Class 5 labour and birth part 1 Flashcards
What are the 2 most important questions when someone comes into triage?
- do you have bleeding?
- is there fetal movement ?
What assessments do we do when someone comes into triage?
Height
Weight
Vitals
Leopolds
Vag exam if indicated (dilation)
Fetal heart rate (IA or EFM)
ROM: obvious or needs more tests?
HDP, GDM
When do we want someone to come to triage?
- Pain management
- bleeding
- contractions stronger and closer together q5 min for 1 hr.
- Membrane rupture ROM
- decreased fetal movement
- feeling unwell - like something isn’t right
What do we give every person after delivery to ensure there’s no postpartum hemorrhage?
oxytocin/syntocinon
What encompases stage 1?
start of true labour
to
complete dilation (10 cm) and effacement
Longest stage
includes latent/early phase & active phase.
What encompasses stage 2?
complete effacement & dilation
to
birth of baby
What emcompasses stage 3?
birth of newborn
to
placenta delivery
What encompases stage 4?
first 2 hours post placenta delivery
how much should someone dilate each hour?
1 cm per hour
what % of effacement is first stage, early/latent phase?
75% effaced
What % of effacement is first stage, active phase?
100% fully effaced
What are contractions like for someone in first stage, early/latent phase?
5-30 min apart
last 30-45 seconds
Irregular
Mild-moderate
What are contractions like for somone in first stage, active phase?
2-5 min apart
40-90 sec
regular
moderate-strong
What are the 5 P’s that can affect labour and birth?
- passageway
- Passenger (fetus)
- Powers
- Position (birther)
- Psychological
What are powers?
Primary powers: involuntary uterine contractions
Secondary Powers: bearing down efforts : pushing
What does passenger (fetus) mean?
presentation
position
station
lie
attitude
what does passageway mean?
birth canal
What fetal position is not ideal?
ROP
LOP
(sunnyside up - pressure on mom spine)
How often should the birther change positions?
q 20 min
What are the mechanisms of labour?
how the fetus adjusts during 1st and 2nd stage of labour
At what point do we determine we have dystocia?
> 4 hours with less than 0.5 cm per hour of cervical dilation during active labour
OR
> 1 hour pushing with no descent
What are the causes of dystocia?
hypotonic- poo poo contractions
ineffective pushing
passageway isn’t great
birther position isn’t helping
unhelpful psychological response
Issues with fetus position etc. size, cephalopelvic disproportion (head is too big)
What is ECV?
external cephalic version
- rotating the baby into cephalic position
What are nursing interventions for Dystocia?
- EFM for 20 min read
- Ultrasound for positioning
- risk assessment
- position changes
- assess the cause and timing (which stage/phase)
How long do we wait to intervene after water ROM has broken?
12 hours we give oxytocin
What 2 things do we NOT want in the ruptured membranes?
meconium (flecks)
odour = infection
What do we administer if ROM goes over 12 hours?
antibiotics
What are the 4 things assessed during vaginal exam?
- dilation
- effacement
- presenting part
- status of membranes
What is chorioamniotnitis?
an infection of the amniotic cavity
What are the risks of chorioamnionitis?
- labour dystocia
- C-section
- pelvic wound abscess
Newborn risks:
PN, bacteremia
sepsis
What are 3 things we do to manage chorioamnionitis?
- Induce labour
- broad-spect IV abx
- birth the fetus
What can advance to chorioamnionitis?
GBS
group B streptococcus
how do we treat GBS?
- IV abx prophylaxis
- Pen G 5 million units IV- loading
- Pen G 2.5 million units IV - maintenance
- q 4 hours until birth
What is the nursing assessment for first stage of labour?
- Vitals
- FHR - IA or EFM
- Uterine activity
- Membranes and vaginal show
- Vag exam
- Oral intake & urinate q2
How often do we check Vitals in first stage , latent phase and active phase?
q 30-q60
temp- q4 if no ROM
q1-2 if ROM
How often do we check FHR and uterine activity during latent phase compared to active phase?
latent- q30-60
active- q15-30 (usually 15)
How often do we do vag exam and check oral intake during first stage latent phase or active phase?
PRN
what stage/phase is the person fully dilated with no urge to push?
seconde stage
Passive phase
What stage/phase is there pushing and crowning?
Second stage/active phase
How often do contractions come in second stage, active phase?
(q2 min) 4-5 contractions in 10 min
last 90 sec
what stage do people tend to experience N &V?
Second stage, passive phase
How often do we assess vitals (BP, HR, RR) during second stage?
Q5-30 min
how often do we check FHR & pattern during second stage?
Q5 min during pushing
how often do we check vaginal show, fetal decent and changes in status of birther (mood, energy, emotions) during second stage?
ongoing
What is really important for the nurse to do at the time of birth?
Write down the time of birth!
Why is episiotomy performed?
prevent tearing to the anus
midiolateral cut
When are forceps indicated?
- to shorten 2nd stage if dystocia is happening
- Fetal:
- abnormal FHR tracing
- abnormal presentation
- arrest of rotation
- extract the head in breech
When is forceps contraindicated?
- cervix isn’t quite dilated
- water hasn’t broken
- fetal head isn’t engaged
what do we document when forceps are used?
- when they are placed
- number of pulling & timing
which do we prefer, vacuum or forceps?
vacuum
what do we document with vacuum use?
- when it is placed
- number of times it pops off
- how many pulls
- max amount of suction used
When is third stage of labour?
baby birth
to
placenta
15 min-1 hr
how do we know the placenta is ready to be delivered?
-cramping
-umbilical cord gets longer
-sudden gush of blood
-you can see it
-feel pressure again
what are nursing interventions in stage 3?
vitals (BP, HR, RR) q 15 min
document placenta delivary time
cord blood collection (check for Rh status of baby)
blood gases & if mom is Rh- then WinRoh
pain management
check fundus
check for PPH
make sure placenta is whole
What is the fourth stage of labour?
recovery
q15 min vitas for first 1 hour
30 min vitals for next hour
temp x1
check perineum, fundus, etc
pain management
hygiene
