Exam 2: Intrapartum Care Flashcards by Bridget B

What assessment finding would cause the nurse to suspect false labor?

No cervical changes

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First stage of labor

From the onset of true labor to full dilation of the cervix
Latent (0-6 cm dilated); >8 hours; mild contractions
Active (6-10 cm dilated); 4-6 hours; much stronger contractions

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Second stage of labor

From full dilation of cervix to the birth of the infant
30 minutes-3 hours
Urge to push
Intense concentration on pushing

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Third stage of labor

Delivery of the placenta
5-10 minutes
Excited, relieved

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Fourth stage of labor

First four hours after delivery
Tired, excited, hungry

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Cervical dilation

Widening or enlargement of cervix (0-10 cm)
Most conclusive sign that contractions are effective

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Cervical effacement

Shortening and thinning of cervix (0%-100%)

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Station

Relationship of fetal head to mother’s pelvis (+3 is head showing, about to be delivered)

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5 P’s of labor

Power
Passenger
Passageway
Position
Psychological Response

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Primary powers

Provided by uterine muscle

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Secondary powers

Bearing down efforts of patient

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Characteristics of contraction

Coordinated
Involuntary
Intermittent

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Ideal way to deliver

Occiput anterior (OA)

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Most common and favorable pelvis shape for vaginal birth

Gynecoid

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Least favorable pelvis shape for vaginal birth

Platypelloid

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Cultural considerations (pain)

Different cultures deal with pain in different ways
Do not make assumptions
Assess pain in all patients
Some PTs do not outwardly express their pain
Important to be able to communicate with patient

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Non-pharmacologic pain management

Labor support
Doula support (therapeutic touch, guided imagery, breathing, massage)
Hydrotherapy
Acupuncture and acupressure
Heat and cold
TENS
Sterile water injections

Nursing care during first stage of labor

Admission assessment
Monitor PT vitals
Monitor fetal heart rate
Comfort measures
Assist in intrapartum procedures
PT education
Psychosocial support
Documentation

Acceleration

Fetal heart rate increases 15 beats for 15 seconds
Nursing interventions:
Be reassuring
No interventions required
Indicate reactive nonstress test

Deceleration types

Early
Late
Variable

Normal reassuring FHR

110-160 BPM with increases and decreases from baseline

Tachycardia (fetus)

FHR greater than 160 BPM for 10 minutes or longer
Nursing interventions:
Administer prescribed antipyretics for maternal fever if present
Administer oxygen (10 L/min) via non-rebreather
Administer IV fluid bolus

Bradycardia (fetus)

FHR less than 110 BPM for 10 minutes or longer
Nursing interventions:
Discontinue oxytocin if being administered
Assist client to side-lying position, administer oxygen (10 L/min) via non-rebreather
Insert IV catheter if not in place and administer maintenance IV fluids
Notify provider

Early deceleration of FHR

Slowing of FHR at start of contraction with return of FHR to baseline at end of contraction
No nursing intervention required

Late deceleration of FHR

Slowing of FHR after contraction has started with return of FHR to baseline well after contraction has ended Nursing interventions: Place PT in side-lying position Insert IV catheter if not in place and increase rate of IV fluid administration Discontinue oxytocin if being infused Administer oxygen via non-rebreather Elevate client's legs Notify provider Prepare for expeditious delivery if pattern not resolved

Variable deceleration of FHR

Transitory, abrupt slowing of FHR 15 BPM or more below baseline for at least 15 seconds, variable in duration, intensity, and timing in relation to uterine contractions Nursing interventions: Reposition PT from side to side or knee to chest Discontinue oxytocin if being infused Administer oxygen via non-rebreather

Category I FHR Tracings

Considered normal and associated with fetal well being Strongly predictive of normal fetal acid-base status No interventions required

Category II FHR Tracings

Indeterminate and not predictive of abnormal fetal acid-base status Require evaluation and intervention

Category III FHR Tracings

Abnormal and predictive of abnormal fetal acid-base status at the time of observation Require prompt evaluation and intervention

Category III FHR Interventions

Discontinue oxytocin or uterotonic agent (per protocol) Turn PT to left or right lateral position or knee to chest (increases placental perfusion) Increase isotonic IV fluid infusion to improve intervascular volume Administer oxygen via non-rebreather Notify provider of pattern and interventions Assess PT for underlying cause If pattern does not resolve in 30 minutes, prepare for expeditious deliver

Periodic Change

Variable Early Acceleration Late *Indicates placental insufficiency*

Underlying Cause

Cord Head Ok Placenta

How to time contractions

Time contractions from the beginning of one contraction to the beginning of the next (frequency) Document frequency in minutes

Normal uterine activity

5 or less contractions in a 10-minute segment averaged over a 30-minute period

Abnormal uterine activity

Contractions occurring 90 seconds (Tetanic) Unusually high resting tone (Hypertonus)

Nursing care during second stage of labor

Assess patient and fetus (VS, FHR, pain) Comfort measures Positioning of PT Psychosocial support Prep of delivery table Documentation

Immediate care of newborn

Assess at delivery Dry neonate, clear airway with blankets

APGAR

Appearance Pulse Grimace Activity Respiration Done at 1 and 5 minutes Not used to guide resuscitation efforts If resuscitation is needed it is done immediately

Nursing care during third stage of labor

Assist in delivery of placenta Assess for signs of potential PT problems Assess newborn response Parental/newborn bonding

Signs of separating placenta

Lengthening of umbilical cord Gush of vaginal blood Globular shaped abdomen PT feels urge to push *3rd stage of labor should last less than 40 minutes*

Nursing care during fourth stage of labor

Administer oxytocin (Pitocin) and assist in perineal repair Assess: PT vitals Fundal checks q15'x4, q30x2, q1 hr until transfer to postpartum unit