exam 2 care during labor Flashcards
what is the orders of delivery?
Induction vs Augmentation
Bishop Score
Continuous monitoring vs intermittent monitoring
Items needed for delivery
Delivery
Documentation
what is important with Leopold maneuvers?
a). Fundal Grip-
Determine fetal part lying in the fundus
Determine presentation: vertex, transverse, breech
Findings….Head is more firm, round, and moves independently of the body.
b). Umbilical Grip-
Identify location of fetal back
Determine position
Findings….Fetal back is smooth, hard, and resistant surface. Knees and elbows are angular.
c). Pawlik’s Grip-
Determine engagement of presenting part
Findings….Presenting part is engaged if not movable.
d). Pelvic Grip-
Determine degree of flexion of fetal head
Determine attitude: If the cephalic prominence is noted to be on the same side as the small parts, the head must be flexed meaning a VERTEX presenting.
However, if the cephalic prominence is noted on the same side as the back, the presenting part is extended and the face is presenting.
Findings….Good attitude- brow correspond to the side of the elbows and knees, Poor attitude- there is an obstruction on the same side as fetal back (hyperextended head). In addition….if brow is easily palpated, fetal is in an OP (occiput pointing towards woman’s back).
Fetal Heart Rate and Contractions?
FHR-Fetal Heart Rate
Determining monitor placement
Looking for PMI of FHR – location where FHR is heard the loudest – usually over fetal back
Perform Leopold Maneuvers
Auscultate the FHR based on fetal presentation identified with Leopold Maneuvers
Chart PMI of FHR using a two-line figure to indicate the 4 quadrants of the maternal abdomen:
RUQ LUQ
RLQ LLQ X/140
Contractions on palpation
Mild – feels like pressing finger on the nose
Mod – feels like pressing finger to chin
Severe – feels like pressing finger to forehead
what is important to note with FHR?
Heard loudest directly over fetal back. In vertex presentation: right or left lower quad, breech, above mother’s umbilicus
Assess after ROM: most common time for umbilical cord prolapse, after any change in contraction pattern or maternal status, and before and after woman receives medication or procedure.
Monitor Fetal heart rate: Easy to remember: 30-60 minutes during Latent/Early phase, q 15-30 minutes during active phase,
**Always immediately after ROM
Bag of H20 (BOW) aminotomy?
Another way to augment or induce labor
SROM – Spontaneous Rupture of Membranes
AROM Artificially Rupture of Membranes
If doesn’t rupture spontaneously, can artificially rupture using Amnihook or surgical clamp
What do we check after??
At risk for infection once BOW ruptures: limit vag exams, assess temp and discharge frequently (q2h)
Prolonged rupture of membranes: more than 24 hours prior to delivery
Premature Rupture of membranes: before 37 weeks.
ROM? Assessment of amniotic membranes and fluid ?
Confirm ROM with nitrazine test for pH or test for ferning
Nitrazine test (detects amniotic fluid- slightly alkaline vs. urine and pus- acidic)
Intact [Negative]- body fluids are mostly are acidic
Yellow [pH 5.0]
Olive-yellow [pH 5.5]
Olive-green [pH 6.0],
Ruptured [Positive]- amniotic fluid is alkaline BUT so are bloody show, insufficient amniotic fluid, and semen.
Blue-green [pH 6.5]
Blue gray [pH 7.0]
Deep blue [pH 7.5]
Ferning – microscopic appearance of a fernlike crystalline pattern
FHR – umbilical cord may prolapse when the membranes rupture. Nursing responsibility to monitor the FHR for several minutes following ROM to ascertain fetal well-being
Color – normally pale and straw colored with white flecks of vernix caseosa.
Greenish-brown – meconium stained due to recent hypoxic episode that caused relaxation of anal sphincter
Yellow – fetal hypoxia > 36 hours prior; fetal hemolytic disease [bilirubin]; infection
Port wine – bleeding associated with premature separation of placenta [abruptio]
Viscosity & odor – normally lacks strong odor. Suspect infection if thick, cloudy, or foul smelling.
Amount – Expected amount is 700 to 1000 ml
Polyhydramnios – >2000 ml; associated with congenital anomalies of the GI tract [fetus can’t drink fluid]; GDM
Oligohydramnios – *<300 ml; associated with absence of kidneys or obstruction of urethra [fetus can’t excrete urine]
Infection – after ROM microorganisms from the vagina can ascend into the amniotic sac causing chorioamnionitis and placentitis. Assess maternal temperature and vaginal discharge q 1-2 hrs so developing infection can be identified early.
spontaneous ROM?
Nitrazine Paper/Swab
Fluid from vaginal area placed on paper or swab
Turns Blue if positive for amniotic fluid (Alkaline)
Stays Yellow if urine (Acidic)
Fern Test
Fluid from vaginal area placed on slide
If amniotic fluid it looks like fern leaves
care of laboring mother?
Warm showers or baths, change linen if becomes wet, change Under pad (Chux, blue pad, pink pad) as needed. Frequent perineal care if ROM. Provide oral hygiene
Clear liquids during early labor (some doctors and midwives allow solid food) and ice chips and sips as labor progresses. IVF for hydration (LR NS) watch for hypervolemia
Elimination: q2 hours, distended bladder can impede descent of presenting part, slow or stop contractions, and lead to decreased bladder tone or uterine atony after birth. Protocols for catheterization. May pass stool during pushing, some multipara women express urge to defecate when needing to push. Check dilation.
Ambulation: encourage ambulation if membranes are intact, after ROM if fetal presenting part is engaged and if no pain meds. Change position q 30 -60 minutes. Always have pillow under one hip to prevent uterus from compressing aorta and vena cava.
If fetus in occiput posterior position, squat during contractions: increases pelvic diameter allowing head to rotate more anterior position. Hand and knees position during contractions or lateral position on same side as fetal spine to help rotate occiput from posterior to anterior position as gravity pulls fetal back forward.
May use birthing ball, peanut ball, lean on partner, partner give low back support
Support: emotions and physical care. Maintain control, helping with discomfort, privacy, advocate, listen
position of mother in labor?
Lithotomy
Semi recumbent
Squatting
Lateral
Knee Chest
Rocking (Cannot be done if client has an epidural)
Affects adaptation to labor
Relieves fatigue, ↑ comfort, & ↑ circulation
Promotes descent of fetus
↑ effectiveness of contractions = shorter labor
↑ cardiac output = ↑ blood flow
Correctly aligns abdomen for ↑ pushing efforts
evidence based L&D care?
Allow labor to begin on its own
Encourage freedom of movement throughout labor
Provide labor support
Avoid routine implementation of interventions
Support spontaneous, non-directed pushing in nonsupine positions
Avoid separation of mother and baby after birth
Labor support measures?
Nourishment
Hygiene
Information & advice
Companionship & reassurance
Positive reinforcement & praise
Collaborative decision making
Relaxing environment
Calm & confident approach
Inform others of patient care preferences
Encourage patient’s support system
Distraction & non-pharmacologic pain measures
nursing care for augmentation/induction?
Amniotomy-artificial rupture of membranes
Induction of labor using cervical ripening methods , Oxytocin
Tachysystole with oxytocin can lead to fetal hypoxemia or acidemia
what are the signs of potential complications?
> 80 mm Hg intrauterine pressure/> 20 mm Hg resting tone
Ctxs > 90 secs
5 ctxs in 10 mins
< 30 secs of relaxation between ctxs
Non-reassuring FHR
Meconium stained fluid
Arrest of labor- dilation/effacement/descent
Maternal temp > 100.4○ F
Foul-smelling vaginal discharge
Persistent bright/dark red vaginal bleeding
what are the obstetrical emergencies?
Abnormal FHR-Fetal Distress
Meconium-Stained Amniotic Fluid
Shoulder Dystocia
Prolapsed Umbilical Cord
Ruptured Uterus
Amniotic Fluid Embolus
what is shoulder dystocia?
Head delivered but shoulders impacted above maternal symphysis pubis
Head outside/chest inside –> preventing respirations
Turtling of the fetal head
McRoberts maneuver (thighs flexed sharply against abdomen) may straighten the pelvic curve
Suprapubic pressure
