Exam 3 Flashcards
oxytocics
agents that stimulate uterine contractions to promote labor
tocolytics
uterine relaxants
agents used for cervical ripening
cervadil and cytotec
misoprostol
- most widely used agent for cervical ripening
- preferred agent for controlling postpartum hemorrhage
- can cause uterine contractions
what does oxytocin target?
the uterus
does oxytocin ripen the cervix?
no; don’t give to someone with an unripened cervix
when should we not use pitocin?
- fetal lungs have not matured
- patient has had previous c-section or uterine surgery
- patient has active genital herpes
- cephalo-pelvic disproportion
betamethasone
steroids given to accelerate fetal lung maturity
main purpose of magnesium sulfate
used to prevent seizures
signs of magnesium toxicity
- respirations < 12 per minute
- significant drop in maternal pulse/BP
- hyporeflexia or absent reflexes
- urine output < 30 mL/hr
- serum mag levels > 9.6
- fetal tachycardia or bradycardia
interventions for mag toxicity
- discontinue mag sulfate
- call provider
- administer calcium gluconate (antidote)
- monitor maternal and fetal status
signs of impeding labor
- lightening: fetus settles into pelvis (10-14 days prior to labor for nulliparas and unpredictable for multiparas)
- braxton hicks contractions
- cervical changes: softening of cervix
- bloody show: pink tinged mucus secretion when mucus plug is expelled (occurs when cervix ripens and starts to dilate)
- nesting: occurs 24-48 hours before labor starts
do braxton hicks contractions cause cervical changes?
no
what is important to remind women about nesting?
forewarn them not to over-exert ~ trauma can lead to abruption
true labor
- regular contractions, increase in frequency, intensity, and duration
- cause cervical dilation and effacement
- does not decrease with walking, showering, etc.
what kind of assessment is cervical dilation?
subjective
what are the 5 P’s of labor?
- passageway
- passenger
- power
- position of mother
- psychological factors
what does the passageway include?
- pelvis
- cervix
- vagina
- external perineum
who is the passenger during labor?
the fetus
open suture lines
- membranous space between bones
- sagittal suture line: between parietal bones on top of head
- coronal suture line: between frontal bone and two parietal bones on front of head
- lamdoidal suture line: between parietal bones and occipital bone on the back of head
anterior fontanel
- junction of coronal and sagittal suture line
- also called “bregma”
- diamond in shape
posterior fontanel
- junction of sagittal and lamdoidal sutures
- triangular in shape
landmarks of fetal skull entering the pelvis
- occiput: area over occipital bone
- sinciput: area over frontal bone
- mentum: chin
best position for fetal skull to enter pelvis
occiput
what part is the widest diameter of the skull?
anterior posterior diameter
transverse diameter
- also called biparietal diameter
- approximately 9.25 cm across
attitude of fetal presentation
describes degree of flexion fetus assumes as well as position of body parts in relation to each other
best attitude for fetus to be delivered
full flexion
moderate flexion
- military style
- chin is not flexed forward
- not usually a problem for delivery
partial extension
- brown presentation
- head is in partial extension
complete extension
- face presentation
- back is arched
- neck is extended
- not successful vaginal delivery, cervix won’t dilate since not a lot of pressure
three types of fetal presentation
cephalic, breech, shoulder
cephalic fetal presentation
“vertex” ~ head down first
breech fetal presentation
a bunch of parts presenting first
how are breech presentations delivered?
via c-section
engagement
presenting part is settled into pelvis and is at level of ischial spines (zero station); determined during vaginal exam
what are the 3 numbers obtained during a SVE?
cm dilated, % effaced, station
Station
relationship of presenting part of fetus to level of ischial spines, when presenting part is at level of ischial spine = 0 station
how do we chart fetal presentation and position?
- maternal pelvis: right or left
- landmark of fetal presenting part: occiput (O), mentum (M), sacrum (S), scapula (Sc)
- maternal pelvis: anterior, posterior, transverse
what will we always see O in for the fetal presentation?
vaginal deliveries
what does LOA mean?
occiput on maternal left, pointing anterior
fastest type of deliveries have what fetal presentation?
ROA or LOA
what kind of deliveries are longer and more painful?
posterior deliveries ~ ROP or LOP (sunny-side up)
four methods to determine fetal position
- abdominal inspection and palpation (leopold’s)
- vaginal exam
- auscultation of FHT (over spine is best way to hear)
- U/S (most accurate)
labor assessment acronym
B - bladder (keep empty)
U - uterine contractions
R - rupture of membranes (causes stronger and harders contractions)
T - temperature (portal of entry from rupture
H - heart tones (fetal)
S - sterile vaginal exam
where does the power come from in uterine contractions?
the fundus of the uterus
how long should uterine contractions occur and last?
- every 2-5 minutes
- should last less than 90 seconds
- should have at least 30 seconds of rest from end of one to beginning of next
frequency of uterine contractions
time between beginning of one contraction to beginning of next
duration of uterine contractions
measured from beginning of contraction to completion
intensity of uterine contractions
strength of contraction
how is intensity of uterine contractions determined?
- by IUPC or by palpating
- palpating fundus can show “indentability” (mild are easily indented and strong cannot be indented)
what must occur for IUPC to be placed?
membranes must be ruptured ~ risk of infetion
what is the only accurate to determine true intensity of contractions?
IUPC
what are uterine contractions responsible for?
- effacement of cervix
- dilation of cervix
- descent of fetus
stages of labor and birth
- first stage: from onset of true labor to complete dilation
- second stage: from complete cervical dilation to birth of baby (pushing stage)
- third stage: from birth of baby to birth of placenta
- fourth stage: postpartum
three phases in the first stage of labor
- latent
- active
- transitional
latent phase
- begins with onset of regular contractions
- mild and short contractions: last about 30-45 seconds
- effacement occurs
- dilation 3-4 cm
- can still walk and talk
- avoid giving analgesia at this time because it can slow or stop contractions
active phase
- dilation progresses form 4-8 cm
- stronger and longer contractions lasting 60 seconds
- frequency of contractions is usually every 3-5 minutes
- painful
- cannot talk through
- good time to give analgesics IV or IM
goals of pharmacologic treatment during labor
- relax and relieve discomfort
- minimal effect on uterine contractions
- minimal effect on ability to push
- minimal effect on fetus
anesthesia
loss of feeling
analgesia
pain control
how far can an epidural be given?
through stage 2
epidural
- blocks nerve pathways
- temporary loss of sensation
- women are not aware of their contractions, or may just feel slight pressure
- will not alter uterine contractions
- may effect urge to push
most common complication from an epidural
maternal hypotension
transitional phase
- dilation from 8-10 cm
- strong and long (60-90 seconds)
- frequency every 2-3 minutes
- usually a rapid phase of labor
- full dilation and complete effacement occur
- very emotional, very moody
- may begin to feel urge to push (say they feel like they have to have a BM)
what phase of labor is usually not a good time for analgesia?
transitional phase
assessments once membranes rupture
- color, odor, time, amount, fetal respose
- fetal HR and temperature every 2 hours
how fast should we try to deliver after ROM?
within 24 hours ~ if not, she will be induced
SROM
spontaneous rupture of membranes
AROM
artificial rupture of membranes
PROM
premature rupture of membranes ~ may occur before onset of contractions
main concerns of ROM
- infection
- prolapsed cord
what do we look for with fetal heart monitoring?
fetal well-being
what can we use to determine fetal position?
leopolds maneuver
where is the best place to listen for fetal heart sounds?
the back
baseline FHR range
110-160 BPM
causes of fetal tachycardia
- early fetal hypoxia
- fetal anemia
- maternal dehydration
- beta sympathomimetic drugs (terbutaline)
- intrauterine infection
- maternal hyperthyroidism
causes of fetal bradycardia
- late fetal hypoxia
- maternal hypothermia
- maternal hypotension
- prolonged umbilical cord compression
- fetal arrhythmia
variability
irregular waves or fluctuations in baseline FHR
no variability
amplitude range undetectable
minimal variability
< 5 BPM
moderate variability
6 - 25 BPM
marked variability
> 25 BPM
short term variability
- beat to beat
- only accurately measured with internal electrode
long term variability
rhythmic fluctuations
causes of decreased variability
- hypoxia and acidosis
- drugs such as demerol, valium, vistaril
- fetal sleep cycle
- fetus less than 32 weeks gestation
causes of increased variability
- early mild hypoxia (compensation)
- fetal stimulation
VEAL CHOP
Variable Decelerations -> Cord Compression
Early Decelerations -> Head Compression
Accelerations -> Okay!
Late Decelerations -> Placental Utero Insufficiency
interventions of early decelerations
- does not require intervention
- benign
- may indicate CPD if they occur early in labor
- peak of contraction and deceleration match up
are late decelerations concerning?
yes! you need to notify HCP
interventions for late decelerations
- does not necessarily warrant immediate delivery
- does warrant close observation
TTOIV
Turn of Pitocin
Turn patient on her side to increase perfusion to placenta
Oxygen to mom: 10-15 L
IV fluids wide open
varibale decelerations
sharp drop from baseline and sharp return to baseline
interventions for variable decelerations
- continue monitoring (usually benign)
- change maternal position
- administer oxygen
- administer amnioinfusion if ordered (LR or NS)
if there are prolonged decelerations, what should you do?
TTOIV
what do we check for with a SVE?
dilation, effacement, station
when should we not do SVE?
if there is significant vaginal bleeding
effacement
thinning and shortening of cervix
second stage of labor
full dilation to birth of baby ~ verified with SVE
crowning
when you start to see baby’s head with pushes
episiotomy
- surgical incision made to prevent a tear
- incision can be a midline episiotomy (straight up and down) or mediolateral episiotomy (out towards legs)
advantages of midline episiotomy
- heals more quickly
- less blood loss
- less discomfort
mediolateral episiotomy
- if it tears, it won’t tear into rectum
modified ritgen maneuver
used to control birth of head using hands
third stage of labor
begins at time baby is born and ends with delivery of placenta
how long does placenta take to deliver after birth of baby?
about 5 minutes
signs of placental separation
- lengthening of umbilical cord
- slight gush of vaginal blood
- change in shape of uterus
expulsion of placenta
- mom starts to gently push
- provider tugs gently
2nd leading cause of infant mortality
preterm labor and birth
initial instructions to prevent preterm labor
- empty bladder
- drink 2-3 glasses of fluid
- lie down on side for 1 hr
- if ctxs q10 minutes or less after 1 hr. call Dr.
when should you call the doctor in any preterm labor?
- any vaginal bleeding
- leaking of fluid
- malodorous discharge
tocolytics
only fairly effective at preventing PT birth; works directly on uterus
why do we prevent birth for 24-48 hours?
- transfer to facility with NICU
- treat an infection/medical condition
- administer corticosteroids to stimulate
- fetal lung maturation
- betamethasone
what does magnesium sulfate do for preterm labor?
- CNS depressant
- relaxes smooth muscles
- decreases calcium in cells
nifedipine (procardia)
- calcium channel blocker ~ decreases calcium in cells
- commonly used as antihypertensive agent ~ may cause hypotension
terbutaline
- relaxes smooth muscles
- bronchodilation
goal to promote fetal lunch maturity
administer at least 24 hours before delivery
what cervix dilation shows inevitable preterm birth?
> 4 cm ~ transfer to high risk hospital
care during inevitable preterm labor and birth
- little or no systemic analgesia
- left side, continuous monitoring
- delay AROM until >= 6cm
- low dose pitocin
- generous episiotomies or C/S delivery
- neonatologist/peds present
- third stage longer ~ small placenta does not readily separate
PPROM
rupture of membranes before labor starts - at least 1 hours
risks of PPROM
- chorioamnionitis
- cord prolapse
induction of labor acronym
Cooks balloon
Oxytocin (pitocin)
Misoprostol (cytotec)
Membrance stripping
AROM
Nipple stimulation
Dinoprostone (cervidil)
amniotomy
- AROM
- only used to induce if cervix is ripe and head is engaged
greatest risk of AROM
infection
contraindications to oxytocin administration
- CPD
- prolapsed cord
- transverse lie
- placenta previa
- prior classic uterine incision
- active genital herpes
- invasive caner of cervix
if concerned about pitocin, what should we do?
stop it and TTOIV
when should a forceps delivery never be used?
on a fetus that is unengaged
dystocia
long, difficult, or abnormal labor
causes of dystocia
- too much pitocin
- maternal fatigue, dehydration, fear
- analgesics/anesthetics
- uterine abnormalities
management of hypertonic dystocia
- reduce anxiety
- comfort measures
- analgesics for sedation
- IV fluids and I/O
- if pattern continues or fetal distress -> C/S
main cause of hypotonic dystocia
excessive narcotics, analgesics, anesthetics in early labor, especially before 3-4 cm dilation
preciptuous labor
labor that lasts < 3 hours
if fetal hypoxia is >5 minutes in a prolapsed umbilical cord, what can happen?
can cause CNS damage or fetal death
if prolapse of umbilical cord an emergency?
yest
how to manage a prolapsed umbilical cord
relieve pressure on cord!
- place fingers on presenting part and push forward
- position mom in knee-chest or extreme trendelenburg position
- if cord is evident, cover with warm, wet sterile towel (if not in hospital)
shoulder dystocia
head is born, but shoulder cannot pass under pubic arch
effects of aging placenta
- 800 mL by 40 weeks
- 400 mL by 42 weeks
- can lead to cord compression/fetal hypoxia
- placental starts to hard/calcify
if there is meconium fluid and oligo, what can be done?
amnioinfusion
