exam 2 Flashcards
5 Ps that could affect L&D
Passenger (fetus and placenta)
passageway (birth canal)
powers (contractions)
position of mother
psychological response
what determines how the fetus moves through passageway
size of head
fetal presentation
fetal lie
fetal altitude
fetal position
anterior fontanel
In front of head
diamond shape
what we want to feel when baby is engaging
posterior fontanel
in back of head
triangular shape
fetal presentation
how baby is facing
Cephalic/vertex- baby is head down
Breech- baby bottom is towards the canal
Shoulder- baby’s shoulder is towards canal
why can’t you deliver a baby if its face first
it can cause nerve damage and facial bruising is likely
fetal lie
the relation of the long axis of the fetus to the long axis (spine) of the mother
3 types of lies
longitudinal- baby back parallel with moms
oblique- baby is crooked
transverse- baby back is perpendicular to moms
what can be performed if breech or transverse
version
fetal attitude
the relation of the fetal body parts to one another
flexion fetal attitude
fetal head is flexed to chest
military fetal attitude
head isn’t really flexed or extended
extension fetal attitude
baby head is extended. not good
how to determine the 3 level abbreviation for fetal position
First letter will be what side baby is laying on in moms abdomen - R or L
Middle letter will be the presenting part - occiput, sacrum, mentum, sinciput
Last letter will be if its anterior or posterior fontanel. Could also be transverse meaning we don’t really have a position.
Ideally we want to feel the anterior fontanel , baby be in occipital presenting part, and the side doesn’t matter
station
measurement of fetal descent
-5 is the highest up in the body. baby is not engaged in birth canal
station 0 is at level with ischial spine
+5 is the lowest point, baby is about to be birthes
We expect to see -2 when mom is at full term, but not in labor process
We expect to see +2 when mom is ready to start pushing and is fully dilated
what is passageway composed with
mothers rigid bony pelvis, soft tissues of cervix, pelvic floor, the vagina, and the introitus
external vs internal os
External os- outer opening of cervix
Internal os- inner opening of cervix
effacement
gradual thinning, shortening, and drawing up of the cervix measured in percentages from 0-100%
primary powers
involuntary contractions- frequency, duration, intensity
responsible for effacement and dilation
secondary powers
voluntary contractions. mom is pushing
signs preceding labor
lighting or dropping
return of urinary frequency
backache
braxton hicks
increased discharge
cervical ripening
possible rupture of membranes
weight loss possible from fluid loss
cervical change!!!!
4 stages of labor
- cervix dilating and thinning
- pushing. Baby born
- delivery of placenta
4.After placenta delivery and thru period of recovery. About 2 hours
7 cardinal movements of labor
engagement
descent
flexion
internal rotation
extension
external rotation
birth by expulsion
what happens in internal rotation
head is under symphysis pubis
what has head reached in the extension cardinal movement of labor
perineum
what 2 cardinal movements occur together
restitution and external rotation. baby automatically rotates
what happens in the expulsion movement of labor
baby is out
how much does cardiac output decrease by in first hour after delivery
50%
factors influencing pain
physiologic factors
culture
anxiety
previous experience
comfort/support
enviroment
non pharmacological pain management
relaxation and breathing techniques
counter pressure
massage
heat/cold
hydrotherapy
aromatherapy
hypnosis
music
can you give opioids when mom is almost fully dilated
No- could cause resp depression in baby
types of anesthesia
spinal
epidural
local perineal anesthesia- for repairs
nitrous oxide
general-For emergent cases that cant get a epidural. Could cause resp depression in baby. Mom will wake up in a lot of pain
what is a epidural and what are side effects
regional anesthesia that blocks pain in a particular region of the body
hypotension, N/V, itching, increase in body temp
serious: spinal nerve damage, convulsions, breathing difficulties
spinal anesthesia block
anesthetic solution inserted into L3, L4 or L5 into the subarachnoid cavity where it mixes with CSF
- most commonly used for C section
takes affect in 1-2 mins, last 1-3 hours
advantages of spinal anesthetic
no fetal hypoxia if BP is fine
mom remains conscious
excellent muscle relaxation
minimal blood loss
no feeling from chest down
disadvantages of spinal anesthetic
hypotension
decreased RR
leakage of CSF
why would baby develop late decelerations after epidural
low BP
fix it with IV vasopressor
what is needed for amnionfusion
IUPC
variable deceleration interventions
*reposition, notify physician, amnioinfusion, discontinue oxytocin, o2, consider vaginal exam
three phases of labor
latent
active
transition
true labor
contractions are regular and increase in intensity. Walking causes intensified contractions as well. Cervix changes from posterior to anterior. Fetus is descending into pelvis
false labor
contractions are temporary. Stop when mom starts walking. Cervix may start to soften but it is not thinning out or dilating, baby isn’t engaged
early laboring mom comfort measure that can be done at home (water hasn’t broke yet but will within few days)
warm shower, repositioning, encourage to walk, distraction methods
latent phase
not dilates yet to 5 cm
relatively calm phase with passive descent of baby through birth canal
active phase
6cm dilated and above
active pushing and urges to bear down
emergency medical treatment and active labor act (EMTALA)
federal regulation that all pregnant woman that come in must be assessed before getting sent home
TOLAC
trial of labor after c section
what is the most important history we want to know about mom
previous pregnancies & complications, blood type, medications, GBS status, any discharge
VBAC
vaginal birth after c section
how many nurses must be in laboring room
2
1 for baby 1 for mom
Contraction assessment
frequency, duration, intensity, resting tone, strength
use TOCA
palpate for strength of contraction
what needs done in the first stage of labor assessment
head to toe with focused OB
vitals- need accurate BP
assessment of fetal HR
assessment of uterine contractions
vaginal exam
what does L&D vaginal exam tell us
Tells us if ruptured, dilation, how much time we have
what labs to look for in a laboring mom
hgb, hct, wbc, plt, UA, AST, CMP, GBS
what needs documented with a rupture of membranes
time
odor
color
amount
what test tells us if patient ruptured membranes
fern test
what to monitor for with amnioninfusion
for fluid to come back out
ferguson reflex
mom has natural urge to push
what is needed as soon as baby is born
immediate assessment
OA position vs OP position of baby
Baby looking down - OA position - desired
Baby looking up- OP position
1st degree laceration
laceration confined to skin. Repair usually isn’t needed
2nd degree laceration
laceration extends through perineal muscles
3rd degree laceration
Laceration that involves injury to the external anal sphincter muscle
4th degree laceration
Laceration that extends completely through the anal sphincter and the rectal mucosa
May need to go to OR after and will cause issues with BM. Usually has significant hemorrhage
when is QBL counted
after placenta is out
what to worry about if placenta didn’t deliver
placenta being embedded in uterine wall
precipitous labor
last less than 3 hours from onset of contraction to birth
preterm labor
regular labor contractions along with a change in effacement and/or dilation
week 20 to week 36 and 6 days
why would a preterm birth be indicated
medical issue
difference between preterm birth and low birth weight
preterm is more dangerous no matter the size of the baby because it had less time in utero
risk factors for preterm births
previous preterm, multifetal, infection, smoking, drug use, high stress, congenital or medical issues.
fetal fibronectin test
picks up protein due to separation of amnion and chorion. If detected early on may mean preterm. Has high false positive rate, but if its negative its negative
if preterm is suspected what do we do
restrict sexual activity
bed rest aside from things such as bathroom
admission if needed
what do tocolytics do
arrest labor
ex- nifedipine, indocin
magnesium sulfate for preterm labor
can be given to relax uterus and to onboard steroids
antenatal glucocorticoid
painful, slow injection given in the buttocks to accelerate fetal lung maturity by stimulating fetal surfactant production
given 24 hours apart
ex- betamethasone
PROM
premature rupture of membranes- happens after labor starts
PPROM
Preterm premature rupture of membranes. happens between 20-37 weeks
may be caused by UTI, weekend amniotic membrane
chorioamnionitis
bacterial infection in the abdominal cavity
most often occurs after membranes rupture or labor begins
risk factors- long labor, PROM, multiple vaginal exams, use of internal monitors
s/s- fever, increased HR
post term weeks and risks
42 weeks or more
risks: fetal Macrosomia, amniotic fluid decreases- cord compression, placenta function decreases, meconium aspiration
dystocia
lack of progress in labor
dysfunctional labor
labor that is long, abnormal, or difficult
latent phase disorders of labor
ineffective contractions
active phase disorders of labor
Arrest of dilation, abnormal labor patterns, mom exhausted to keep bearing down
induction of labor- cervix ripening
medication (cervidil) put in cervix to help thin out
amniotomy
procedure to break the water to induct labor
oxytocin
High alert med with a lot of risks. Synthetic form of oxytocin. Can be used for labor process for contractions and after if mom is at risk for hemorrhage.
can be used for labor induction
types of operative vaginal delivery
forceps assisted
vacuum assisted
why may someone get a C section
Malpresentation, non reassuring fetal HR, herpes, failure to progress, placental abruption, they want it
why is meconium stained amniotic fluid a OB emergency
aspiration risk for baby
shoulder dystocia
baby shoulder gets stuck in vaginal delivery
life threatening injuries may occur- brachial plexus palsy, death, asphyxia, broken clavicle
amniotic fluid embolism
amniotic fluid gets into maternal circulation causing cardiovascular collapse.
high mortality rate
sudden onset of hypoxia, hypotension and hemorrhage
unsure why it happens and is not preventable
OB emergencies
meconium stained amniotic fluid
shoulder dystocia
prolapse of umbilical cord
uterine rupture
amniotic fluid embolism
risk for developing shoulder dystocia
The greatest risk factor is a previous shoulder dystocia, as well as diabetes because of the risk for macrosomia, but we do not always know why a woman develops this problem in delivery. Women have had shoulder dystocia with smaller babies.
two maneuvers for shoulder dystocia
McRoberts Maneuver (pulling moms legs back as far as you can) and the application of Suprapubic pressure.
what can cause a prolapse of umbilical cord and how to fix
water breakage before baby is engaged
try to keep baby off cord
C section delivery
keep mom in trendelenburg position
provider try to keep pressure by doing a vaginal exam to physically keep pressure off the cord
uterine rupture
separation of the layers of the uterus or previous scar
high risk if mom has had many c sections
s/s- abnormal fetal heart patterns, sharp abdominal pain, bright red bleeding, hypovolemic shock
late decel intervention
Reposition-turn on side, oxygen, stop Pitocin, administer fluid bolus, notify physician, administer terbutaline. We may need to prepare for C section.
variable decel interventions
Reposition mom, which will hopefully reposition the baby. We may need to oxygenate mom, do a vaginal exam, discontinue oxytocin, or do amnioinfusion. When this happens, we should also notify the provider.
