EXAM #2 Flashcards
Powers:
Primary:
-Uterine contractions
-Causes dilation and effacement
-Increment, acme, decrement, relaxation
Secondary:
-Maternal pushing
-Urge to bear down
-Should NOT push if the cervix is not fully dilated.
What devices measure uterine contractions?
Tocodynamometer (TOCO): external
Intrauterine pressure catheter (IUPC)
What is Increment, acme, decrement?
-Increment: building of contraction
-Acme: Peak
-Decrement: decrease of the contraction
Frequency of contractions is defined as:
The beginning of one contraction to the beginning of the next one.
A mild contraction feels like the…
nose
A moderate contraction feels like the…
chin
A strong contraction feelss like the…
forehead
Define Effacement:
Process of shortening and thinning of the cervix.
Passageway
Baby must pass through the Inlet, midpelvis and the outlet.
Passenger:
Fetal lie:
*Longitudinal: baby is upside-down
*Transverse: baby is coming out shoulder first
*Oblique: baby is coming out bottom first
Fetal attitude/presentation:
*Flexion: Vertex. Fetal head is flexed so that the chin is tucked to the chest
*Moderate flexion: Military, straight up
*Poor flexion or extension: Brow presentation
*Full Extension: face presentation
*Breech presentation:
-Frank: legs are extended up
-Footling
-Complete: Legs are flexed
Engagement:
When the widest part of the fetal presenting part had passed through the pelvic inlet
Station:
The level of the presenting part in relation to the ischial spine.
Station zero
Will usually start pushing at +1
Position:
*Right or left of the patient
*Occiput: Position of head coming into the uterus
*Sacrum: Breeched
*mentum: chin
* Acromian process: shoulder
*Anterior,posterior or transverse
Characteristics of false labor:
-Contractions are irregular
-Pain is abdominal
-No change in cervix
-Walking lessens pain
Characteristics of true labor:
-Contractions are at irregular intervals
-Pain is in lower back and radiates to the abdomen
-Cervical changes occur
-Walking increases labor pain
Signs and symptoms of impending labor:
-Lightening: Baby’s head settles in pelvis at 38W
-Braxton Hicks
-Cervial effacement: thinning and softening
-ROM
-Bloody show: bloody mucus plug
-Energy Spurt
-Weight loss
-GI disturbances
What to assess on a mother in impending labor:
-Interview
-Fetal & Maternal assessment
-Psychosocial & cultural assessment
-Lab tests (Blood type, Rh factor, CBC, Hemoglobin, Hematocrit, glucose, STIs; UA: WBC, protein, glucose and ketones)
-IV start
What is Leopold maneuvers?
Abdominal Palpation of the fetal position.
What is baseline fetal heart rate?
The average FHR that observed between contractions over a ten minute period
-110 to 160bpm
What can cause tachycardia in a fetus?
-Fetal anemia & hypoxia
-Maternal fever & dehydration
-Medications & substances
-Infection
What can cause bradycardia in a fetus?
-Medications
-Maternal hypotension
-Maternal or fetal hypoglycemia, hypothermia and dehydration
-Prolonged cord compression or prolapse
Variability predicts…
fetal oxygenation during labor
Absent variability
Undetectable, may represent fetal cerebral asphyxia
Minimal variability
2-5bpm
May be related to narcotics, mag sulfate, anesthetic agents, supine hypotension, cord compression, unterine tachysystole, or fetal sleep (30min)
Moderate variability
6-25bpm
Fetal well-being
Marked variability
over 25bpm
Fetal hypoxia
Periodic changes:
Accelerations and decelerations in relation to UC
Episodic changes:
Accelerations and decelerations that are not associated with UC
Accelerations
An increase in FHR of 15bpm over the baseline that lasts 15 seconds to 2 minutes
Decelerations
Any decrease in FHR below the baseline.
What is an Early deceleration?
Gradual decrease in and return of the FHR associated with UC.
When does the lowest part of the early deceleration occur with the peak of the contraction?
At the same time. Mirrored image
What do we do for an early deceleration?
Nothing
What is a variable deceleration?
Abrupt decrease in FHR below the baseline is 15+ bpm that lasts for at lease 15 seconds to 2 minutes.
-Occurs at any time of the UC and looks like a W or V
-Repetitive ones are a concern
What do we do for variable decelerations?
Help patient with anxiety and decrease pain and enhance uterine blood flow.
-Change position (side to side or knee chest)
-Decrease or stop pitocin (give terb for tachysytole)
-Give oxygen
-Vaginal exam
-Give amnioinfusion
-Change pushing technique
-IF NOT CORRECTED: prepare for birth
What is a late deceleration?
A gradual decrease in and return to baseline FHR associated with UC.
-Begins around the peak of the contraction
-Indicates uteroplacental insufficiency (decline in placental function)
What do we do for late decelerations?
-Position patient on their side
-Give bolus if theres hypotension
-Assess for tachysystole & labor progression
-Stop oxytocin
-Give oxygen
-IF NOT CORRECTED: prepare for birth
What is a prolonged deceleration?
Abrupt decrease in the FHR below the baseline that is greater than or equal to 15 bpm and lasts 2 to 10 minutes.
What do we do for prolonged decelerations?
-Assess baseline variability
-Reposition
-Stop oxytocin
-Give oxygen
-Give bolus
-Give amnioinfusion
-IF NOT CORRECTED: prepare for birth
What can cause a prolonged deceleration?
tachysystole, cord compression/prolapse, profound head compression or rapid fetal descent.
What is considered tachysystole?
Greater than 5 contractions in 10 minutes averaged over a 30 minutes period
What occurs in the latent phase of labor?
-Onset of regular contractions that are mild in intensity
-5 minutes apart and lasts 30-45 seconds
-0-3 cm dilated
-Excited, talkative, confident, anxious, withdrawn
What occurs in the active phase of labor?
-More active contractions that are moderate in intensity
-3-5 minutes apart, lasts about 60 seconds
-4-7 cm dilated
-Focused inwardly & quieter
What occurs in the transition phase of labor?
-Most intense part with strong contractions
-2-3 minutes apart and lasts 60 to 90 seconds
-8-10cm dilated
-Difficult to cope, irritable, agitated, hopeless, tired
What is the Friedman curve?
A graph used to help identify whether a patient’s labor is progressing in a normal pattern
-Cervical changes over time
How often should each stage of labor be monitored using intermittent ausculation without any complications?
-Latent: Q1hr
-Active: Q 5-15 minutes
-Transition: Q 5-15 minutes
How often should each stage of labor be evaluated using continous monitoring without any complications?
-Latent: Q 30 minutes
-Active: Q 15 minutes
Q 5 minutes whild pushing
What factors can change electronic fetal monitoring?
-ANS (blood pressure, RR, temp.)
-Medications: Increase or decrease variability and baseline
-Anesthetics: decreased bp
-Uterine & maternal condition
What do we give before giving an epidural?
Give fluid bolus to increase blood pressure. If that fails give ephedrine.
When the uterus is contracting too often, what should we do?
Give Terb and fluids with sugar.
What is VEAL CHOP?
Variable deceleration Cord Compression
Early decelerations Head compression
Accelerations Okay
Late deceleration Placental insufficiency
What occurs during the second stage of labor ?
Starts with full effacement and dilation.
Ends with the birth of the baby
Woman feels the urge to bear down
What is laboring down?
Allowing the mother to rest with the use of an epidural as the fetus descends.
Open glottis pushing
-Involuntary pushing, usually in unsedated patients
-When the mother pushes when she feels the urge to push
Closed glottis pushing
-Directed/coached pushing, usually with an epidural
-Pushes when fully dilated and effaced regardless of the urge to push
Define 1st degree laceration:
Involves the perineal skin and vaginal mucous membrane
Define 2nd degree laceration:
Involves the skin, mucous membrane, and the fascia of the perineal body
Define 3rd degree laceration:
Involves the skin, mucous membrane, and muscle of the perineal body and extends to the rectal sphincter
Define 4th degree laceration:
Extends into the rectal mucosa and exposes the lumen of the rectum
What is an episiotomy?
A surgical incision of the perineum performed to enlarge the vaginal orfice during th second stage of labor.
What are the cardinal movements of the second stage of labor?
Engagement, descent, flexion, internal rotation, extension, external rotation, expulsion.
Remember: every darn fool in egypt eat raw eggs.
What occurs during descent?
The progression of the fetal head into the pelvis
4 forces:
-Pressure of the amniotic fluid
-Direct pressure of the uterine fundus on the fetal breech
-Contraction of the muscles
-Extension and straightening of the fetal body
What occurs during flexion?
Occurs as the fetal head descends and comes into soft tissues of the pelvic floor & cervix.
What occurs during internal rotation?
The head will rotate to fit into the pelvic cavity
What occurs during extension?
The head is born as it slides under the pubic symphysis.
What occurs during external rotation?
The shoulders align causing the head to continue to turn farther to one side
What occurs during expulsion?
Pushing efforts push the fetal shoulder under the pubic symphysis. once the shoulders are born the rest of the body quickly follows.
When should the cord be clamped in a term infant?
Delay for 60 seconds
When should the cord be clamped in a pre-term infant?
Delay for 60 to 120 seconds if the baby does not need resuscitation in the first minute of life.
What occurs during the third stage of labor?
-Begins with the birth of the infant
-Ends with the delivery of the placenta (5-30min)
-Uterus becomes spherical in shape & rises upward
-Umbilical cord descends further through the vagina
-Gush of blood occurs once the placenta detaches from the uterus.
What should the nurse do during the third stage of labor?
-Give a high dose of oxytocin (IM or IV)
-Observe and palpate the uterus
-Assess for retained placenta and vulvar injuries
-Monitor V/S
-Emotional support
-Initiate infant attachment
What occurs during the fourth stage of labor?
-Period of maternal physiological adjustment
Begins with delivery of the placenta and continues through the first two hours after birth.
What should the nurse do during the fourth stage of labor?
-V/S Q 15 min
-Fundal assessment
-Perineal assessment
-Comfort measures
What are non-phamacological methods of pain relief during labor?
-Music
-Relaxation techniques
-Focusing strategies
-Massage & touch
-Effleurage: stroke the abdomen to distract.
-Sacral pressure & counter pressure
-Breathing techniques
-Hydrotherapy & aromatherapy
-Acupressure
Pain relief meds for the latent stage of labor:
Sedatives: Secobarbital. kicks in in 15 min, lasts for 3-4hrs
Anxiolytics: Benzo to decrease anxiety
H1 receptor antagonist: Produces sedative and antiemetic effects (Phenergan)
Pain relief meds for the active phase of labor:
Opioids: Demerol, stadol
Nerve block analgesia: Epidural and spinal
What should the nurse assess before giving opioids?
The cervix, RR of mom and baby (at delivery)
Other meds that affect the uterus to give during labor:
Tocolytics: Terbutaline. Slows contractions
Uterotonics: gives uterus tone in case of hemorrhage. Oxygen, Cytotec, Methergine, and Hemabate
What are containdications for hemAbate & metHergine?
hemAbate: Asthma
metHergine: Hypertension
what phase of the first stage of labor should we avoid opioids?
Transition phase, have narcan at bedside
Epidural:
Baseline VS, bolus of IV fluid 500 to 1000ml
-Test dose
-Left in place until after delivery
-PCEA
Spinal:
One time injection
-Smaller dose
-Patient should remain flat for several hours and administration to avoid spinal HA
Assessment for Epidual and spinal:
-place foley and monitor output
-RR & BP
-Sensation and movement: reposition
What is dystocia?
Long, difficult or abnormal labor
-Hyper or hypotonic
What is hypertonic labor?
Strong, painful contractions that do not effecively produce effacement and dilation.
Contractions are happening often and can lead to fetal hypoxia
Nursing interventions for hypertonic labor:
-Rest, hydration, and sedation
-rotate the fetus
-promote walking
-decrease anxiety
medications for hypertonic labor:
acetaminophen, Benadryl, demerol, dilaudid and morphine
What is hypotonic labor?
UC that decrease in frequency and intensity.
Fewer than 2 to 3 contractions in 10 minutes
The uterus can easily be indented at the peak of a UC
Nursing interventions for hypotic labor:
-Walking
-Massage
-Relaxation
-regular v/s and cervical checks
-nipple stimulation
Medication for hypotonic labor
Oxytocin infusion
What is chorioamnionitis?
Infection of the amnionic sac that can infect the baby and the uterus.
-characterized by: fever of 104, fetal tachycardia, uterine tenderness, and foul emniotic fluid
-DX: cultures on the placenta
Interventions for chorioamnionitis:
Delivery and antibiotics (ampicillin) throughout labor and postpartum
Shoulder dystocia definition, signs and resolution:
When the baby’s shoulder is caught on the pubic bone.
-Emergency
-Slowed labor progression
-Turtle sign: retraction instead of protuding with UC
-Perform suprapubic pressure and McRoberts maneuver
What is the Bishop score tool?
The method to assess if induction will be more successful.
-Looks at: Dilation, effacement, station, cervical consistency and position.
-The higher score is deemed more successful
What is Prostaglandin E1 (cytotec) and Prostaglandin E2 (Cervidil) used for?
Cervical ripening, stimulates UC.
What mechanical methods can help cervical ripening?
Baloon Cath & Laminaria tents (seaweed)
When is vacuum assisted birth needed?
When labor has stalled, can’t push effectively, or emergency delivery due to fetal distress.
What requrements are there for vacuum assisted birth and forceps?
vertex presentation, ruptured membranes, and absence of CPD
When are forceps needed?
Dystocia, inability to push with contractions, and prevent worsening of complications
Cephalopelvic Disproportion (CPD):
Occurs when the baby is too large.
Most likely needs a C-section.
Nursing interventions for CPD:
-Change to upright position or squatting
-Relaxation
-Water therapy
-Pain Management
What is a nuchal cord?
A cord that is wrapped around the baby’s neck and a cord with knots.
Can be fixed when the head is born. The cord is either loosened and slipped over the head or it is double clamped and then cut.
How is a nuchal cord dx?
US & doppler
What is oligohydramnios?
Less than 300ml of amniotic fluid. Caused by fetal renal abnormalities, poor placental fusion or PROM.
Intervention for oligohydramnios and meconium-stained fluid:
Amnioinfusion
What is hydramnios (polyhydamnios)?
Greater than 2L of amniotic fluid.
Caused by: multiple gestations, anomalies, diabetes.
What is meconium-stained amniotic fluid?
The baby passes meconium in utero
Caused by: hypoxia, breech, cord compression
Placenta previa:
Bleeding when the lower uterine segment begins to differentiate from the upper segment in late pregnancy and the cervix begins to dilate.
Medical management for placenta previa:
-If the FHR is good and the mother is stable at less than 36 weeks the mother is monitored.
-Little to no bleeding, the mother may attempt vaginal birth
-If the fetus is 37+Wks, in labor and persistently bleeding, theres a need for a c-section.
Placental abruption:
Occurs when the placenta partly or completely separates from the inner wall of the uterus before delivery.
Caused by HTN, cocaine use, trauma, or previous hx.
Medical management for placental abruption:
With moderate to severe blood loss and the fetus being near term, delivery is facilitated.
-Artificial membrane rupture and augment with oxytocin
-If birth is not imminent, a c-section will occur
Nursing interventions for placental abruption:
-Lay patient on lateral side
-No vaginal exams or enemas
-Assess urine output
What are two complications of placental abruption?
-Couvelaire uterus (accumulation of blood between separation of the uterus and placenta)
-DIC
What meds/products to give when DIC develops?
IV fibrinogen, cryoprecipitate, packed RBCs and platelets
Disseminated intravascular coagulation (DIC) definition and s/s:
Release of large amount of thromboplastin.
-Bleeding from multiple sites
-Widespread petechiae and bruising
-Tachycardia
-Diaphoresis
Uterine inversion:
uterus is turned inside out
Uterine inversion medical management:
manual replacement of the fundus under general anesthesia
Medications for Uterine inversion:
Oxytocin and antibiotics with possible blood transfusions and fluid resuscitation.
Velamentous cord insertion/vasa previa
Occurs when the fetal vessels separate at the distal end of the cord and insert into the placenta at a distance away from the margin
Succuriate lobe:
Contains one or two separate lobes with their own circulation. After birth, one lobe may be retained and impede contractions, causing hemorrhage. Must be removed.
