A
  • support the expulsion of the fetus and placenta
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66
Q

the mechanisms of labor refer to?

A
  • the movements and adjustments made by the fetus during the 1st and 2nd stages of labor
  • how the passenger navigates the passageway, facilitated by the primary & secondary powers, and supported by fetal positioning, positioning of birth, and psychological response of the birther
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67
Q

what are the 7 cardinal movements of labour

A
  • engagement
  • descent
  • flexion
  • internal rotation
  • extension
  • external rotation
  • birth
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68
Q

describe the cardinal movement: engagement

A
  • when the biparietal diameter of the head passes the pelvic inlet
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69
Q

describe the cardinal movement: descent

A
  • progress of the presenting part thru the pelvis
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70
Q

describe the cardinal movement: flexion

A
  • fetal head flexes so that the chin is brought to the chest as it meets resistance from the cervix, plevis, or pelvic floor
  • reduces fetal head diameter
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71
Q

describe the cardinal movement: internal rotation

A
  • rotation of the presenting part from its original position (usually transverse, head looking to side), to the anterior position as it passes thru the bony pelvis
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72
Q

describe the cardinal movement: extension

A
  • the presenting part rotates under the symphysis pubis
  • the presenting part has now passed out of the birth canal and is now at the perineum and crowning
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73
Q

describe the cardinal movement: external rotation

A
  • aka, restitution
    1. the occiput and spine assume the same position, head rotates to the position it was in when engaged in the inlet
    2. the shoulders rotate internally to fit the pelvic oulet (midline, anterior-posterior position), which causes further visible external rotation of the head
    3. shoulders are birth when anterior shoulder is guided under the pubic arch, then the posterior shoulder
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74
Q

describe the cardinal movement:birth

A
  • aka expulsion
  • the head and shoulders are lifted up toward the birther’ s pubic bone and the trunk & rest of the body is born (flexed laterally in the direction of the symphysis pubis = birth
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75
Q

how long is the first stage of labor

A
  • from the time the cervix begins to dilate until full dilation at 10 cm
  • can last 1-18 hours
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76
Q

early/latent labour: how much is the cervix dilated? effacement? onset?

A
  • cervix goes from closed to 3cm dilated
  • effacement <1cm or 75% effaced
  • exact onset difficult to determine
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77
Q

active labour: dilation?contractions?

A
  • from 4 cm to full dilation (nulliparous people)/4-5 cm (multiparous people)
  • contractions more intense and frequent
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78
Q

once active labor has begun, the cervix should dilate how much and how often?

A
  • 1cm/hour
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79
Q

describe what is included in initial nursing assessment in triage(14)

A
  • what brings them into the hospital today
  • if in labour, start of contractions, contraction freq, intensity, length, persistent
  • status of rupture of membrane –> intact? ruptured? timing? clarity of fluid?
  • fetal mvmt?
  • any bleeding?
  • name/age/pronouns
  • allergies
  • prenatal info
  • any issues w previous anaesthesia
  • surgery before?
  • birth plan
  • height and weight
  • VS
  • obstetrical assessment (if labour is presenting concern)
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80
Q

what info is important to collect regarding prenatal info during initial nursing assessment (8)

A
  • obsterical hx
  • prenatal hx
  • EDD
  • social hx
  • gestational age
  • any complications?
  • blood/labwork from current pregnancy –> hgb, Rh, GBG status,
  • location of placenta
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81
Q

what is included in the obstetrical assessment for initial nursing assessment, if assuming labor is presenting concern (6)

A
  • leopold’s maneuvers (abdominal palpation) –> fetal position and presentation
  • contractions (uterine activity)
  • HFR
  • if rupture of membranes –> usually confirmed by nitrazine or ferning test
  • vaginal exam
  • specific assessments of complications (HDP, GDM)
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82
Q

what is included in vaginal exam of an obstetrical assessment (4)

A
  • cervical effacement and dilation
  • fetal presentation
  • position
  • station
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83
Q

describe the procedure to perform leopold’s maneuver (5)

A
  • wash hands
  • empty bladder
  • supine position, knees slightly flexed, slight R or L tilt
  • 4 maneuvers
  • document
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84
Q

what is the focus of nursing assessment in the 1st stage of labor

A
  • monitor progress
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85
Q

describe what is included in nursing assessment in the 1st stage of labor (10)

A
  • birther VS
  • leopold’s maneuver
  • HFR and pattern
  • uterine activity
  • vaginal show/amniotic fluid if membranes have ruptured/status of membranes
  • progress in labor –> vaginal exams as needed
  • assess pain and coping
  • oral intake/elimination
  • lab tests as required
  • birther overall status
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86
Q

describe the timing of maternal Bp, P, and RR in the active stage of the first stage of labour. what is it for temp?

A
  • BP, pulse, and RR q30-60 min
  • maternal temp q4 hr if membranes intake –> q1-2 hr if ruptured
87
Q

describe the timing of FHR and pattern & uterine activity during the active phase of the first stage of labour

A
  • q 15-30 min
88
Q

describe the timing of the vaginal exam during the active phase of the 1st stage of labour; what is an imp consideration w this

A
  • as needed to identify progress
  • r/o infection
89
Q

describe the timing of the assessment of the birther status during the active phase of the 1st stage of labour; what is included in this

A
  • mood
  • affect
  • energy level
  • comfort lvl
  • on going
90
Q

describe the timing of the partner/coach/supports status during the active phase of the 1st stage of labour;

A
  • ongoing
91
Q

what is included in the Psychological response of labor and birth

A
  • the psychological state of the birther and their response are very important in labour
  • supports (family, nurse, doula, friends) are essential
92
Q

what is included in assessment of uterine activity (contractions) (4)

A
  • freq
  • intensity
  • duration
  • resting tone
93
Q

why is resting tone of uterine activity important?

A

..

94
Q

describe what is included in FHR assessment (5)

A
  • baseline rate
  • presence of accelerations
  • presence of decelerations
  • variability (if electronic FHR monitoring)
  • rhythm (if intermittent auscultation of FHR)
95
Q

what is imp to note regarding the relationship between assessment of uterine activity and FHR

A
  • FHR is ALWAYS assessed in conjunction w uterine activity during L&D
96
Q

describe the rupture of membranes (ROM) in L&D

A
  • the baby is surrounded by the amniotic sac which is filled w amniotic fluid
  • this sac can rupture prior to labour, beginning, during labor, and can even remain intact throughout the delivery
  • can rupture spontaneously or artifically
97
Q

define: amniotomy

A
  • artificial rupture of membranes done by the primary health provider
98
Q

describe the assessment of the ROM during L&D (6)

A
  • accurate record of the time is important
  • if ruptured at home, try to estimate timing as closely as possible & confirm rupture of membranes
  • color
  • viscosity
  • amount
  • odour
99
Q

why is accurate record of the time of ROM important?

A
  • risk of infection increases if membranes are ruptured longer than 48 h prior to delivery
100
Q

what does PROM stand for & mean

A
  • premature rupture of membranes
  • ROM prior to labour
101
Q

what does PPROM stand for and mean

A
  • preterm premature rupture of membranes
  • preterm PROM
  • membranes rupture before the completion of 37 weeks gestations –> associated w 10% of all preterm births
102
Q

what does SROM mean

A
  • spontaneous ruptire of membranes
103
Q

what does ARM stand for

A
  • artificial rupture of membranes
104
Q

what 4 things are assessed in the vaginal exam

A
  • dilation
  • effacement
  • presenting part
  • status of membranes –> ruptured? unruptured? color? clarity?odour
105
Q

what is the dilation of the vagina? how is it measured? whats an imp consideration w this?

A
  • the degree to which the cervical os (opening) is dilated (open)
  • measured in cm
  • somewhat subjective, but most HCP will have similar assessmentsq
106
Q

what is effacement of the vagina? how is it expressed?

A
  • the thinning and softening of the cervix
  • expressed as a % up to 100%
107
Q

what is assessed r/t the presenting part? (3)

A
  • what is the presenting part?
  • position and station?
  • moulding?
108
Q

pain is experienced during 1st of labor due to? (3)

A
  • cervical changes
  • distension of the lower segment of the uterus
  • uterine ischemia
109
Q

describe pain during 1st stage of labor (2)

A
  • referred pain –> starts in uterus then radiates to the back, iliac crests, gluteal area, and down the thighs
  • usually experience pain during contractions and have “a break” in between
110
Q

describe supportive care during the 1st stage of labor (12)

A
  • understand desires/goals for birth experience
  • support the birther –> what they want & feel they should be doing
  • support birther decision making
  • answer questions, provide info
  • encourage birth position changes
  • discuss comfort lvls and provide pharm and non-pharm mngmt
  • admin interventions for pain chosen by the birth as able –> assess effectiveness
  • communicate w team –> birther, labor support team, primary care provider, charge nurse, anesthsia
  • encourage oral intake (as allowed) and elimination (q2h, so not in way)
  • support general hygiene –> perinuem/pad changes, especiallyw ROM
  • initiate IV as needed
  • treat for GBS as needed
111
Q

describe group B streptococcus (GBS) in non-pregnant person

A
  • usually considered normal flora in non-pregnant person
112
Q

what someone is GBS positive prenatally, what can occur

A
  • transmission from birther to the newborn during birth process
113
Q

what is the treatment for all birth’s who test GBS positive

A
  • IV antibiotic prophylaxis , usually penicillin G
  • 5 million units IV loading dose, then 2.5 million units q4h until birth
114
Q

what occurs if GBS status is unknown but risk factors exist?

A
  • may still be treated
115
Q

what are risk factors for neonatal GBS infection (5)

A
  • positive prenatal culture for GBS (this pregnancy)
  • preterm birth
  • prolonged rupture of membranes (>18 hrs)
  • birth intrapartum fever of >38
  • previous history
116
Q

what are some non-pharma interventions for pain in 1st stage of labor (12)

A
  • childbirth prep
  • supportive team
  • breathing techniques/relexation
  • imagery and visualization
  • position changes –> walking
  • massage/counter pressure/effleurage
  • heat/cold packs
  • water/hydrotherapy (showers, bath, birth tub)
  • birth balls
  • double hip squeeze
  • TENS
  • intradermal sterile water injections
117
Q

what is included in touch& massage for pain mngmt

A

can include:
- holding pt’s hand
- embracing
- head, hand, back, shoulder, and foot massage

118
Q

what are pharma interventions for pain in 1st stage (3)

A
  • nitrous oxide
  • systemic analgesia (opioids: morphine and fentanyl)
  • epidural anesthesia and analgesia (regional)
119
Q

how is nitrous oxide (N2O2) administered?

A
  • inhaled gas that is admin thru a self-administered face mask (only pregnant person holds)
  • mask applied and N2O2 inhaled as soon as contractions starts til it ends, breathe normally without mask between contractions
120
Q

what is the onset, duration of N2O2

A
  • rapid onset and rapid termination of effects
  • duration: great for short term relief
121
Q

describe the effect of N2O2 on fetus/newbornw

A
  • no evidence of effect
122
Q

include assessment after admin of N2O2 (4)

A

observe birther for:
- NV
- drowiness
- dizziness
- LOC

123
Q

describe admin of morphine in 1st stage of labour (3)

A
  • subcut
  • IM
  • IV
124
Q

what effect does morphine have on birther

A
  • creates a feeling of well-being and euphoria –. can enhance a birther’s ability to rest between contractions
125
Q

what side effect can morphine have on the birther

A
  • can inhibit contractions
126
Q

what is an important consideration w morphine

A
  • consider giving in early labour due to long half life & risk of resp depression to the newborn/neonatal sedation
127
Q

describe the admin of fentanyl during the 1st stage of labour

A
  • IV –> can be PCA
128
Q

describe the similarities/difference between morphine and fentanyl

A
  • similar in many ways
  • fentanyl is more potent and shorter acting
129
Q

what is the protocol for monitoring for fentanyl

A
  • must have continuous monitoring of O2 sats until 2 hrs after last dse
130
Q

fentanyl is great for..

A
  • short term relief
131
Q

describe the impact that both fentanyl and morphine have on the birther (3)

A
  • create a feeling of well-being or euphoria
  • allow rest in between contractions and relaxation
  • can limit mvmt/position changes –> think of safety precautions
132
Q

describe the impact that both fentanyl and morphine have on the fetus (2)

A

Cross the placenta and affect the fetus and newborn:
- FHR variability
- neonatal resp depression

133
Q

d/t the risk of neonatal resp depression w morphine and fentanyl, what is potentially done?

A
  • naloxone hydrochloride (narcan) is given to the newborn if opioid-induced resp depression in the newborn is suspected
134
Q

what is the onset of action of morphine vs fentanyl

A
  • morphine: 5-30 min depending on route
  • fentanyl: 2-3 min
135
Q

what is the duration of morphine vs fentanyl

A
  • morphine: 4-5 h
  • fentanyl: 30-60 min
136
Q

when is the best timing for the admin of morphine vs fentanyl

A
  • morphine: early labor (do not give if birth in 4 h)
  • fentanyl: active labor, for short term pain relief (ex. during procedure, while awaiting epidural)
137
Q

what is the side effects of morphine and fentanyl (5)

A
  • NV
  • dizziness
  • drowsiness
  • pruritis
  • resp depression
138
Q

what is considered nerve block analgesia & anesthesia

A
  • epidural analgesia and/or anesthesia
139
Q

what is the most effective pharmacologic pain relief method for labor pain

A
  • epidural
140
Q

what is an epidural

A
  • local anesthetic and/or opioid analgesia are injected into epidural space
141
Q

epidural is best used when?

A
  • when the birther is in good established labour
142
Q

epidural usually involves??

A
  • PCEA (pt controlled epidural analgesia)
143
Q

describe the impact of epidural on newborn

A
  • little to no lasting effects
144
Q

epidural insertion is commonly performed where?

A
  • between 4th and 5th lumbar vertebrae
145
Q

describe how an epidural works (3)

A
  • epidural needle is used to introduce a catheter into the epidural space, needle then removed
  • catheter remains in situ until the 4th stage of labor
  • nerve conveying pain from the uterus enter the spinal canal at the region of the lower chest while nerves from the lower birth canal enter in the region of the sacrum
146
Q

injecting local anesthetic and/or opioid into the lumbar area allows the med to??

A
  • spread upwards and downwards to cover both areas
147
Q

epidural medications work by temporarily interfering w nerve transmission. what are 3 types of nerve fibers?

A

A
B
C

148
Q

what is the function of group A nerve fibers (2)

A
  • control sensation
  • motor function
149
Q

describe the blocking of group A nerve fibers

A
  • difficult to block as they are myelinated
150
Q

describe the fnxn of group B nerve fibers

A
  • control autonomic fnxns
151
Q

describe the blocking of group B nerve fibers (2)

A
  • when blocked, a sympathetic block results in vasodilation
  • blocked the fastest
152
Q

what is the fnxn of group C nerve fibers

A
  • pain and temp
153
Q

d/t the function of group C nerve fibers, how can we check the lvl at which pain impulses are blocked?

A
  • checking the lvl at which the birther can detect temp
154
Q

describe the impact of epidural on birther (3)

A
  • preserves motor function
  • block pain & temp signal transmission
  • can cause sympathetic block –> vasodilation –> hypotension
155
Q

an epidural can be used for??

A
  • both vaginal & c-section
156
Q

describe the impact of epidural in the 2nd stage

A
  • will still feel pressure in 2nd stage
157
Q

what is the nurses role during epidural insertion? (13)

A
  • contact anesthesiologist and provide pt history
  • 18G IV
  • have birther void ahead of procedure
  • remove all clothing under gown & tongue piercings
  • provide birther w OR hat (nurse & labor support to wear OR hat and mask)
  • gather epidural cart, pump, med
  • pt education
  • support
  • monitor HFR during procedure
  • monitor birther VS
  • support w applying dressing and tape
  • document
  • labour support can remain in room
158
Q

what pt education should be given r/t epidurals (4)

A
  • imp for them to stay still during procedure
  • communicate when contractions are starting
  • focus on breathing
  • informed consent
159
Q

describe the birther’s position during epidural insertion (4)

A
  • side lying
  • or sitting position w her lower back pushed out
  • ensure bed is flat and raised as needed
  • also depends on MDs preference
160
Q

what prenatal history is imp for epidural insertion (5)

A
  • prenatal history
  • labour progress
  • recent blood work
  • BMI
  • baseline VS
161
Q

what is done shortly after the epidural catheter is inserted?

A
  • a “test dose” of local anesthetic is given to ensure catheter is placed in correct space
162
Q

what are warning signs that an epidural is not in the right space? (6)

A
  • ringing in ears
  • tingling lips
  • metallic taste
  • blurred vision
  • confusion
  • slurred speech
163
Q

what risk r/t VS is associated w epidural

A
  • hypotension
164
Q

how often should BP be monitored after an epidural insertion

A
  • q2 min x10 min
165
Q

why should FHR be assessed after epidural insertion

A
  • risk for placental perfusion d/t r/o hypotension of birther
166
Q

what is included in assessments for epidural insertion (10)

A
  • ongoing monitoring of VS (increased freq of BP once epidural established)
  • pain (effectiveness of epidural)
  • sensory block and motor block per protocol
  • dermatome lvls –> use ice
  • motor function
  • FHR monitoring
  • mindful of bladder –> support birther to ambulate BR or bedpain
  • before getting pt up to ambulate, test their leg strength
  • education r/t PCEA
  • continue w support care
167
Q

when is an epidural catheter usually removed

A
  • in 4th stage of labor
168
Q

why is it important to be mindful of the bladder with an epidural (2)

A
  • birthers w an epidural require accurate measurement of urine
  • may require urinary catheter
169
Q

what are advantages of an epidural:

A

-

170
Q

what are disadvantages of an epidural

A

-

171
Q

what is the 2nd stage of labor? when does it start?

A
  • from the time the cervix is fully dilated to time of birth
  • may not always know the exact start as it requires a vaginal exam
172
Q

what is the general duration of the 2nd stage of labor? for nulliparous person? multiparous?

A
  • can last from few min to couple of hours (or more)
  • nulliparous: 50-60 min
  • multiparous: 20-30 min
173
Q

duration of the 2nd stage of labor is affected by? (3)

A
  • parity
  • maternal size
  • fetal size, position, and descent
174
Q

the most intense time for the mother in the 2nd stage of lavor is when?

A
  • when the widest portion of the baby’s head is being delivered –> crowning
175
Q

what is the passive phase of the 2nd stage of labor?

A
  • birther is fully dilated, but no urge to push –> may start to feel pressure/urger to push/bear down (monitor for increase in this sensation
  • working on descent
176
Q

in the passive phase of the 2nd stage of labor, delay pushing until?

A
  • until urge is noted, as able
177
Q

what is the active phase of the 2nd stage of lavour

A
  • pushing phase
  • descent and birth
178
Q

describe what occurs during the active phase of the 2nd stage of labor (3)

A
  • strong urge to “bear down”/push/increasing pressure
  • grunting/expiratory sounds
  • may describe burning sensation during crowning due to vaginal stretching
179
Q

what assessments should be done during the active pushing phase? (7)

A
  • VS
  • FHR and pattern
  • vaginal show
  • signs of fetal descent
  • changes in maternal status overall (emotional status, exhaustion)
  • contractions and pushing/bearing down efforts
  • pain
180
Q

how often is FHR and pattern assessed in the active pushing phase

A
  • ongoing/every 10-15 min
181
Q

how often is vaginal show assessed in the active pushing phase

A
  • ongoing/q10-15 min
182
Q

how often is overall maternal status assessed in 2nd stage of labor

A
  • ongoing
183
Q

how often is contractions/pushing efforts assessed in the active pushing phase

A
  • w each effort and encourage as needed
184
Q

how often is pain assessed in the active pushing phase

A
  • ongoing assessments and interventions
185
Q

why does pain occur in the 2nd stage of labour (2)

A

due to:
- stretching and distension of perineal tissue and the pelvic floor as baby passes thru the birth canal
- soft tissue laceration and pressure exerted on bladder, bowel, and other pelvis structures

186
Q

how is the pain in the 2nd stage of labor described (4)

A
  • intense
  • sharp
  • burning
  • well-localized
187
Q

what 3 types of pharma pain interventions used in the 2nd stage of labour

A
  • epidural analgesia/anesthetic
  • nitrous oxide
  • fentanyl
188
Q

describe nursing cate during the 2nd stage (11)

A
  • support pushing efforts/provide encouragement
  • encourage position changes/activity as needed to promote descent
  • support to conserve energy/rest between contractiosn
  • hydration/elimination –> is bladder full?
  • hygiene –> blood, amniotic fluid, fecal matter
  • pain mngmt
  • emotional support
  • provide info
  • prepare for birth
  • birth care
  • provide immediate care for newborn
189
Q

why is it imp to assess elimination during the 2nd stage of labor

A
  • if bladder is full, it will impede birth
190
Q

describe nursing care during the preparation for birth (3)

A
  • communicate w HCP, charge nurse, neonatal team
  • set up delivery equipment
  • prepare neonatal equipment
191
Q

what is included in nursing care during birth? (4)

A
  • call HCP when ready for birth
  • support HCP w birth
  • note time of birth
  • admin oxytocin if ordered w delivery of anterior shoulder
192
Q

when does the strong urge to bear down or push become activated?

A
  • as the presenting part puts pressure on the stretch receptors of the pelvic floor
  • feeling intensified as the fetus progresses further down the birth canal
  • may start to feel urge to bear down around +1 station
193
Q

the pressure of the presenting part on the stretch receptors of the pelvic floor stimulates?? what effect does this have?

A
  • stimulates the release of oxytocin from the posterior pituitary gland –> stimulates stronger contractions
194
Q

describe the effect of an epidural on the urger to push

A
  • pressure is still experienced w an epidural in place, but likely at greater lvl of descent than without
195
Q

what should you encourage the birther to do during purshing

A
  • encourage to listen to their body –> work w their body to push
196
Q

pushing or bearing down efforts involve the birther…

A
  • exerting pressure by contracting their abdominal muscles while relaxing the pelvic floor –> usually involuntary spontaneous
  • often involved a strong grunt/groan by the birther as they exhale –> encourage
197
Q

what is the benefit of working with the body during pushing (2)

A
  • decreases fatigue
  • enhances comfort
198
Q

local anesthesia to provided to the perineum for which purpose?

A
  • to numb the perineum just before birth to allow for episiotomy and repair of either episiotomy or laceration
199
Q

pudendal???

A
200
Q

when does the 3rd stage of lavor occur

A
  • from time of baby’s birth to delivery of the placenta
201
Q

how long does the 3rd stage of labor las

A
  • minutes, up to one hour –> usually 15 min
202
Q

what are signs that the placenta is ready to delivery (5)

A
  • cramping
  • umbilical cord segment lengthens
  • sudden gush of blood
  • visualization of placenta at vaginal opening
  • feeling pressure again
203
Q

what is established during the 3rd stage of labour (2)

A
  • skin to skin contact
  • possibly breast/chest feeding
204
Q

what is increased as the length of the 3rd stage increases?

A
  • risk of hemorrhage
205
Q

what is included in nursing care for 3rd stage of labor (4)

A
  • pain mngmt
  • education
  • encourage breast/chest feeding
  • encourage attachment process
206
Q

what is included in assessments during the 3rd stage of labor

A
  • VS
  • assess for signs of placental separation
  • support collection cord blood or segment collection for blood gasses
  • support collection cord blood if Rh negative
  • passive or active mngmt of 3rd stage of labour
  • support assessment and repair perineal trauma (lacerations and episiotomy)
  • closely examine placenta for completeness
207
Q

what do birthers often receive following the delivery of the placenta and why?

A
  • synthetic Oxyotocin (syntocinon) to promote contraction of the uterus
208
Q

what else stimulates the uterus to contract during the 3rd stage of labor (2)

A
  • skin to skin contact
  • chest/breastfeeding
209
Q

what occurs after delivery of the placenta?

A
  • the bands of muscle in the uterus acts as a “living ligature” to clamp down on the blood vessels at the site of placental attachment (depending on position of attachment), which are exposed once the placenta detaches from the wall of the uterus
210
Q

when does the 4th stage of labour occur? what period is this for the birther and baby

A
  • first 1-2 hrs after birth
  • transition period for birther and baby
211
Q

what is done for the newborn during the 4th stage of labor (3)

A
  • newborn assessment
  • VS
  • breastfeeding/chestfeeding/newborn feeding
212
Q

what is done for the birther in the 4th stage of labour (8)

A
  • admin of oxytocin or other uterotonic meds to stimulate uterine contractions
  • pain mnmgt
  • VS
  • assess vaginal bleeding and fundus
  • hygeine
  • elimination (for full bladder, encourage to void)
  • support the repair perineal trauma
  • assess perineum and repair
  • post anesthesia recovery –> removal of epidrual catheter
213
Q

how often are VS done in 4th stage of labour

A
  • q15 min x4
  • then every 30 min (BP, pulse, RR)
  • temp x1
214
Q

what is an imp consideration w touch and massage for pain

A
  • ask abt pt’s preferences

NURS 4500: Midterm Material (19 decks)

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