Exam 3 (module 9-11) Flashcards
Forces of labor: 5 P’s
powers, passageway, passenger, position, psyche
powers (contractions)
purpose is to dilate cervix and aid in expulsion; measured by frequency, duration, and intensity; mild = nose, moderate = chin, strong = forehead
IUPC
intrauterine pressure catheter to assess intensity of contractions; mild <40 mmHg, moderate40-70 mmHg, strong >70 mmHg
passageway
route the fetus must travel; maternal pelvis, maternal soft tissue (cervix), gynecoid it true female pelvis (~50% of women)
dilation and effacement
effacement happens first by thinning of cervix then cervix dilates
passenger
fetal attitude: relationship of fetal body parts to others (flexion or extension, you want flexion); fetal lie: relationship of infant spine to mothers spine (horizontal or longitudinal, you want longitudinal
types of cephalic presentations
~95% of the time; mentum (head extended back), brow (head extended slightly back), sinciput (head neutral, vertex/occiput (fully flexed, chin tucked)
types of breech presentations
~3-4% of the time; frank (feet by face and legs crossed, full (feet crossed low; criss-cross apple sauce), footling (one foot extended)
shoulder presentation (transverse)
~1%; not favorable for vaginal delivery; requires C-section
station
relation of presenting part of head to maternal pelvis; zero station is when presenting part engaged in pelvis at level of ischial spines; - is floating
fetal position
relation of presenting part to maternal pelvis; 3 letters; direction the presenting part faces (either mother L or R)
presenting parts of fetus
o = occiput (most common), m = mentum (chin, fetal head extended),
Sa = sacrum (breech presentation),
A = acromion process (transverse presentation)
relationship to pelvis
a = anterior, p = posterior, t = transverse
leopold maneuvers
done to determine fetal presentation and position
4 maneuvers of leopold
1st maneuver: superior side of fundus; 2nd maneuver: each side of uterus; 3rd maneuver: suprapubic area; 4th maneuver: fetal attitude and extension (only in cephalic position)
maternal assessment (antepartum)
focused assessment to determine condition of mother/baby, maternal history, maternal testing/prenatal labs
maternal history consists of
allergies, current/recent meds, pregnancy history (previous pregnancies, type of delivery, complications)
maternal testing/prenatal labs consists of
blood type/Rh, hematocrit/hemoglobin, GBS, Hep B, HIV, ultrasonography, NST
maternal physical assessment
vital signs, uterine activity, bladder status/I&O, bloody show/bleeding, membrane status, response to labor, maternal discomfort, cultural needs
fetal physical assessment
fetal presentation and station, FHR, fetal gestation and growth
external fetal heart rate monitor
toco
internal fetal heart rate monitor
requires rupture of membrane; fetal scalp electrode to measure HR and IUPC to measure contractions
Fetal heart trace
each box = 10 seconds; dark line to dark line = 1 minute
what to look for in FHR tracing
baseline FHR, variability, accelerations, periodic changes/decelerations
types of periodic changes or decelrations
early = head compression, late = placental insufficiency, variable = cord compression
FHR baseline normal
110-160
FHR tachycardia
mild: 161-180; severe: >180
FHR bradycardia
below 110bpm for >10 minutes; mild: 100-109; moderate: 70-99; severe <70
minimal variability
less than or equal to 5 bpm change
4 responses to periodic changes
accelerations, early decelerations, late decelerations, variable decelerations
marked variability
> 25 bpm
Periodic changes in FHR d/t
response to contractions and fetal movement, short term changes in rate rather than baseline, last few seconds to 1-2 minutes
FHR accelerations
increase of 15bpm and lasts 15 seconds x2; used for stress test (want accelerations), typically good reaction between SNS and PNS
Early decelerations FHR
mirror image; d/t contractions causing pressure on skull;nursing interventions do not want this to happen
late decelerations FHR
occur late in contraction, indicative of fetal hypoxia; nursing interventions: need to stop oxytocin and change pt to left lateral in order to promote perfusion
variable decelerations FHR
occur anytime during contraction, secondary to cord compression; nursing interventions: relieve compression of cord, change position, fix cord prolapse, give O2, stop pitosin
VEAL CHOP
variable = cord
early = head compression
acceleration = oxygenated fetus
late = placental problems
FHT categories
category I - normal and no intervention is required; category II - requires evaluation and continued monitoring; category III - predictive of abnormal fetus acid base status and require prompt evaluation and interventions
respiratory acidosis result of
fetal stress
initiation of labor factors
uterine stretching, oxytocin release, decreased progesterone, increased prostaglandin secretion, cortisol release, placental aging
true definition of labor
- presence of regular phasic uterine contractions increasing in frequency and intensity 2. progressive cervical effacement and dilation (blood show may or may not be present)
signs of impending labor
lightening, increased vag. d/c, increased energy (nesting), GI symptoms (N/V, diarrhea), cervical change, bloody show, ROM, lower back pain, weight loss, uterine contractions
false labor
irregular contractions, no regular pattern, discomfort in lower abd. and groin, show not present, no cervical change, contractions might stop with walking or rest; sedation will stop or decrease contractions
active labor starts at
4cm dilation; doctors want contractions 5 min apart and regular
1st stage of labor
from initiation of labor until full effacement and dilation
first stage of labor consists of
early labor, active phase, transition phase
early labor (latent phase)
0-3cm, mildly uncomfortable, every 10-30 minutes for 20-40 seconds, then every 3-7 minutes for 30-40 seconds, excited and sociable; signs of progress when contractions are longer, stronger, and closer together
active phase labor
dilation 4 to 7cm, fetal descent, contractions are stronger, last longer, closer together, every 2-5 minutes x 40-60 seconds, increase in anxiety and discomfort is normal, instinctual behavior
transition phase labor
short but intense, dilation 8 to 10cm, painful intense contractions every 1.5-2 minutes for 60-90 seconds, very irritable and may lose control, N/V is common
second stage of labor
descent and expulsion of fetus; from full dilation to birth of baby; overwhelming urge to push; increased feeling of control; pressure feeling
third stage of labor
expulsion of placenta: detaches about 5-10 minutes after birth (up to 30); signs of occurring are uterus becomes smaller, blood gushes, and cord lengthens
fourth stage of labor
immediate postpartum: first 4 hours following birth, may experience chills, afterpains, tiredness; assess for hemorrhage
psyche (emotional response)
influenced by pain, parity, age, culture, coping mech., relaxation methods, emotional factors, other discomforts, length of labor, intensity of labor, maternal positions, fetal position
pain during birth d/t
tissue anoxia, stretching of cervix (dilation), pressure on pelvic floor
non-pharmacological pain management
cutaneous stimulation strategies, sensory stimulation strategies, cognitive strategies
cutaneous stimulation strategies
counterpressure, effleurage (light massage), therapeutic touch and massage, walking, rocking, changing positions, application of heat/cold, transcutaneous electrical nerve stimulation, acupressure, hydrotherapy
sensory stimulation strategeis
aromatherapy, breathing techniques, music, imagery, use of focal points
cognitive strategies
childbirth education, hypnosis, biofeedback
pharmacological pain management
analgesia-partial or full relief of painful sensations using medication that decreases or alters pain perception; anesthesia-partial or complete loss of sensation with or without loss of consciousness
systemic analgesics
can slow down labor, can affect fetus; opioids- morphine, meperidine, fentanyl, stadol, nubain; inhaled analgesia- nitrous oxide; tranquilizers- vistaril, phenergan
regional anesthesia/analgesia
epidural- need to watch for hypotension; spinal- risk of spinal headache; general anesthesia- potential fetal distress
pre-term labor
diagnosis defined as regular contractions occurring between 20-37 weeks gestation followed by one of the following: progressive cervical change, cervical effacement >80%, dilation >1cm
risk factors for preterm labor
intrauterine infection/inflammation, decidual hemorrhage, excessive uterine stretch a9d/t multiples or polyhydramnios), maternal or fetal stress, demographic risks, medical risks in current pregnancy/predating pregnancy, environment/behavioral/psychosocial risks
biochemical marker predicting preterm labor
fetal fibronectin produced during pregnancy and acts as biological glue attaching fetal sac to uterine lining; cannot be detected between 24 and 34 weeks of pregnancy
warning signs of pre-term labor
uterine cramping, backache, pressure in pelvis, increase or change in vaginal discharge, abd. cramping, change in fetal movement
tocolytic therapy
process of administering drug for purpose of inhibiting uterine contractions; no drugs for pre-term labor but main goal is to prolong birth enough to administer corticosteroids for fetal lung maturity
tocolytic contraindications
severe HTN or preeclampsia, evidence of fetal compromise, fetal death, fetal anomaly incompatible with life, mature fetal lungs
tocolytics
magnesium sulfate, beta-adrenergic agonist, Ca channel blockers (nifedipine/procardia), prostaglandin inhibitors
Terbutaline MOA
Beta-agonist, promotes smooth muscle relaxation, my be given IV or SQ, rapid onset of action, no better than mag. for PTL but higher incidence of maternal side effects
side-effects of terbutaline
maternal tachycardia, pulmonary edema, fetal tachycardia, hyperglycemia, hypokalemia, hypotension, cardiac insufficiency, arrhythmias, myocardial ischemia, maternal death
Magnesium sulfate MOA
prevents reflux of calcium into myometrial cells causing uterine relaxation (CNS depressant); used primarily for fetal neuroprotection instead of tocolytic (still used as tocolytic but not primarily)
side effects of mag sulfate
maternal “flushing” or warmth, headache, nausea, blurry vision
mag. sulfate toxicity
loss of deep tendon reflexes (serum~8mg/dl), mental status change/change in LOC, respiratory depression, pulmonary edema, profound hypotension, cardiac arrhythmias
magnesium sulfate antidote
calcium gluconate 1 gram IV over 3 minutes
indomethacin
powerful anti-inflammatory that inhibits prostaglandin synthesis and readily crosses placenta; used in conjunction with other tocolytic therapy; effective in prolonging pregnancy 48-72 hours
indomethacin risk
risk of premature closure of fetal ductus arteriosus if administered after 32nd week
nifedipine
calcium channel blocker, smooth muscle relaxer, potent vasodilator (monitor for hypotension)
nifedipine side effects
hypotension, flushing, headache, tachycardia, nausea, dizziness, palpitations
promotion of fetal lung maturity in pre term labor
betamethasone or dexamethasone are both corticosteroids that stimulate lung maturity
Pre-term labor risk factors
infection of urinary tract/vagina/chorioamnionitis, previous PTB, multifetal pregnancy, hydramnios, <17 or >35, low socieconomic status, smoking, substance abuse, domestic violence, hx of multiple miscarriages/abortions, DM, HTN, lack of prenatal care, recurrent premature cervical dilation, placenta previa/abruptio placentae, preterm PROM, short interval between pregnancies, uterine abnormalities
dystocia
abnormal, long, or difficult labor or delivery
dysfunctional labor
uterine contractions do not dilate cervix, efface cervix, or descend presenting part
hypotonic contractions
coordinated, infrequent, weak, brief, mildly painful contractions that do not efface, dilate, or cause descent
tachysystole
> 5 uterine contractions in 10 minutes averaged over 30 minutes with less than 60 seconds of relaxation
tachysystole potential complications
fetal deoxygenation, uterine rupture
cephalopelvic disproportion
fetal head larger than maternal pelvic diameter, lack of fetal descent in presence of strong contractions, labor usually prolonged
dystocia assistance devices
forceps, vacuum extraction
vacuum extraction risks
caput seccedaneum, cephalohematoma, intracranial hemorrhage
forceps risks to infant
soft tissue injury, facial palsy, skull fracture
forceps risk to mom
injury to cervix, vagina, bladder, rectum, increase in pain
labor enhancer
pitocin (oxytocin)- stimulates/increases contractions but does not efface or dilate
pitocin cautions
fetal distress, prematurity, over-distension of uterus
pitocin side effects
increased contractions, increased resting tone, increased HR, decreased BP, water intoxication, fetal tachycardia
pitocin side effects
fetal hypoxia, uterine rupture, placental abruption, pph, fetal hypotension
cesarean section
32% of all births
pfannenstiel incision
most common; horizontal
classic incision
increased risk of uterine rupture in subsequent pregnancies and labor
cesarean section post-op surgical care
monitor: pain, respiratory function, I&O, incision, bowel function, circulation, psychological response
intrapartum emergencies
shoulder dystocia, cord prolapse, amniotic embolism
shoulder dystocia
impaction of anterior fetal shoulder behind maternal symphysis pubis
shoulder dystocia risk factors (what makes you more at risk)
fetal macrosomia (>4000g or 9lbs), maternal diabetes, maternal obesity, previous shoulder dystocia
cord prolapse
obstetrical emergency when umbilical cord drops down alongside or in front of presenting part of fetus; circulation can be reduce or stopped causing physiologic effects of fetus
nursing care of prolapsed cord
get pressure off cord by placing in tredelenberg, knee to chest, or elevate part of fetus on cord with sterile glove
if cord is visible…
avoid handling and cover with warm, sterile, saline-soaked gauze; assess FHR continuously
amniotic fluid embolism
escape of amniotic fluid into maternal circulation; usually enters through open sinus at placental site; usually fatal to mother
signs and symptoms of amniotic fluid embolism
dyspnea, chest pain, cyanosis, shock
therapeutic interventions of amniotic fluid embolism
deliver the baby, provide cardiovascular and respiratory support of mother
postpartum complications
pph, breast feeding complications, postpartum infections: UTI/endometritis/mastitis/wound infection, thrombophlebitis, pulmonary embolism, postpartum psychiatric disorders
postpartum hemorrhage
more than 500mL after vaginal and more than 1000mL after cesarean; any amount of bleeding that places mother in hemodynamic jeopardy
early pph
first 24 hours after delivery; usually caused by uterine atony
late/delayed pph
24 hours to 6 weeks postpartum; usually caused by retained placental tissue
4 T’s associated with PPH
tone, tissue, trauma, thrombin
Tone PPH
altered muscle tone d/t overdistention, prolonged or rapid labor, infection, anesthesia/medications that inhibit contractions like nifedipine
Trauma PPH
cervical lacerations, vaginal lacerations, hematomas of vulva, vagina, or peritoneal areas
Tissue PPH
retained placental fragments, uterine inversion, subinvolution
Thrombin PPH
disorders of clotting mechanism
Risk factors for PPH
Uterine overdistention (large infant, polyhydramnios), grand multiparity, anesthesia/MgSO4, trauma, hypo/hypertonia, oxytocin admin., prolonged labor, maternal anemia, maternal hemorrhage
signs of impending hemorrhage
excessive bleeding (>2 pads in 30min-1hr); lightheadedness, nausea, visual disturbances, anxiety, pale, clammy skin, hematomas, increasing P and R but same or lower BP, peripheral cyanosis
MAP to perfuse kidneys, brain, coronary arteries
atleast 60
interventions for PPH
inspect placenta, avoid over-manipulation of uterus, fundal massage, empty bladder, oxytocin/cytotec/methergine/hemabate, monitor blood loss (weigh pads), frequent VS, cross-match blood, start IV
postpartum infections
pueperal sepsis, pathogens,
puerperal sepsis
any infection of genital canal withing 28 days after abortion or birth; >100.4 temp on atleast 2 of 10 day following first not including first 24 hours OR 101 and higher within first 24 hours
common infections following birth
endometritis, wound infections, UTI, mastitis
preconception infection risk factors
HX of venous thrombosis/UTI/mastitis/pneumonia, DM, alcoholism, drug abuse, immunosuppression, anemia, malnutrition
endometritis
involves endometrium, decidua, adjacent myometrium of uterus; causes lower ABD tenderness/pain, temp., chills, foul-smelling lochia, tachycardia, subinvolution
endometritis interventions
broad spectrum antibiotic, analgesia, emotional support, watch for septic shock, increase fluid intake, monitor vitals/lab values/ proper positioning to drain urine
wound infections
surgical incision is most common site, episiotomy/laceration occur less commonly
wound infection interventions
aseptic wound management, frequent perineal pad changes, good hand washing, administer antibiotics, analgesics
breast complications following birth
engorgement, sore/cracked nipples, blocked ducts, mastitis
mastitis
caused by S. aureus (often from hands of mother/caregivers entering through crack in nipple); infected fissure causes edema and obstructs milk flow in lobe; engorgement and stasis frequently precede
therapeutic management of mastitis
antibiotics and decompression by breastfeeding/pumping; bedrest during acute phase; fluids and analgesics for discomfort
risk factors for developing UTI
urinary catheterization (straight cath recommended over indwelling to prevent CAUTI), frequent cervical exam in labor, epidural anesthesia, genital tract injury during delivery, cesarean birth, atonic bladder and urethra post delivery
symptoms of lower UTI
dysuria, frequency, urgency, suprapubic pain, low-grade fever, hematuria, cloudy urine, foul smell
symptoms of upper UTI
pyelonephritis, develops day 3-4, chills, fever, costovertebral angle tenderness, N/V
treatment of UTI
vital signs every 4 hours, encourage fluid intake, monitor I&O, antibiotics, antipyretics, antispasmodics, antiemetics, encourage rest
thromboembolic disease
superficial thrombosis, deep thrombosis, pulmonary embolism
superficial thrombosis
involves veins of superficial saphenous system
deep thrombosis
occurs most often in lower extremities; involvement varies but can extend from foot to iliofemoral region
pulmonary embolism
complication of DVT; clot travels to lung
risk factors for thrombosis
normal changes in coagulation during pregnancy, hx of thromboembolic disease/varicosities, increased parity, obesity, advanced maternal age, immobility, c-section, tissue trauma, blood type other than O, dehydration
postpartum thrombophlebitis assessment
hot, red, edematous areas of lower extremities or groin area, homans signst
postpartum thrombophlebitis treatment
superficial- analgesics, bedrest, elevation; deep- anticoagulants
pulmonary embolism symptoms
sudden onset dyspnea, sweating, pallor, chest pain, cyanosis, confusion, tachypnea, cough, hemoptysis, increased temp., increased jugular pressure, sense of impending death
postpartum psychological compications
postpartum depression and postpartum psychosis
postpartum depression
occurs in 10-20% of all postpartum patients
postpartum depression symptoms
intense pervasive sadness, mood swings, intense fear. anxiety, anger, unable to care for self or infant, irritability that may lead to violence, rejection of infant, obsessive thoughts
treatment of PPD
guided by severity; psychotherapy, medication, electroconvulsive therapy (ECT), combination therapy
postpartum psychosis
syndrome characterized by depression, delusions, bizarre/irrational behavior, thoughts of harming infant or self; may require psychiatric hospitalization; antipsychotics/mood stabilizers like lithium re good choice
treatment of pulmonary embolism
elevate head of bed, give O2 (8-10L), narcotics, clot busters
prevention of postpartum thrombophlebitis
inflatable compression devices, encourage early ambulation, antiembolism stockings for c-section mothers, assess for thrombus formation
