Exam 1 Flashcards
A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. What should you do first?
- Prepare the woman for labor
- Notify the primary health care provider
- Document the color of the fluid
- Assess fetal heart rate
- Assess fetal heart rate
The nurse expects to administer an oxytocic to a woman after expulsion of her placenta in order to:
Stimulate contractions
A vaginal exam in maternity triage reveals the following information: LOA, -1, 65%, 4cm. An accurate interpretation of this data would include which of the following?
A. Attitude: vertex B. Station: 4 cm below the ischial spines C. Presentation: cephalic D. Lie: longitudinal E. Effacement: 65% complete F. Dilation: 4 cm to reach full dilation G. Position: oblique
A, C, D, E
If baby is LOA, that means the attitude must be ___, the presentation must be ___, and the lie must be ___
attitude: vertex
presentation: cephalic
lie: longitudinal
spermatogenesis
formation of male gametes, or sperm, in the maturing adolescent.
climacteric
transitional period, which starts as female fertility
declines and extends through menopause and the postmenopausal period.
In most women, the climacteric occurs between ages 40 and 50 years.
Maturation of ova and production of ovarian hormones gradually decline.
The external and internal reproductive organs atrophy
somewhat as well.
How is a woman’s breast size related to the amount of milk she can produce?
unrelated
What is the function of Montgomery’s tubercles?
sebaceous glands in the areola.
They are inactive and not obvious except during pregnancy and lactation, when they enlarge and secrete a substance that keeps the nipple soft.
active milk production occurs in response to
the infant’s suckling (not produced automatically)
full term pregnancy ranges from ____ weeks of fertilizations age or ____ weeks from gestational age
Full term ranges from 36 to 40 weeks of fertilization age calculated from date of conception, or 38 to 42 weeks of gestational age (after last menstrual period).
How does Nagele’s rule work? Calculate based off LNMP August 30, 2014
Nagele’s rule is often used to establish the EDD.
subtract 3 months from the date the LNMP began, add 7 days and then correct the year, if appropriate.
For example:
•LNMP: August 30, 2014
•Subtract 3 months: May 30, 2014
•Add 7 days and change the year: June 6, 2015
The average duration of pregnancy from the first day of the LNMP is
40 weeks or 280 days
The abdomen is large enough to contain
all its normal contents by __ weeks
10 weeks
During weeks 9-12, the head is approximately ___ the total length of the fetus
half
Blood formation occurs primarily in the ___ during week 9 but shifts to the ___ by the end of week 12.
liver
spleen
When can fetal gender be established?
By the end of week 12
What is quickening?
During weeks 13-16, fetal movements strengthen, and some
women, particularly those who have been pregnant before, are able to detect them.
Vernix caseosa
a fatty, cheeselike secretion of the fetal sebaceous glands
covers the skin to protect it from constant exposure to amniotic fluid.
diminishes as fetus reaches term
Lanugo
fine, downy hair that covers the fetal body and helps the vernix adhere to the skin.
diminishes as fetus reaches term
When is brown fat deposited, where, and why?
weeks 17-20
a special heat-producing fat that helps the newborn maintain temperature stability after birth. It is located on the back of the neck, behind the sternum, and around the kidneys
To reduce respiratory distress of prematurity, ____ may be given to infants who are at risk for a deficiency because of their immaturity.
artificial surfactant
During early pregnancy the fetus floats freely within the amniotic sac. However, the fetus usually assumes a head-down position during this time for two reasons:
- The uterus is shaped like an inverted egg. The overall shape of the fetus in flexion is similar, with the head being the small pole of the egg shape and the buttocks, flexed legs, and feet being the larger pole.
- The fetal head is heavier than the feet, and gravity causes the head to drift downward in the pool of amniotic fluid. The head-down position is also most favorable for normal birth.
Growth of all body systems continues until birth, but the rate of growth ___ as full term approaches.
slows
At birth, boys are slightly ___ than girls.
heavier
What is surfactant?
a surface-active lipid that makes it easier for the baby to breathe after birth.
Surfactant reduces surface tension in the lung alveoli and prevents them from collapsing with each breath.
placenta, 2 sides, functions
The placenta is a thick, disc-shaped organ.
two components: maternal and fetal
(1) metabolic functions
(2) transfer functions
(3) endocrine functions
The fetal side is smooth, with branching vessels covering the membranecovered surface.
The maternal side is rough where it attaches to the uterus
During early pregnancy, the placenta is ___ than the embryo or fetus.
However, the fetus grows faster than the placenta, so the placenta is approximately ___ the weight of the fetus at the end of a fullterm pregnancy.
larger
one sixth
Maternal and fetal blood normally ___ mix in the placenta, although they flow very close to each
other. Exchange of substances between mother and fetus occurs within the ____of the placenta.
do not
intervillous spaces
The umbilical cord contains the umbilical __ and ___ to transport blood between the fetus and placenta.
arteries (2) and vein (1)
arteries carry deoxygenated blood and waste
veins carry oxygenated blood
The closed fetal circulation is important because the blood types of mother and fetus may not be ___.
compatible
The placenta produces some nutrients needed by the embryo and for placental functions. Substances synthesized include ___, ___, and ____
glycogen, cholesterol, and fatty acids
glucose is major energy source for fetal growth and metabolism
Oxygen and carbon dioxide pass through the placental membrane by ____
simple diffusion.
___ is major energy source for fetal growth and metabolism
Glucose
The preterm infant has little protection from maternal
antibodies because ____.
they are transferred during late pregnancy and are
poorly transferred if placental function is inadequate
Human placental lactogen, also called human chorionic somatomammotropin
promotes normal nutrition and growth of the fetus as
well as maternal breast development for lactation.
This placental hormone decreases maternal insulin sensitivity and glucose use, making more glucose available for fetal nutrition.
Functions of progesterone include the following:
- Causes secretory changes in the endometrium, providing nourishment as the conceptus enters the uterus.
- Causes the changes in endometrial cells that convert them into the larger and thicker cells of the decidua, which characterize pregnancy.
- Reduces muscle contractions of the uterus to prevent spontaneous abortion.
- May induce some immune tolerance in the mother’s body for the conceptus.
- Acts with estrogens and other hormones to cause growth of the breasts, budding of the alveoli that will secrete milk, and development of secretory characteristics in the alveolar cells.
What structure takes over the corpus luteum?
As the placenta develops further, it takes over estrogen
and progesterone production and the corpus luteum regresses.
Amniotic fluid protects the fetus by the following actions:
- Cushioning against impacts to the maternal abdomen
- Maintaining a stable temperature
Amniotic fluid promotes normal prenatal development by the following actions:
- Allowing symmetric development as the major body surfaces fold toward the midline
- Preventing the membranes from adhering to developing fetal parts
- Allowing room and buoyancy for fetal movement
What 2 sources is amniotic fluid derived from?
(1) fetal urine and
(2) fluid transported from the maternal blood across the amnion.
What are two sources for the higher rate of twins in the US?
higher age of maternity
infertility treatments
The two types of twins are
monozygotic and dizygotic
Monozygotic twins
are conceived by the union of a single ovum and
spermatozoon, with later division of the conceptus into two.
Monozygotic twins have identical genetic complements and are the same gender.
However, they may not always look identical at birth because one twin may have grown much larger than the other or one may have a birth defect such as a cleft lip.
Monozygotic twins have a higher rate
of birth defects, preterm births and low birth weight.
Dizygotic twins
arise from two ova that are fertilized by different
sperm.
Dizygotic twins may be the same or different gender, and they may not have similar physical traits.
term
38-42 weeks of gestation
lightening
By 40 weeks, the fetal head descends into the pelvic cavity, and the uterus sinks to a lower level.
This descent of the fetal head is called lightening because it reduces pressure on the diaphragm and makes breathing
easier.
Lightening is more pronounced in first pregnancies.
Braxton Hicks contractions.
Throughout pregnancy, the uterus undergoes irregular contractions called Braxton Hicks contractions.
During the contractions, the uterus temporarily tightens and then returns to its original relaxed state.
During the first two trimesters, the contractions are infrequent and usually not felt by the woman.
Contractions occur more frequently during the third trimester and may cause some discomfort. They are called false labor when they are mistaken for the
onset of early labor.
hyperemia
congestion with blood
Chadwick sign
After conception, increasing levels of estrogen cause
hyperemia (congestion with blood) of the cervix, resulting in the characteristic bluish purple color that extends to include the vagina and the labia.
This discoloration, referred to as the Chadwick sign, is
one of the earliest signs of pregnancy.
Goodell’s sign
Before pregnancy, the cervix has a consistency similar to that of the tip of the nose.
After conception the cervix feels more like the lips or earlobe.
The cervical softening is referred to as the Goodell sign.
colostrum
a thick, yellowish fluid which is
secreted from breasts as early as 16 weeks of gestation
physiologic anemia of pregnancy
dilution of RBC mass during pregnancy causes a decline in maternal hemoglobin and hematocrit.
This condition is frequently called physiologic anemia of pregnancy, or pseudoanemia of pregnancy, because it reflects dilution of RBCs in the expanded plasma volume, rather than an actual decline in the number of RBCs, and
does not indicate true anemia.
During pregnancy, the enlarging uterus lifts the diaphragm about
4 cm
(1.6 inches).
Breathing becomes thoracic rather than abdominal, adding to the dyspnea that as many as 60% to 70% of women experience beginning in the first or second trimester
epulis
highly vascular hypertrophy of the gums
regresses spontaneously after childbirth.
ptyalism
excessive salivation.
The cause of ptyalism may be decreased swallowing associated with nausea or stimulation of the salivary glands by the ingestion of starch
Small, frequent meals and use of chewing
gum and oral lozenges offer limited relief to some women
melasma
Areas of pigmentation include brownish patches called melasma, chloasma, or the “mask of pregnancy.”
Melasma involves the forehead, cheeks, and bridge of the nose and occurs in about 70% of pregnant women
linea nigra
The linea alba—the line that marks the longitudinal division of the midline of the abdomen—darkens to become the linea nigra
striae gravidarum
stretch marks
diastasis recti
The abdominal muscles may be stretched beyond their capacity during the third trimester, causing diastasis recti, separation of the rectus abdominis muscles
Maternal thyroid hormones are important for fetal neurologic function because the fetus does not synthesize thyroid hormones until ____ of gestation
12 weeks
In healthy women, the pancreas produces additional
insulin. In some women, however, insulin production cannot be increased and these women experience periodic ___ or ____
hyperglycemia or gestational diabetes
women of normal prepregnancy weight are encouraged to gain an average of ___ to ___ lbs during pregnancy
11.5 to 16 kg (25 to 35 lb)
Because of hemodilution, colloid osmotic pressure
decreases slightly, which favors the development of ____ during pregnancy.
edema – further increases when weight of uterus compresses the veins of the pelvis
amenorrhea
Absence of menstruation (presumptive sign)
Hegar sign
About 6 to 8 weeks after the last menses, the lower uterine segment is so soft that it can be compressed to the thinness of paper. This is called the Hegar sign (Figure 7-9).
The body of the uterus can be easily flexed against the cervix.
ballottement
midpregnancy, a sudden tap on the cervix during vaginal examination may cause the fetus to rise in the amniotic fluid and then rebound to its original position
uterine souffle
late in pregnancy a soft, blowing sound may be
auscultated over the uterus.
This is the sound of blood circulating through the dilated uterine vessels and it corresponds to the maternal pulse.
funicc souffle
the soft, whistling sound heard over the umbilical cord
and corresponding to the fetal heart rate.
Fetal heart sounds can be heard with a fetoscope by ___ to ___ weeks of gestation
18 to 20
The normal fetal heart rate is ____ bpm in the third
trimester.
110 to 160
folic acid recommendations
400 to 800 micrograms (mcg) (0.4 to 0.8 mg) of folic acid daily for at least 1 month before conception and 2 to 3 months after conception to decrease the risk of neural tube
defects
An intake of 600 mcg (0.6 mg) is recommended for the rest of pregnancy
abortion
spontaneous or elective termination of
pregnancies before the twentieth week of gestation
spontaneous abortion is frequently called miscarriage
gravida
refers to a woman who is or has been pregnant, regardless
of the length of the pregnancy
primigravida
a woman pregnant for the first time
multigravida
has been pregnant more than once.
Para
refers to the number of pregnancies that have ended at 20 or more weeks, regardless of whether the infant was born alive or stillborn
nullipara
a woman who has never been pregnant or has not completed a pregnancy of 20 weeks or more
primipara
has delivered one pregnancy of at least 20 weeks
multipara
has delivered two or more pregnancies of at least 20 weeks.
GTPAL
G = pregnancies or gravida, T = term pregnancies
delivered, P = preterm pregnancies delivered, A = abortions, and
L = living children.
Jennie is 6 months pregnant. She had one spontaneous and one elective abortion in the first trimester. She has a son who was born at 40 weeks of gestation and a daughter who was born at 34 weeks of gestation. What is her GTPAL?
She is gravida 5, para 2, T = 1 (the son born at 40 weeks); P = 1 (the daughter born at 34 weeks), A = 2, L = 2. The two abortions are counted in the gravida but not included in the para because they occurred before 20 weeks
of gestation.
Therefore, Jennie’s GTPAL would be 5-1-1-2-2.
Attitudinal barriers to prenatal care
Women rely on advice from family and friends
Hurried exams perceived as unimportant
Depression from or denial of unintended pregnancy
How should the nurse respond to a newly pregnant patient’s questions, and what specific things should the nurse discuss at each visit?
Anticipatory guidance:
- Gather information
- Establish a therapeutic alliance
- Provide education and guidance
Pertinent to upcoming needs and changes
Prenatal visits schedule
Every 4 weeks for the first 28 weeks’ gestation
Every 2 weeks from 28 weeks’ until 36 weeks’
After week 36, every week until childbirth
Presumptive Indications of Pregnancy
- Amenorrhea (cessation of menstruation)
- Nausea & vomiting
- Fatigue
- Urinary frequency
↑ during 1st trimester (hormonal changes)
↓ in the 2nd trimester (uterus more abdominal)
↑ with 3rd trimester (fetus larger, quickening) - Breast changes
- Perceived Fetal movement (quickening)
- Skin changes
Probable Indications of Pregnancy
- Abdominal enlargement
- Cervical softening (Goodell’s sign)
- Flexion and softening of uterus against cervix (Hegar’s sign)
- Fetus pushes away from examiner’s fingers (Ballotment)
apparent at the 16th week of pregnancy - Irregular painless contractions (Braxton Hicks)
- Blood flow through the placenta (Uterine Souffle)
- HCG in urine
Blood flow through the placenta is called
Uterine Souffle
Irregular painless contractions are called
Braxton Hicks
Cervical softening is known as
Goodell’s sign
Flexion and softening of uterus against cervix
Hegar’s sign
Fetus pushes away from examiner’s fingers
Allotment (apparent at the 16th week of pregnancy)
Positive Indications of Pregnancy
- Auscultation of fetal heart sounds (starting at 6 weeks gestation)
- Fetal movements by examiner
- Visualization of fetus via ultrasound
Steps of the nursing process
- Assessment
- Diagnosis
- Outcome Identification
- Planning
- Implementation
- Evaluation
reason behind leopold maneuvers is to
identify the baby’s position/ baby’s back so you can get the heartbeat
fundal height at 8 weeks, 20-21 weeks, 30-38 weeks
at 8 weeks, just above the bone
most common at 20-21 weeks at the umbilicus
highest point is 30-38 weeks, and then the head drops
the earlier in pregnancy, the ____ the fetal heart rate is
higher
Basic Screening Tests at initial visit
Pap smear, STI cultures
U/A, Urine C and S
Ultrasound – if warranted by history or physical
Maternal serum labs
standard of care is ultrasound between___ weeks
16-20
Maternal serum labs at initial visit
Blood type and Rh typing, antibody screen (ABO sensitization)
Complete blood count with diff
Syphilis (RPR/VDRL)
HIV screen
Tuberculosis screen
TORCH:
Toxoplasmosis, “Other”, Rubella, Cytomegalovirus, Hepatitis surface antigen/DNA
Rubella titer
Lead level
Drug screen
Genetic screen for chromosome traits:
Sickle cell
Cystic fibrosis
Tay-Sachs
14 to 22 weeks gestation (best at 16 -18 wks) additional lab tests
Multiple Marker:
“Triple Marker”
- MSAFP, Quantitative Beta hCG, Estriol
“Quadruple Marker”
- adds Inhibin-A
MSAFP =
maternal serum alpha veto-protein
Elevated MSAFP -> Neural tube defect, anencephaly, omphalocele/gastroschesis
Low MSAFP -> Down Syndrome
additional lab tests at 24-28 weeks
1-hr 50g glucose tolerance test (GTT) - only if indicated
additional lab tests at 35 to 37 weeks
- HIV retest
- Group Beta Strep (GBS) vaginal/rectal culture
IUGR =
intrauterine growth restricted
SGA, LGA
small for gestational age, large
functions of ultrasound
- Detect pregnancy – can detect FHR @ 6 weeks
- Gestational age
(Most accurate in 1st trimester – 4 to 7 days
Routine: at 14 to 16 wks) - Position of fetus
- Position of placenta
- Size & dates of fetus – SGA, IUGR, LGA
- Any gross fetal anomalies – nuchal neck, extrophy
- Evaluation of fetal status
- Alloimmunization: ascites, edema, fetal heart size
Maternal Psychological Responses: First Trimester
Uncertainty
Ambivalence
The self as primary focus
Factors Influencing Psychosocial Adaptations
Age Multiparity Social support Absence of a partner Abnormal situation Socioeconomic status
physiologic anemia is the result of
dilution of hemoglobin concentration
Ballottement happens when?
4-5 months
Chloasma happens when?
4-5 months
Strait Gravidarum happens when?
6 months
Linda Nigra happens when?
5 months
Quickening happens when?
20 wks primigravida, 16- 18 wks multigravida
Maternal Psychological Responses: Second Trimester
Physical evidence of pregnancy:
- Fetus as the primary focus
- Narcissism and introversion
- Body image
- Changes in sexuality (4th month is libido increase)
There is increased cardiac output in the ___ trimester
3rd
placenta is a ___ term organ
short term
only lasts 40 weeks
Maternal Psychological Responses: Third Trimester
- Vulnerability
- Increasing dependence
- Preparation for birth - Nesting behavior
Rubin - Maternal Tasks of Pregnancy (4)
- Seeking safe passage
- Securing acceptance
- Binding in to unknown child
- Learning to give of self
Duvall Stages of Family Development (4)
- Prepare for role as childcare providers
- Reorganize home, family member duties, patterns of money management
- Reorient family relationships
- Each pregnancy—adjust to transitions in relationships with each other, children
3 phases of paternal adaptation
- “Announcement” phase
- “Moratorium” phase
- “Focusing” phase
Couvade
father showing similar symptoms to the mom in pregnancy (weight gain etc)
Adaptation of Siblings
Toddlers: Regression
Preschoolers: May not grasp reality of a baby in the family
School-age: Excited, happy
Adolescents
According to the Cochrane collaboration, what works for labor management?
Epidural, spinal, inhalation (general anesthesia)
According to the Cochrane collaboration, what MAY work for labor management (Not much evidence but good satisfaction)?
Immersion, Relaxation, Acupuncture, Non-opioid, Massage
According to the Cochrane collaboration, what MAY work for labor management (Not much evidence, not much satisfaction)?
Hypnosis, Biofeedback, Aromatherapy, TENS, IV opioids
According to Lamaze, what is the desired Effect of Nursing Interventions?
- [Alleviate] Pain intensity
- Satisfaction with pain relief
- Sense of control in labor
- Satisfaction with childbirth experience
Lamaze points
Pyschoprophylactic – Stimulation/Response conditioning
Controlled breathing may reduce pain during labor
Labor “coach”
Focal point, memory prompts
Breathing patterns
Slow chest breathing
Accelerated/Decelerated
Pant - Blow
Pushing
DON’T hold breath during labor, why?
Valsalva maneuver can decrease maternal cardiac output and compromise fetal circulation
Both Lamaze and Bradley advocate ___ medications during childbirth
NO
Bradley Method of Natural Childbirth
12 week course
Natural childbirth -> no medications preferred
Exercises, relaxation, to prepare
Abdominal breathing, and massage to manage labor
Partner-coached -> an active role
During the pregnancy, labor, and early newborn period
Exercises:
Pelvic rocking - influences baby’s position
Tailor sitting - strengthens lower back muscles
Dick-Read Method
Fear -> Tension -> Pain
Education reduces fear, which reduces pain
Leboyer
“Birth Without Violence”
Odent
Birthing pool of water to reduce low lumbar pain
HypnoBirthing
State of deep relaxation to block distractions, pain
how long it takes for sometime to die if they don’t have water? without food?
no water - days
no food - months
fluids is always prioritized over food
Maslow Hierarchy of Needs
- Physiological
- Comfort – warmth, pain management
- Fluids, Food, Elimination
- Safety - psychological - Love and Belonging
- Self-Esteem
- Self-Actualization
Prioritizing Nursing Diagnoses
ABCs
Safety
Maslow Hierarchy of Needs
2 things you talk about at every visit:
- breastfeeding
2. infant safety - back to sleep technique
in the first trimester, you should only gain ___ pounds
2-4
4 prong lab result diagram
WBC left
HCT top
HGB bottom
Platelets - right
Developmental tasks of adolescence
Personal value system Body image and sexuality Vocation or career Independence from parents Achievement of a stable identity
Pregnant teens
- Normal adolescent developmental tasks conflict with tasks of pregnancy
- May not seek prenatal care (Non-compliant with care plan)
- Not future oriented
- Acceptance of pregnancy hindered
standard of care is to have ____ on methadone during pregnancy
everyone who is already on methadone
the baby will be born going through methadone withdrawal
Factors that Stimulate Labor
- Onset of Uterine muscle contractions
- Oxytocin
- Estrogen
- Fetal Cortisol
- Prostaglandins
Premonitory Signs of Labor (5)
- Lightening
- Energy spurt
- “Bloody Show”
- Braxton Hicks contractions
- Increase in clear and nonirritating vaginal secretions
Engagement
Relationship between mom’s pelvis and the presenting part of the baby
passes the pelvic inlet
False Labor signs (6)
- No cervical change occurs
- Discomfort usually in lower abdomen
- Contractions irregular and short in duration
- Intensity does not correlate with time
- Medication and activity affect contractions
- Usually no bloody show
True Labor signs (6)
- Discomfort in front and back
- Frequency, duration, and intensity increase
- Palpable hardening of uterus
- Pinkish mucous
- Cervical Changes
Effacement
Dilatation - Bulging of membranes
Six concepts which make labor and birth as natural as possible are:
- labor should begin on its own, not be artificially induced
- women should be able to move about freely throughout labor, not be confined to bed
- women should receive continuous support from a caring other during labor
- interventions such as intravenous fluid should not be used routinely
- women should be allowed to assume a nonsupine position such as upright and side-lying for birth
- mother and baby should be housed together after the birth, with unlimited opportunity for breast-feeding
5 “P”s of Labor
- Powers = physiologic forces
- Passageway = maternal pelvis
- Passenger = fetus and placenta
- Passageway AND Passenger = pelvis and fetus
- Psychosocial (Psyche) = influences
What are the 2 forces under “Powers” in labor?
- Uterine contractions—primary force
- Involuntary
- Dilate the cervix - Maternal pushing efforts—secondary force
Voluntary
Compress the uterus -> birth of fetus
Pattern of uterine contractions
- Increment
- Acme
- Decrement
uterine contractions Palpation
nose-chin-forehead
At the acme of the contraction, there is ___ blood flow to the uterus
no
What is EFM and what is its purpose
Electronic fetal monitoring
- to evaluate contractions
- to assess fetus response to contractions
Fetal lie (3)
- Longitudinal*
- Oblique
- Transverse
Fetal presentation (3)
Cephalic* (head down)
Shoulder (shoulder down)
Breech (butt down)
Shoulder presentation
- Fetus in transverse lie
- Cannot be delivered vaginally unless rotated
- Manual rotation performed by OB, CNM
- Membranes must be ruptured, cervix dilated
Most often C-section delivery
4 varieties of Breech presentation
- Complete (butt and both feet down)
- Incomplete (1 foot down)
- Frank (both feet up) - CAN be delivered vaginally
- Footling (looking like it’s standing up on one leg with the other crossed)
3 main Breech complications
- Risk of cord prolapse
- Presenting part less effective in cervical dilation
- > risk of prolonged labor
- Risk of cord compression
Attitude
Flexed
- Vertex
Extended
- Military
- Brow
- Face (9.5)
Flexed Vertex attitude
ideal position
9.5cm - can get through cervix
Extended Military attitude
head is straight coming down into pelvic inlet is 12.5 cm diameter - this will NOT get through the cervix
Extended Brow attitude
you can feel the baby’s forehead, eyes, and brow bone — this position has the widest circumference (13.5) and will NOT be delivered vaginally
Fetal position landmark? What is optimal?
“Landmark” = occipital bone
optimally the back of the baby’s head in LOA (left occipital anterior) or ROA
we want the occipital bone of the baby’s head to be coming down LOA or ROA
if you feel the occipital bone towards the back of mom’s pelvis (ROP, OP, LOP), it means that
the head is banging into the bony part of the sacrum with each contraction - the mom is complaining of “back labor” - back labor will take longer
Station
relationship of presenting part to ischial spines
(–) minus station =
Above ischial spines
“floating” not engaged
0 station =
At Ischial spines
engaged
(+) plus station
Below ischial spines
What number station is crowning?
“crowning” at +4 / +5
-> delivery
Psychosocial Influences (5th power) on Successful Labor and Delivery - 5
- Confidence in readiness
- Educational preparedness
- Cultural views of childbirth
- Role transition facilitated by positive childbirth experience
- Negative experience interferes with bonding and maternal role attainment
First stage of labor
Onset of regular contractions to full dilation
Second stage of labor
Full dilation to delivery of fetus
Third stage of labor
Delivery of fetus to delivery of placenta
Fourth stage of labor
1 - 4 hrs after delivery of the placenta (recovery)
What are the three phases of the first stage of labor and their characteristics of dilation and contractions?
- Latent phase
dilated 0 to 3 cm
contractions are for 0-30 secs, more than 5 mins apart - Active phase
dilated 4 to 7 cm
contractions are 40-60 secs, every 2 to 5 mins - Transition
dilated 8 to 10 cm
contractions are 60-90 secs, every 1 to 2 mins
the purpose of vaginal exam is to determine
how well mom is progressing through labor - just an assessment
would also do it to check the result of using pitocin
cervical effacement and dilatation - this is an approximate measure
station
4 ways to determine station of baby via vaginal exam
- Palpate the sagittal suture
- Identify the posterior fontanel
- Identify the occipital bone
- Identify the the anterior fontanel
be aware that Cardinal Movements are
the fact that the baby’s head turns as it comes down - do not need to memorize each - turning head, then shoulders, then shifting at the end
Nursing interventions for second stage of labor
- Promote effective pushing
2. Position of comfort
TRIAGE:
Vital signs 110/70, 98.2, 76, 18
Contraction 4 min, 40-50 sec,
Moderate intensity
Vaginal Exam:
4 cm, 90%, +2, clear fluid
Stage and Phase?
First stage, she’s just started into ACTIVE phase
3 ways to assess fetal heart sounds
- Auscultation
- Doppler
- Electronic Fetal Monitor
3 ways to assess baby position
- Abdominal palpation(early labor)
or - Vaginal examination
- Ultrasound
Assessment of Fetal Wellbeing includes
- position (fundal height)
2. Fetal heart sounds (FHR)
non-reassuring FHR
changes, dips, bradycardia or increase with contractions
an increase or decrease of more than 25 is concerning
5 steps upon admission
- Establish positive relationship
- Collect admission data
- Initiate admission interventions
Physical assessment – mother and fetus
Psychosocial assessment
Cultural assessment
Laboratory tests - Initiate care plan in EMR
- Ongoing focused assessment and interventions
5 components of labor support
Emotional: encouragement, distraction, reassurance
Physical: touch, position change, heat or cold applications
Information: provide education, coaching, interpret medical jargon
Advocacy: support decisions, let others know her wishes
Support family: role model support, encouragement, provide breaks
Maternal Positions in Labor
Standing Sitting Side-lying Hands and knees Recumbent Upright
7 signs of imminent birth
- Bulging of the perineum and rectum
- Flattening and thinning of the perineum
- Increased bloody show
- Labia begin to separate
- “Crowning”
- Burning sensation
- Intense pressure in rectum
common practice (almost standard of care) is that every woman receive PITOCIN after delivery of baby because
it’s synthetic oxytocin which contracts the uterus and decreases likelihood of postpartum hemorrhage
Immediate Care of Newborn includes…(6)
Airway Breathing Circulation Warmth Appraisal—Apgar score Identification of newborn
Third Stage of labor
Birth of baby to complete delivery of placenta
- Lengthening and protrusion of cord
- Gush of blood from vagina
Smaller, spherical uterus
Elevation of uterus in abdomen
Fourth Stage of labor
From delivery of placenta through 1 to 4 hrs
Monitor position and firmness of uterus
What to do if “Boggy,” soft uterus?
- Initiate fundal massage
- Assess bleeding
Physiological indicators of pain (3)
Increased catecholamines
Increased blood pressure and heart rate
Altered respiratory pattern
Culture and pain: Nigeria
women do not show pain while in labor to demonstrate proper modesty, strong extended family support
Culture and pain: Benin, Africa:
women are taught to give birth in silence
Culture and pain: Black, Puerto Rican, and Middle Eastern
verbalize their pain
Culture and pain: Asian
quiet in pain, not to bring shame onto themselves or their family
Culture and pain: Hispanic
moan in a rhythmic way and rub their thighs and abdomen
First stage pain in labor
visceral pain: deep, dull and aching, poorly localized, felt only during contractions
Second stage pain in labor
somatic pain: sharp, intense, well localized, burning, or prickling caused by stretching of perineal body, distention and traction, and soft tissue lacerations
First Stage of Labor, Active and Transition phase, pain is due to what 4 things?
- Dilatation of cervix
- Stretching of the lower uterine segment
- Pressure on adjacent structures
- Hypoxia of uterine muscle cells during contractions
Second Stage of Labor, Transition pain is due to what 4 things?
- Hypoxia of uterine muscle cells during contractions
- Distention of the perineum and vagina
- Pressure on adjacent structures
3 non-pharm massage pain techniques
- Effleurage
- Counter Pressure
- Intuitive touch / therapeutic touch
Analgesia vs. anesthesia
analgesia: relief from pain
anesthesia: lack of sensation
what anti-anxiety sedatives are used for labor pain?
Barbiturates – rarely used
secobarbital (Seconal)
Benzodiazepines:
diazepam (Valium)
lorazepam (Ativan)
Antiemetics – H1 Receptor Agonists:
promethazine (Phenergan)
hydroxyzine (Vistaril)
diphenhydramine (Benadryl)
Systemic Medications
can cross the placental barrier
Analgesics used in labor:
- Stadol, Nubain - 2-3 hr half-life (most common)
- Dilaudid, Demerol - long half-life in neonate
- Fentanyl, short-acting, may not cross placenta –>
May still cause respiratory depression
Analgesic Potentiaters
Decrease anxiety and increase effectiveness of analgesics (Phenergan, Vistaril)
Opioid Analgesics side effects
Nausea, Vomiting
Itching
Dizziness
Opioid Analgesics side effects- More serious but not likely
- Loss of protective airway reflexes
- Hypoxia due to respiratory depression
Systemic Analgesia – Opioids
hydromorphone (Dilaudid) meperidine (Demerol) fentanyl (Sublimaze) butorphanol (Stadol) nalbuphine (Nubain)
Opiate Antagonist
Naloxone (Narcan)
Reverses effect – if sx of respiratory depression present
Can be used for mom or baby
What patients should NOT receive Narcan?
If they’re addicted to narcotics and receiving any kinds of opioids
It can reverse their high immediately and they can end up with seizures -severe negative consequences for baby
2 most common regional nerve blocks for labor:
spinal - usually only for anesthesia
epidural - can be used for both anesthesia and analgesia
compare different spaces, locations, and onset for spinal and epidural
Different spaces:
- Spinal into subarachnoid
- Epidural into dura
Different locations:
- Spinal below L2 to avoid hitting spinal cord
- Epidural into C T L spaces
Different onset:
- Spinal – faster acting
- Epidural – slower acting
potential complications for Regional spinal anesthesia block (4)
maternal hypotension
decreased placental perfusion
ineffective breathing pattern
Spinal Headache
how do you treat spinal headache?
with autologous blood patch
Regional epidural analgesia in labor, anesthesia in c/s - complications (3)
maternal hypotension, bladder distention, prolonged second stage
Contraindication for both Spinal + Epidural:
low platelets
if platelet count is
because of the potential complication of Maternal hypotension, what 3 things needs to happen with epidural
Monitor VS and respiratory
Bolus before insertion
Epinephrine available
advantages of epidural during labor (7):
- PCEA!
- Relieves discomfort during labor
- Fully awake during birth
- Fewer fetal effects
- > no respiratory depression
- Mom rests before 2nd stage
- Fetus can labor down
- Access for LA morphine
disadvantages of epidural during labor (6):
- Maternal hypotension
- Limited mobility
- Can slow fetal descent
- Less effective pushing
- Urinary retention – insert foley
- Blood coagulation
the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions
health literacy
The fetoscope should be placed in
the left lower quadrant for a fetus
positioned in the ____ position
LOA
The fetal heart is best heard through the fetal ___.
back
Most women find ____ breathing effective during the latent phase.
slow chest
The average length of transition in multiparas is ___ minutes.
10
It is essential, however, that the fetal heart be monitored immediately _____ for 1 full minute to identify
the presence of any late or variable
decelerations.
after contractions
Only when ___ is the client in true labor
the cervix dilates
A tracing showing moderate variability—that is, 6 to 25 ppm wide—indicates what?
adequate variability and this, in turn, indicates normal pH and oxygenation of the fetus.
Analgesics will ____ the variability of the fetal heart rate
decrease
During the third stage, the following physiological changes occur. Please place the
changes in chronological order.
1. Hematoma forms behind the placenta.
2. Membranes separate from the uterine wall.
3. The uterus contracts firmly.
4. The uterine surface area dramatically decreases.
3
4
1
2
For the anesthesiologist to be able to insert the epidural catheter into the epidural space, the woman must
be placed in either the ___ position or ____.
fetal
sitting with her chin on her chest and her
back convex
The fetal heart should ___ in response to scalp stimulation.
accelerate
