Exam 2 - week 9 Flashcards
1
Q
What is laboring down?
A
-(promotion of passive descent)
-alternative strategy for 2nd-stage management in women w epidurals.
-Using this approach, the fetus descends and is born w/o coached maternal
pushing.
2
Q
Nursing education for 2nd stage of labor
A
- Teach woman prenatally about benefits of upright positions
- During labor, encourage woman to change positions frequently; suggested positions include squatting, semi-recumbent, standing, and upright kneeling
3
Q
What are possible birthing positions?
A
• Bed, birthing chair, delivery table o Recumbent / lithotomy position – Should be avoided o Semi-fowlers o Left lateral Sims’ position o Squatting o Hands and knees / all fours o Using a Birthing Bar
4
Q
Nursing care for 2nd stage of labor
A
• Evaluate physical parameters o Increased frequency of assessment • Provide support and info about labor progress • Assist with pushing o Efforts o Positioning o Laboring Down
5
Q
What teaching can we give women about breathing/breath holding during labor?
A
- discourage prolonged maternal breath holding (ESP FOR WOMEN WITH HEART PROBLEMS)
- should hold breat for 6-8 seconds tops (NEVER 10 SECONDS)
6
Q
nursing support for 2nd stage of labor
A
- Allow woman to rest until she feels an urge to push
- Encourage spontaneous bearing down
- Support, rather than direct, the woman’s involuntary pushing efforts
- Discourage prolonged maternal breath holding
- Validate the normalcy of sensations and sounds the woman is voicing (think of puking example)
7
Q
a nurses preparation for birth includes: (4 things)
A
- Nurse washes hands
- Opens sterile prep tray
- Dons sterile gloves
- Clean vulva, perineum
8
Q
How to assist with birth in emergency situation?
A
• Fetal head distending perineum
o Support perineum and baby’s head very gently (**make sure it doesn’t “pop out” too quickly and tear perineum)
• Palpate fetal neck for presence of cord (If cord is around head/neck, gently unwrap it)
• Restitution and external rotation
o Suctioning (not always necessary)
o Support baby to release anterior shoulder
9
Q
2 possible types of episiotomy
A
- midline (down middle, towards rectum. Cuts through less muscle)
- mediolateral (off to side. Cuts through more muscle, takes longer to heal)
10
Q
what is an episiotomy
A
Incising the perineum area to provide more space for the presenting part
-this should be done selectively, rather than routinely
11
Q
Types of lacerations (5 types)
A
o First Degree-little tear through mucosa
o Second Degree-through mucosa and part of muscle
o Third Degree-through anal sphincter
o Forth Degree-through anal sphincter and part of anterior rectal wall
• Cervical Laceration – (RARE, can happen if woman pushes forcefully before being fully dilated)
12
Q
Nursing care/education for lacerations
A
• initially ice (1st 24 hours)
• then warmth/sitz bath/warm showers bc this increases circulation which helps to promote healing
• Tighten buttocks, sit straight down on something soft
–AVOID SITTING on donut pillows (can cause skin to separate further causing more damage)
13
Q
How can we assist with cord clamping?
A
- Delayed clamping encouraged (waiting for it to stop pulsating allows extra blood to flow to baby)
- Two Kelly clamps – cut in between them (can Allow partner to cut)
- Examine cord for vessels (3)
- Cord blood collection
14
Q
3 things that can help with placenta expulsion
A
o Maternal bearing-down effort
o Controlled cord traction
o Fundal pressure (gentle)
15
Q
what is the 3rd stage of labor
A
delivery of the placenta
16
Q
3 ways to observe for placental separation?
A
o Palpate uterus gently to check for ballooning/rising
o Visible lengthening of cord
o Slight gush of blood
17
Q
nursing care during 3rd stage
A
- Inspection of placental membranes / Cotyledons (make sure it’s all intact.)
- Vagina and cervix inspected for lacerations
- Disposal of placenta (or, Some ppl want to save this for health benefits)
- Use of oxytocics
18
Q
What is the immediate care that needs to be provided to a newborn?
A
• Respirations first priority!!! • Provide and maintain warmth o Skin-to-Skin o Newborn in radiant-heated unit • Beneficial for breastfeeding and also microbiome • Provide newborn care
19
Q
5 criteria of APGAR?
A
o Heart rate o Respiratory effort o Muscle tone o Reflex irritability o Skin color
20
Q
Acrocyanosis
A
blueness of the extremities (common in newborns)
21
Q
What is considered the fourth stage (aka restorative stage or immediate post-partem stage) of labor?
A
-the first 1-4 hrs immediately after birth
-Considers physical and emotional factors as nurse focuses on carefully monitoring the woman and newborn, promoting maternal comfort, providing appropriate education and support, and facilitating attachment behaviors
-begins with completion of the expulsion
of the placenta and ends w initial physiologic adjustment and stabilization of the mother
-This stage initiates postpartum period.
-mother usually feels a sense of peace and excitement, is wide awake, and is very talkative initially.
22
Q
When is the APGAR test performed?
A
- at 1 minute and again at 5 minutes after birth
- if baby’s score is
23
Q
Maternal adaptations immediately following birth?
A
- Blood pressure – Returns to pre-labor level
- Pulse – Slightly lower than in labor
- Uterine fundus – midline at umbilicus or 1-2 fingers below (continues to go down each day)
- Lochia – Red (rubra), small to moderate amt (from spotting on pad to 1/4-1/2 of pad in 15 min)
- Bladder – Nonpalpable
- Perineum – Smooth, pink, w/o bruising or edema
24
Q
what is lochia?
A
vaginal discharge
25
normal lochia immediately after birth?
Red (rubra), small to moderate amt (from spotting on pad to 1/4-1/2 of pad in 15 min), small clots are normal
26
how should the bladder feel immediately after birth?
nonpalpable (unless mother has a full bladder)
27
how often should the fundus be palpated in 4th stage of labor?
-q15 min for 1 hour
28
Nursing care during 4th stage of labor?
* Palpate fundus every 15 minutes for 1 hour
* Assess vaginal bleeding
* Encourage bonding and breastfeeding
* Assess perineum
* Perineal care
29
how often is the perineum assessed during 4th stage of labor?
-q15 minutes
30
perineum care in 4th stage of labor?
* Assess Perineum q15 minutes
* Evaluate for redness, edema, ecchymosis, discharge, approximation
* Check: sutures intact
* Apply cool compresses or ice packs to the affected area initially (then use warmth)
31
What do we assess for in the uterus in 4th stage of labor?
-is fundus midline at umbilicus? (0r 1-2 fingers below)
-check for uterine atony (lack of tone)
o Clots present?
o Massage carefully to expel any blood clots (this can remind the uterus to contract)
32
Things to remember when palpating the fundus?
* If palpable above level of umbilicus and to the R: result of a full bladder (Encourage to void before)
* Poorly contracted uterus: boggy or very soft in the abdomen (bad sign, can lead to more bleeding)
* Bladder: assess amount, frequency, and any difficulties initiating voiding
* Pressure on bladder: perineal trauma, edema
33
What is REEDA?
-acronym frequently used for assessing perineum status. -derived from 5 components identified to be associated
w healing process of perineum. These include:
1. Redness
2. Edema
3. Ecchymosis
4. Discharge
5. Approximation of skin edges
34
how to assess the perineum (positioning, vocab to use, etc)
* Is there an episiotomy, laceration, or an intact perineum
* If midline epis: pt to lie on either side for assessment
* Right mediolateral (RML) or left mediolateral (LML): pt to lie on the side w episiotomy next to the bed
* Lift pt’s upper buttock
* Allow for adequate light: visualization
35
Ways to promote attachment in 4th stage
* Emotional time for family
* Lights can be dimmed
* Complete assessments w baby on mother’s chest, abdomen
* Breastfeeding encouraged
* Enhance attachment as much as possible
36
comfort measure for mother in 4th stage
• Tremors common
o Provide heated blanket (some women have chills after delivery) and/or warm drink
• Provide food
• Encourage rest
• Transfer to postpartum unit when stable
37
Initial care of a newborn?
* Abbreviated systematic physical assessment (can be done on mother’s chest)
* Contour, size of head, fontanelles
* Posture, movement
* Inspect face, ears, neck, palate
* Inspect skin
* DELAY weight if possible
38
Rules about newborn identification
* Mother and newborn need ID codes
* Bands on wrist of mother & partner
* Newborn – 2 ID bands (foot and arm)
* Security device on cord clamp, ID bracelet
* Footprints – not reliable (done more now bc they’re cute and parents like it)
39
Important points of record keeping about newborn/birth process
* Position of fetus at birth
* Presence of cord around neck
* Time of birth
* Apgar scores
* Gender
* Time of expulsion of placenta
* Method of placental expulsion
40
5 potential ways that fetal O2 supply can decrease
* Reduction of O2 content in maternal blood as result of hemorrhage or severe anemia
* Reduction of blood flow through maternal vessels as result of: Maternal HTN
* Hypotension caused by supine maternal position, hemorrhage, epidural anesthesia (can decrease amt of blood flow thru placenta and to baby)
* Alterations in fetal circulation w compression of umbilical cord
* Reduction in blood flow to intervillous space in (aging) placenta
41
Continuous fetal monitoring should be recommended to whom?
only high risk pregnancies (for low risk, intermittent monitoring is sufficient)
42
What is electronic fetal monitoring and what is its purpose?
-uses machine to produce continuous tracing of the FHR. When monitoring device is in place, a sound is produced w each heartbeat. A graphic record of the FHR pattern is produced.
-Primary objective is to provide info about fetal oxygenation and prevent fetal injury
that could result from impaired fetal oxygenation during
labor.
-Purpose of electronic fetal monitoring is to
detect fetal heart rate changes EARLY before they are prolonged and profound.
43
how have fetal outcomes changes since the invention of electronic fetal monitoring?
• **No documented changes in outcome because of fetal monitoring!
44
How is fetal well-being measured?
• by response of FHR to uterine contractions (UCs)
45
Name 2 FHR patterns that are REASSURING
```
o Baseline FHR in normal range of 110 to 160 beats/min, with no periodic changes and a moderate baseline variability
o Accelerations (elevations of HR in response to fetal movements or contractions is a GOOD thing) of FHR with fetal movement
```
46
what is a fetal "acceleration"
transitory abrupt increases in the FHR above the baseline that last
47
What are NONreassuring FHR signs? (4)
• Baseline FHR more than 160 or less than 110
- late decelerations
- absent or minimal variability
- prolonged variable decelerations
48
what are the methods of fetal monitoring?
* Electronic Fetal Monitoring (EFM) (can be external, Internal, OR Combination)
* Intermittent Auscultation and Palpation
* Intermittent vs Continuous EFM
49
Are decelerations a good or bad thing?
only bad when they happen in association with decreased blood flow through placenta and umbilical cord (i.e. late decelerations or prolonged variable decels)
50
if variability decreases, what is required for the fetus to remain stable?
oxygen
51
what is meant by FHR "variability"
* The amount of beat to beat fluctuation in the fetal heart rate
* Reflects interaction between sympathetic and parasympathetic nervous system
* Oxygen is required when variability decreases
52
What is the most important prognostic indicator of fetal oxygenation?
variability
53
categories of variability (4)
• Absent
• Minimal (Mild)
-moderate (IDEAL)
• Marked > 25 bpm
54
changes in variability can result from:
hypoxemia, acidosis, medications, sleep states
55
what are the pros of continuous EFM? (6)
* Continuous record
* Ongoing assessment
* “trend over time”
* Less personnel intensive
* Some improved accuracy of data
* Very effective IF we’re concerned about the pts well-being
56
What are the cons of continuous EFM?
* Limitation of movement (could slow labor leading to a need for more interventions)
* Limited data re: improved outcomes
* Potential loss of patient contact (nurses sit at station & only monitor from there)
* May or may not be invasive
57
what is an RN's responsibility with regard to EFM?
o Assess contractions and FHR patterns
o Apply fetal monitors
o Independently assess, interpret and intervene related to FHR patterns
o Communicate findings in a TIMELY manner
58
6 aspects to pay attention to when assessing uterine activity
* Contraction
* Frequency
* Duration
* Intensity
* Resting Tone
* Patient tolerance
59
how to distinguish intensity of contractions on palpation
* Mild or 1+ (easily dented)(tip of nose)
* Moderate or 2+ (can slightly indent) (chin)
* Strong or 3+ (cannot indent uterus) (forehead)
60
what is average baseline FHR?
110-160
61
how is baseline FHR calculated?
average HR during a 10 min segment (excluding:
o Accelerations
o Decelerations
o Periods of marked variability
62
Difference between periodic changes and episodic changes in FHR
* Periodic changes occur with Uterine Contractions (UC)
| * Episodic (non-periodic) not associated with UCs
63
3 types of decelerations
1. Early decelerations
2. Late decelerations
3. Variable decelerations
64
what is an early deceleration?
-response to fetal head compression (with increased pressure on head there’s a NORMAL vagal response causing slowed HR in response to this, then it will usu go back up after peak of contraction) WE DON’T WORRY ABOUT THIS
65
what is a late deceleration
caused by uteroplacental insufficiency – WE DO WORRY ABOUT THIS (not if it's only 1 time, but if it keeps happening, we worry)
66
what is a variable deceleration
associated with cord compression.
• visually apparent abrupt decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions.
• Shape of variable decelerations may be U, V, or W, or they may not resemble other patterns (usu drop looks DRASTIC)
• These look bad and sound scary BUTbabies can still come out healthy. Only scary IF:
-drops below 60bpm or if they're prolonged (meaning there's a prolapsed cord)
67
when is the onset of an EARLY deceleration
at beginning of a contraction
68
what are nursing interventions for LATE decelerations?
```
– Try changing position (laying on side)
– Hydrate mother
– Provide O2
– May need to resort to C-section if not resolved by other interventions.
-NEED TO PREVENT HYPOXIC DAMAGE TO BABY
```
69
when do late decelerations appear?
- starts AT OR AFTER PEAK (ACME) of contraction
| - It's uniform in shape and not very drastic
70
when do we worry about variable decelerations?
- if they don't recover quickly (if they're very prolonged)
| - if they drop below 60
71
when do we worry about FHR (3 most common times)
decreased variability; prolonged variable deceleration; and late decelerations
72
nursing interventions for variable decelerations
change positions
73
interventions for decelerations
```
-treat probably underlying cause
• Most decelerations can be alleviated by changes in the mother’s position
• Additional interventions:
o Increased IV fluid rate
o Administration of supplemental oxygen
o Modified pushing
o Amnioinfusion
```
74
monitoring of fetal well-being includes: (3 main things)
o FHR assessment
o Watching for meconium-stained amniotic fluid- indicates baby may be in serious distress causing relaxation of anal sphincter)
o Assessment of maternal vital signs and uterine activity
75
what causes pain during 1st stage of labor?
* Progressive cervical dilation
* Intensity and duration of contractions
* Pressure from fetal position
76
what causes pain during 2nd stage of labor?
perineal distention
77
what causes pain during 3rd and 4th stages of labor?
contraction of the uterus
78
What is the nurses role in pain management during labor?
* Offer alternative therapies if pharmaceuticals not desired
* Support decision for pharmaceutical pain relief
* Support changes in decision
* Educate about options
79
What are the pain management options during labor?
* Non-pharmacologic methods (heating pad, massage, etc)
* Systemic Analgesia
* Regional Anesthesia / Analgesia-epidural, spinal
* Local Anesthesia
* General Anesthesia –puts mother to sleep
80
What are examples of non-pharmacological pain management?
* Relaxation breathing
* Touch, Massage and Counter Pressure
* Positioning
* Hydrotherapy – water, baths, tubs
* Acupressure / acupuncture
* Music
* Aromatherapy
* Pain medication is only ONE TOOL we can use
81
what are the 2 primary types of systemic analgesia?
sedatives and narcotics
82
3 important factors to consider when giving systemic analgesia to laboring woman?
* Woman’s medical status
* Labor progress / labor status – some narcotics we don’t want to give too close to delivery time
* Potential effects on fetus
83
When are sedatives typically used in labor and for what reason?
- during latent phase
| - for relaxation and sleep
84
What are common sedative medications given during labor?
* Barbiturates: Seconal and Ambien
* Benzodiazepines: Valium
* H1-receptor antagonists: Phenergan, Vistaril, Benadryl
* Also antiemetics
85
When are narcotics typically given during labor and for what reason?
- during active phase (of 1st stage)
- for pain management
- always have Narcan ready!
86
Nursing responsibilities for sedatives and narcotic administration
* Patient assessment pre and post administration
* Response to medication
* Safety Precautions
* Typical route of administration during labor for all narcotics is IV Push
* Primary risk is post administration respiratory depression
* Risk to fetus for neonatal respiratory depression with multiple doses or timing close to delivery
87
what is the typical route for all narcotics during labor?
IV push
88
common narcotics given during labor
* Stadol (Butorphanol tartrate)
* Nubain (Nalbuphine hydrochloride)
* Sublimaze (Fentanyl)
89
what is the most common regional anesthesia used during labor?
epidurals
90
what is regional anesthesia
* Temporary, reversible loss of sensation
* Prevents initiation, transmission of nerve impulses
* Newer medications combinations: more options
* Types
* Epidural
* Spinal
* Combined epidural-spinal
91
what is epidural anesthesia?
* Injection of local anesthetic into epidural space
* Continuous block
* Complete pain relief
* Common during labor and birth
92
what are some advantages of an epidural? (5)
* Produces good analgesia
* Woman fully awake during labor and birth
* “Walking epidural”- is lighter dose than full epidural
* Continuous technique allows different blocking for each stage of labor
* Dose of anesthetic agent can be adjusted
93
what are some disadvantages of an epidural? (7)
* Maternal hypotension
* Potential FHR late decelerations
* Post-dural puncture leading to: headache, seizures, meningitis
* Cardiorespiratory arrest (rare)
* Onset of analgesia may not occur for up to 30 min– usually sooner
* May slow contractions (esp if done too early): Increased need for Pitocin
* May interfere with fetal descent and rotation
94
what are possible adverse maternal reactions (Mild and common side effects) to anesthetic agents?
* Palpitations tinnitus, headache, metallic taste
* Moderate reactions
* Itching, dizziness, urinary retention
* Severe reactions
* N/V/ hypotension
95
nursing care of women receiving an epidural?
• Assessment
• Pain
• Labor status/Fetal status/Maternal Vital Signs
• Preload with IV fluids (give loading dose/increased IV fluidswhen the epidural relaxes muscles it can decrease venous return to heart, so loading extra fluids can help increase circulating blood flow and prophylactically decrease mother getting hypotension)
o 500 mL to 1000 mL 0.45% NS or LR
• Positioning: Sitting or side-lying
• Intra-procedure management
• Sterile field
• Assist patient to remain still
• Notification and support during contractions
96
how should you reposition a woman post epidural?
* Reposition patient in semi-reclining with lateral tilt for no less than 10 minutes
* HOB elevated 25 degrees
97
how often should you check BP for a woman post epidural?
* BP assessment Q 1-2 (or 5) minutes for 10 minutes
| * BP Q 15 minutes for duration of labor
98
what to do if hypotension occurs (BP
-Increase IV fluids
• Notify anesthesia for administration of ephedrine 5-15 mg IVP
• If late decelerations persist position in Left lateral position, increase IV fluids, anesthesia management
99
For a woman post epidural, what nursing mngt should we consider about the bladder?
-regularly monitor bladder status and ability to self-void
100
What impact on the labor process might an epidural have?
- may slow the labor process after epidural
| - ability to push may be impaired
101
What is a spinal block?
* May be used for Planned Cesarean section
* Immediate onset of anesthesia
* Relative ease of administration
* Smaller drug volume
* Maternal compartmentalization of the drug
* Low failure rate
102
What are potential complications of spinal anesthesia?
* Hypotension
* Drug reaction
* Total spinal neurologic sequelae
* Spinal headache
* Complete or total spinal anesthesia
103
What is a pudenal block?
* Perineal anesthesia
| * Many providers no longer use this technique
104
what are the advantages and disadvantages of a pudenal block?
* Advantages: Absence of maternal hypotension
| * Disadvantages: Urge to bear down may be decreased (but less of
105
When is a pudenal block typically administered?
• Second stage of labor, birth, episiotomy repair
| an impact compared to epidural?)
106
when is local anesthesia used?
for episiotomy repair
107
what are the advantages and disadvantage of local anesthesia?
* Advantage: Least amount of anesthetic agent
| * Disadvantage: Burning sensation with injection
108
What is general anesthesia during labor?
• Induced unconsciousness
109
what are the common indications for general anesthesia during labor?
o Perceived lack of time
o Contraindications to regional
o Failure to successfully insert regional
o Patient refusal of regional
110
possible methods of general anesthesia?
```
• Intravenous injection
o Sodium thiopental (Pentothal)
o Ketamine
• Inhalation of anesthetic agents
o Nitrous oxide
o Low-dose halogenated agents
```
111
Potential complications of general anesthesia?
```
• Fetal depression: Depth and duration
• Uterine relaxation
• Potential for chemical pneumonitis:
o Decrease in gastrointestinal motility
o Acidic gastric secretions
```
