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OB > Exam one class 3 notes > Flashcards

Exam one class 3 notes Flashcards

1
Q

Theories of Labor Onset

A

-Uterine Distention
-Placental Aging
-Hormonal Mediation
1. Progesterone withdrawal
2. Prostaglandin synthesis
3. Corticotropin releasing hormone
-Psychological aspects
-Fetal Adrenals

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2
Q

signs of impending labor (within the next couple of weeks)

A
  • 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
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3
Q

what is lightning

A
  1. The fetus drops into the pelvis
    -Easier to breathe, harder to walk
    -↑ in Braxton-Hicks push the fetus down into ‘ready’ position
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4
Q

why do you have weight loss when its close to labor

A
  • due to ↑ in loose stools
  • Prostaglandins
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5
Q

SROM

A
  • 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
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6
Q

AROM

A

artificial rupture of membranes during labor or to help start labor

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7
Q

PROM

A

pre-labor rupture of membranes
Prior to the onset of labor

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8
Q

pPROM

A

preterm pre-labor rupture of membranes
- pre term ( before 37 weeks) before labor starts

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9
Q

Membrane descriptions

A

-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)

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10
Q

SORM causes you to be at increased risk for

A

-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

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11
Q

how to confirm SROM

A

-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

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12
Q

first stage of labor

A
  • Cervical Change (dilation/effacement)- opening and thinning
  • Onset of regular contractions to complete effacement & dilation:
    -0-10 centimeters dilation (opening)
    -0-100% effacement (thinning)
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13
Q

Early stage of first stage of labor

A
  • 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
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14
Q

active phase of the first stage of labor

A
  • 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
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15
Q

second stage of labor

A
  • Birth of the BABY
  • Full dilation until delivery of the neonate (10 centimeters with descent of presenting part to birth)
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16
Q

Second stage: pushing to birth of the baby

A
  • 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
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17
Q

third stage of labor

A
  • Birth of the PLACENTA
  • Delivery of neonate to delivery of placenta
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18
Q

third stage: birth of the placenta

A
  • 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
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19
Q

fourth stage of labor

A
  • Recovery
  • Postpartum Stabilization: 1st 4 hours after delivery
  • Maternal-newborn bonding & breastfeeding
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20
Q

fourth stage: immediate recovery

A
  • 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
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21
Q

first stage of labor nursing care

A

-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

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22
Q

pre labor (false)

A

-No rupture of membranes
-Irregular
-Space-out when lying down
-NO CERVICAL CHANGE

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23
Q

true labor

A
  1. ↑ in U/C
    -Frequency
    -Duration
    -Intensity (strength)
  2. Progressive cervical dilation, effacement & descent of presenting part
  3. Rupture of membranes
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24
Q

Can you have true labor with membranes intact

A

yes

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25
Q

OB triage

A

-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

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26
Q

the P’s associated with labor and birth

A

-Powers
-Passageway
-Passenger
-Position
-Psyche
-Pee pee
-Placenta
-Partner
-Powerful parents or in-laws
-Pain

  • all of these can affect the progression
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27
Q

powers

A

-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

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28
Q

Contractions

A
  • 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
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29
Q

secondary powers: pushing

A
  1. physiologic pushing (open glottis)
  2. closed glottis pushing
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30
Q

Physiologic Pushing

A

‘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

31
Q

Closed glottis pushing

A

‘Take a deep breath & push to the count of 10’
Less 02 to baby, muscle & placenta

32
Q

passageway: soft tissues

A
  1. 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.)
33
Q

CERVICAL EFFACEMENT

A

0% = 5 CM LONG
100 % = PAPER THIN

34
Q

dilation comparisons

A
  1. 1 cm = cheerio
  2. 3 cm = slice of banana
  3. 4 cm= cracker (ritz)
  4. 7 cm = soda can
  5. 10 cm = bagel
35
Q

passageway: hard structures

A

Remember:
Relaxin acts on joints to allow extra room

36
Q

passenger (fetus)

A
  1. Number: Singleton or multiple babies
  2. Lie
  3. Presentation
  4. Station: Passenger + Passageway
37
Q

Fetal lie

A
  1. Relationship of long axis of fetus (spine) to long axis of mother (spine)
    - Longitudinal: spines parallel to moms
    - Transverse: spine is transverse to moms
38
Q

Fetal Presentation:

A
  1. 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

39
Q

attitude

A

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

40
Q

The Passenger: Attitude- Fetal Presentation: Breech

A

Attitude:
-Complete: knees & hips flexed
-Frank: hips flexed, knees extended
-Footling: oops!
Single footling (incomplete)– 1 knee & hip flexed
Double footling–full extension

41
Q

The Passenger: Position

A
  1. 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
42
Q

the passenger: station

A
  • 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
43
Q

Effacement, Dilation & Descent3 processes in tandem

A
  1. Effacement
    0 – 100%
  2. Dilation
    0 to 10 cm’s
  3. Descent
    -2, -1, 0, +1, +2, +3
44
Q

maternal positions

A

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

45
Q

Psyche

A

Role of Psychological Stress
Role of Readiness
Cultural Beliefs
Support Persons Available

*all of these impact labor and its progression

46
Q

Pee Pee

A
  1. 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)
47
Q

People: Partner, Parents, etc.

A

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!”

48
Q

Pain

A

Labor pain is different from all other pain.
assess how coping with it- dont use number scale

Purposeful
Anticipated
Intermittent
Normal

49
Q

Passageway + Passenger: The Negotiation

A

-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

50
Q

Initial & On-going Nursing Interventions

A

-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

51
Q

2nd Stage of Labor: Nursing Care

A

-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

52
Q

Cardinal Movements

A

Descent
Flexion
Internal rotation once in pelvis
Extension of head
External rotation once head is out
Expulsion

Or “tuck, turn and out”

53
Q

The Passenger: The Fetal Head

A

-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
54
Q

what is placenta accreta

A
  • placenta grown into the muscle layers of uterus
  • increases risk of hemorrhage
55
Q

3rd Stage of Labor: Nursing Care

A
  1. Promote bonding and initiate breastfeeding
  2. 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
  3. Patients with placenta accreta consider:
    -Tranexamic Acid (TXA) after cord clamped
  4. Fundal massage AFTER the placenta is out
    *Placental massage BEFORE the placenta has detached may cause partial separation -> postpartum hemorrhage11
56
Q

what med can you give during third stage of labor to prevent hemorrhage

A

-Pitocin 10-40 U in IV 500-1000 ml LR fast (pump to 999)
-Pitocin 10 Units IM if not IV

57
Q

what meds can you give in the 4th stage of labor to prevent hemorrhage

A

-Pitocin (if wasn’t given in third stage)
-Methergine
-Hemabate
-Cytotec (misoprostol)
-Tranexamic Acid (TXA)

58
Q

methergine dose

A

0.2 mg IM

59
Q

hembate dose

A

250 mcg IM, intracervical, intrauterine

60
Q

cytotec dose

A

800-1000 mcg rectally

61
Q

Tranexamic Acid (TXA) dose

A

1 gram in 50 mL NS IV over 10 minutes: Used in the first 3 hours after birth

62
Q

4th Stage of Labor: Nursing Care

A
  1. Anticipate need for:
    -Suture
    -Sponges
    -New sterile gloves
    -Local anesthesia without epi : 1% Lidocaine if no epidural or its wearing off
  2. Once repair is finished: basin of warm water, washcloths, clean chux, clean gown, water to drink and warm blanket
  3. 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
  4. Urinary catheter to empty bladder as full bladder will impeded the ability of the uterus to contract and prevent hemorrhage
63
Q

hembate contraindications

A
  • asthma
  • may cause massive explosive diarrhea so give with antidiarrheal
64
Q

methergine contraindications

A
  • HTN
65
Q

Lacerations & Episiotomy

A
  1. Lacerations
    -Despite adequate support of the perineum, the fetal head will take the room it needs
  2. 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

66
Q

what is shoulder dystonia

A
  • shoulder stuck between the symphasis and saccrum
67
Q

Laceration Locations

A

-Peri-urethral
-Cervical
-Vaginal wall (sulcus)
-Labial tears
-Clitoral tears
-Perineum

68
Q

first degree laceration

A

vaginal mucosa or perineal skin
- may not need sutures if not bleeding

69
Q

second degree laceration

A

1st degree + bulbocavernosus muscle, transverse & deep transverse muscles & fascia

70
Q

third degree laceration

A

1st + 2nd + anterior anal sphincter

71
Q

fourth degree laceration

A

1st + 2nd + 3rd + anterior rectal mucosa

72
Q

Episiotomies

A
  1. 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
  2. Mediolateral episiotomy
    -deeper muscles of the perineal floor
  3. Increased risk for extensions (3rd or 4th degree)
  4. Associated with longer postpartum pain and dyspareunia (compared to lacerations)
  5. Benefit?!?! History?!?
73
Q

Contemporary Labor Progress

A

-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.

OB (12 decks)

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