Exam one class 3 notes Flashcards
Theories of Labor Onset
-Uterine Distention
-Placental Aging
-Hormonal Mediation
1. Progesterone withdrawal
2. Prostaglandin synthesis
3. Corticotropin releasing hormone
-Psychological aspects
-Fetal Adrenals
signs of impending labor (within the next couple of weeks)
- lightning
- cervical mucous/ bloody show: mucous plug comes out as cervix opens (clump of nasty looking snot like big wad with some blood in it)
- weight loss due to increase in loose stools
- burst of energy
- nesting
- ↑ in Braxton-Hicks contractions (practice contractions)
? Change in sleep cycles
what is lightning
- The fetus drops into the pelvis
-Easier to breathe, harder to walk
-↑ in Braxton-Hicks push the fetus down into ‘ready’ position
why do you have weight loss when its close to labor
- due to ↑ in loose stools
- Prostaglandins
SROM
- spontaneous rupture of membranes ( breaks on own and leaks fluid)
- Always check FHTs!
- Confirm SROM:
1. nitrazine or pH paper
2. ferning
3. pooling
4. Valsalva - Document
AROM
artificial rupture of membranes during labor or to help start labor
PROM
pre-labor rupture of membranes
Prior to the onset of labor
pPROM
preterm pre-labor rupture of membranes
- pre term ( before 37 weeks) before labor starts
Membrane descriptions
-Clear: straw colored +/- flecks of vernix
-Meconium stained: greenish color from fetus’ BM (can be thick and nasty): problematic
-Non-malodorous vs. Malodorous: you can’t miss it
-Amount (big gush or little trickle)
SORM causes you to be at increased risk for
-infection: no longer around baby to protect it
-prolapsed cord: umbilical cord could slip down in front of head if the baby is not down in the pelvis
cord compression -> variable decelerations: fluid not protecting the cord
how to confirm SROM
-nitrazine or Ph paper (will turn blue)
-ferning (ice crystals on slide)
-pooling (are you seeing cervix or spurts of fluid come out when cough)
-valsalva
first stage of labor
- Cervical Change (dilation/effacement)- opening and thinning
- Onset of regular contractions to complete effacement & dilation:
-0-10 centimeters dilation (opening)
-0-100% effacement (thinning)
Early stage of first stage of labor
- cervix = 0-5 cm
- mean 10 hours but this is the most variable phase
- Contractions: may begin irregular; progressively become more regular and closer together
q5-10 min/30-60 secs - woman is Excited “I’ve got this!”
- Loose stools
Backache - Encourage alternating rest/activity
- Distraction
- Hydrate, light meals, shower
active phase of the first stage of labor
- cervix = 6-10 cm
- Contractions: stronger, more regular
q3-5min/60 secs - towards the end of this phase- ~8-9 cm
Contractions: Very strong and close
q1-3 min/ 90secs - More serious/ apprehensive
- Completely engrossed during contractions
- “Wait…this is harder than I expected”
- Completely engrossed all the time, may feel panic, amnesic
- “I can’t do this! HELP ME!”
- Increased bloody show
- Increased pelvic pressure
- Shaking, sweat on upper lip, nausea/vomiting
Increase of bloody show - Active support with position changes, breathing, massage, focus
- Continuous support needed for each contraction, need LOTS of reassurance
second stage of labor
- Birth of the BABY
- Full dilation until delivery of the neonate (10 centimeters with descent of presenting part to birth)
Second stage: pushing to birth of the baby
- Nullip:
Up to 3 hours - Multip: Up to 2 hours
- Epidural: + 1 hour
- Contractions: May space out some
q 2-3 min/60 -90 sec - Actively involved
Pushing with contractions
Resting between contractions - Intense rectal pressure
Urge to push
May have urination/defecation
“Ring of Fire” as head emerges - Continuous support
Increase physical support
Depending on position choices
third stage of labor
- Birth of the PLACENTA
- Delivery of neonate to delivery of placenta
third stage: birth of the placenta
- 5-30 minutes
- Contractions: Uterus contracts, causing placental separation
- Highly distracted by the baby, may not even notice placental birth
- Range of response from elated to exhausted
1. Signs of Placental detachment:
-Change in uterine shape
-Lengthening of cord
-Gush of blood
-Uterine contractions perceived by patient
-Urge to push again - Promote initial bonding
Repair support
Active management-prevent hemorrhage
fourth stage of labor
- Recovery
- Postpartum Stabilization: 1st 4 hours after delivery
- Maternal-newborn bonding & breastfeeding
fourth stage: immediate recovery
- First 4 hours after birth
- Uterus remains in contracted state to minimize blood loss from placental site
- May have the “shakes”
Tired
Hungry
May have perineal pain - Promote bonding
Initiate breastfeeding
Ice packs to perineum
Hygiene
Hemorrhage Prevention
first stage of labor nursing care
-Educate women AND support people
-Encourage ambulation and help with selecting and changing positions (q 30 min)
-Assist with birth ball, squat bar, rocking chair, etc.
-Encourage hydrotherapy: tub/shower
-Teach/perform massage (effleurage, hand/foot, counter pressure, double hip squeeze)
-Hydrate/light meals
-Support non-pharm pain relief techniques (breathing techniques, visualization, warm/cold compresses, etc.)
-Empty bladder (q2h)
-Provide comfortable environment (adjusting lights, music, people, smells, etc. PRN)
-Hygiene (chux, washcloth, mouthwash)
-Support the support people
-Medications PRN
pre labor (false)
-No rupture of membranes
-Irregular
-Space-out when lying down
-NO CERVICAL CHANGE
true labor
- ↑ in U/C
-Frequency
-Duration
-Intensity (strength) - Progressive cervical dilation, effacement & descent of presenting part
- Rupture of membranes
Can you have true labor with membranes intact
yes
OB triage
-Chief Complaint: “I think I’m in labor”; “My water broke”
-Review history- this pregnancy and prior ones; significant medical history
-Brief Physical Exam or systems assessment
-Interpretation of baseline EFM strip
-Labs: CBC and type and screen
-Maternal vital signs
-Abdominal exam/ultrasound for presentation
-Psychosocial: Support, preparation, cultural assessment
-Cervical exam (if membranes intact): Dilation, effacement, station, presenting part
the P’s associated with labor and birth
-Powers
-Passageway
-Passenger
-Position
-Psyche
-Pee pee
-Placenta
-Partner
-Powerful parents or in-laws
-Pain
- all of these can affect the progression
powers
-Role of the uterus is to contract, pushing baby down on to the cervix, then out through the vagina
-Secondary powers are the bearing down efforts of the mother
Contractions
- these gradually push the babies head into the cervix (pushes fetus down and pulls up on the cervix)
- contractions and the pressure of the babies head dilate the cervix
secondary powers: pushing
- physiologic pushing (open glottis)
- closed glottis pushing
Physiologic Pushing
‘Grunting’
More 02 to uterine muscle, placenta & baby
May take more time
- better
- not hold breath
- dont count
- curl back grunt and push baby down
Closed glottis pushing
‘Take a deep breath & push to the count of 10’
Less 02 to baby, muscle & placenta
passageway: soft tissues
- Pelvic Soft Tissue
-Cervix: must come forward, soften, efface (thin) & dilate (open)
-Pelvic Floor Muscles: must be taut enough to help passenger’s head flex to fit through when hits cervix
-Vagina: must be elastic
-Amount of adipose tissue must not impede passageway (in vagina, thighs, etc.)
CERVICAL EFFACEMENT
0% = 5 CM LONG
100 % = PAPER THIN
dilation comparisons
- 1 cm = cheerio
- 3 cm = slice of banana
- 4 cm= cracker (ritz)
- 7 cm = soda can
- 10 cm = bagel
passageway: hard structures
Remember:
Relaxin acts on joints to allow extra room
passenger (fetus)
- Number: Singleton or multiple babies
- Lie
- Presentation
- Station: Passenger + Passageway
Fetal lie
- Relationship of long axis of fetus (spine) to long axis of mother (spine)
- Longitudinal: spines parallel to moms
- Transverse: spine is transverse to moms
Fetal Presentation:
- What enters the pelvis first, “the presenting part”
-Cephalic (Vertex) : 97% births are cephalic & flexed (head first and flexed)
-Breech
-Shoulder (Acromion)
*Malpresentation if not cephalic
attitude
Relationship of the fetal parts to one another
1. flexed: chin on chest, want this
2. military: flat 90 degree angle standing at attention like
3. brow: head extended
4. face: extended with face coming out first
The Passenger: Attitude- Fetal Presentation: Breech
Attitude:
-Complete: knees & hips flexed
-Frank: hips flexed, knees extended
-Footling: oops!
Single footling (incomplete)– 1 knee & hip flexed
Double footling–full extension
The Passenger: Position
- Fetal Position: relationship of fetal presenting part to maternal pelvis
-right or left side of maternal pelvis
-occiput (o)- back of head, mentum (m)- face, sacrum (s)- butt
-anterior (a)- this is toward the pelvic symphysis, posterior (p)- toward sacrum, transverse (t)
-ROP ROA ROT
-LOP LOA LOT (L OC transverse where the occipital is against the ischial spines
-Direct OA (right under pelvic symphysis), Direct OP (right on sacrum)
- Positions other than occiput ARE MALPOSITIONS
- best if: OCCIPITAL IS LOA,OA,OR ROA
the passenger: station
- how hight or low the baby is in relation to ischial spine
- -5 to +5
- further away from the vagina and closer to her head = negative
- as baby engages = 0 (reaches the ischial spines)
- as it moves farther down = positive
- crowning = + 4 or +5 when you can see the babies head and it is sitting on the perineum
Effacement, Dilation & Descent3 processes in tandem
- Effacement
0 – 100% - Dilation
0 to 10 cm’s - Descent
-2, -1, 0, +1, +2, +3
maternal positions
Upright: forward leaning and helps use gravity to move down better
Ambulating
Left lateral
Semi-recumbent
Hands and knees: good to provide counter pressure against lower back and helps move fetus when in OP
Squatting
Sitting on
Birth ball
Psyche
Role of Psychological Stress
Role of Readiness
Cultural Beliefs
Support Persons Available
*all of these impact labor and its progression
Pee Pee
- A full bladder:
-Displaces the presenting part in the pelvis making baby not be able to descend
-Interferes with the uterus’ ability to contract in a functional pattern in all stages
So…
-Empty q2h
-Place a Foley or perform q2 hour straight catheterization with an epidural (may be able to pee on own in bedpan)
People: Partner, Parents, etc.
1.Facilitate positive energy in the room
2.Send others off to “boil water” who are not helpful to get food water or take a break
3.Be a positive addition to the experience
-Model positive behavior
-Intimate experience
-Talk quietly
-Don’t chat/ask her questions when she’s having a contraction
-Tell her “You ARE doing it!”
Pain
Labor pain is different from all other pain.
assess how coping with it- dont use number scale
Purposeful
Anticipated
Intermittent
Normal
Passageway + Passenger: The Negotiation
-The largest diameters of the fetal head must negotiate past the smallest diameters (planes) of the bony pelvis
- diameter is larger from side to side than it is from front to back but the babies head is larger front to back than side to side
- once the baby gets into the inlet of the pelvis and it comes to mid pelvis the diameters chnage and its bigger front to back and smaller side to side
- the baby will rotate so the diameters of head match up with where it is biggest
Initial & On-going Nursing Interventions
-Orient to environment
-Obtain informed consents
-Maintain hydration (PO or IV)
-Provide reassurance & information
-Encourage bladder emptying q 2 hours
-Assess pain or coping; provide comfort measures
-Encourage position changes q 30 min
-Prevent supine hypotension
-Prepare emergency equipment
-Monitor maternal and fetal well-being
2nd Stage of Labor: Nursing Care
-Call MD, CNM
-Provide comfortable environment
-Support her in different positions
-Support non-pharm pain relief techniques (cold cloth, etc.)
-Keep bladder empty
-Get delivery table/warmer ready (need resuscitation gear ready for every birth)- Tell them what you are doing!
-“Police” family & other visitors she might not want in the room
-Pericare, pericare, pericare
Cardinal Movements
Descent
Flexion
Internal rotation once in pelvis
Extension of head
External rotation once head is out
Expulsion
Or “tuck, turn and out”
The Passenger: The Fetal Head
-Still pretty tight, so babies do things to adjust to fit
-Fontanels: Anterior & posterior ‘soft’ spots
-Bones of the cranium are soft
-Sutures between the bones are non-calcified
-All allow soft tissue “swelling” —> caput
and
overriding of the bones —> “molding”
Without damage to the brain
- will round out within 24 hours of birth
what is placenta accreta
- placenta grown into the muscle layers of uterus
- increases risk of hemorrhage
3rd Stage of Labor: Nursing Care
- Promote bonding and initiate breastfeeding
- Prevent hemorrhage (Active Management of 3rd stage—after delivery of anterior shoulder or cord clamped)
-Pitocin 10-40 U in IV 500-1000 ml LR fast (pump to 999)
-Pitocin 10 Units IM if not IV - Patients with placenta accreta consider:
-Tranexamic Acid (TXA) after cord clamped - Fundal massage AFTER the placenta is out
*Placental massage BEFORE the placenta has detached may cause partial separation -> postpartum hemorrhage11
what med can you give during third stage of labor to prevent hemorrhage
-Pitocin 10-40 U in IV 500-1000 ml LR fast (pump to 999)
-Pitocin 10 Units IM if not IV
what meds can you give in the 4th stage of labor to prevent hemorrhage
-Pitocin (if wasn’t given in third stage)
-Methergine
-Hemabate
-Cytotec (misoprostol)
-Tranexamic Acid (TXA)
methergine dose
0.2 mg IM
hembate dose
250 mcg IM, intracervical, intrauterine
cytotec dose
800-1000 mcg rectally
Tranexamic Acid (TXA) dose
1 gram in 50 mL NS IV over 10 minutes: Used in the first 3 hours after birth
4th Stage of Labor: Nursing Care
- Anticipate need for:
-Suture
-Sponges
-New sterile gloves
-Local anesthesia without epi : 1% Lidocaine if no epidural or its wearing off - Once repair is finished: basin of warm water, washcloths, clean chux, clean gown, water to drink and warm blanket
- Prevent hemorrhage
-Pitocin
-Fundal massage
4.Treat hemorrhage
-Pitocin
-Methergine 0.2 mg IM
-Hemabate 250 mcg IM, intracervical, intrauterine
-Cytotec (misoprostol) 800-1000 mcg rectally
-Tranexamic Acid (TXA) 1 gram in 50 mL NS IV over 10 minutes: Used in the first 3 hours after birth - Urinary catheter to empty bladder as full bladder will impeded the ability of the uterus to contract and prevent hemorrhage
hembate contraindications
- asthma
- may cause massive explosive diarrhea so give with antidiarrheal
methergine contraindications
- HTN
Lacerations & Episiotomy
- Lacerations
-Despite adequate support of the perineum, the fetal head will take the room it needs - Episiotomy
-“Cut” from vagina down to rectum or off the the side to make more room performed to facilitate faster delivery of the fetal head due to:
-Maternal exhaustion
-Fetal distress or bradycardia
OR in the case of:
-Vacuum or forceps assisted birth
-Shoulder dystocia (to allow room for hand maneuvers) to change bodies positions
**Lacerations heal as well or better than episiotomies
what is shoulder dystonia
- shoulder stuck between the symphasis and saccrum
Laceration Locations
-Peri-urethral
-Cervical
-Vaginal wall (sulcus)
-Labial tears
-Clitoral tears
-Perineum
first degree laceration
vaginal mucosa or perineal skin
- may not need sutures if not bleeding
second degree laceration
1st degree + bulbocavernosus muscle, transverse & deep transverse muscles & fascia
third degree laceration
1st + 2nd + anterior anal sphincter
fourth degree laceration
1st + 2nd + 3rd + anterior rectal mucosa
Episiotomies
- Midline episiotomy (MLE): more common
-same structures as a 2nd Degree Laceration
- straight line from vagina to rectum
- may increase risk for 3rd or 4th degree extensions - Mediolateral episiotomy
-deeper muscles of the perineal floor - Increased risk for extensions (3rd or 4th degree)
- Associated with longer postpartum pain and dyspareunia (compared to lacerations)
- Benefit?!?! History?!?
Contemporary Labor Progress
-Rate of dilation in the active phase is much slower than that described by Freidman
-Maximum slope in rate of change often doesn’t start until 6 cm
- with new guidelines: 6 cm is when active phase of labor begins.
