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Intrapartum Flashcards

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1
Q

Definition of Intrapartal Period

A

From contractions that cause cervix to dilate, through delivery of neonate & placenta, +
first 1-4 hours after delivery

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2
Q

Theories of Labor Onset: Progesterone Deprivation Theory

A

Pregnancy: both estrogen and progesterone increased (from placenta), but ratio of
estrogen low: progesterone high
Estrogen stimulates, progesterone relaxes

Just before labor: ratio shifts

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3
Q

Theories of Labor Onset: Oxytocin Theory

A

Oxytocin stimulates uterine contractions, but uterus not sensitive until closer to term

Therefore, unlikely oxytocin works alone to cause labor onset

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4
Q

Theories of Labor Onset: Fetal Endocrine Control Theory

A

Anencephalic fetus: low levels fetal steroids; pregnancy prolonged
? if steroids cause release of precursors to prostaglandins, which stimulate uterus to
contract

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5
Q

Theories of Labor Onset: Prostaglandin Theory

A

Prostaglandins: lipid substances
Induce contractions at any point in pregnancy
Used for:
1. IUFD (intrauterine fetal demise); suppository form
2. Induced abortion; injectable form
3. Cervical ripening; gel, tampon ( Cervidil), tablet forms

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6
Q

Labor = Myometrial Activity

A

Feedback loop: stretching of cervix causes increase of oxytocin, which increases
myometrial activity
Fetus distends uterus: ? relationship

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7
Q

In true labor, uterus divides

A

Upper segment: active & contractile, thickens as labor progresses
Lower segment & cervix: passive, thins and expands as labor progresses

In between 2 areas: physiologic contraction band

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8
Q

lower segment transverse (LST) AKA lower cervical transverse (LCT)

A

If patient desires trial of labor after Cesarean (TOLAC) to attempt a vaginal birth after
Cesarean (VBAC), must have this uterine incision

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9
Q

Vertical Uterine Incisions

A

Higher risk of uterine rupture with labor
In upper segment (contractile)
Will have future repeat C/S

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10
Q

Effacement of Cervix

A

Taking-up of internal os and cervical canal into uterine sidewalls
Usually precedes dilatation in primigravidas
Express in percentage: 0% - 100%
Some subjectivity

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11
Q
A
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12
Q

Dilation of Cervix

A

Longitudinal muscle fibers of uterus pull upward over baby’s head
Combined with pressure from bag of waters (BOW)
Cervix dilation from 0 cm to 10 (“complete”, “fully”)

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13
Q

“Pushing”

A

Once completely dilated, woman pushes to expel fetus & placenta
Using intra-abdominal pressure
Must be “complete” or can bruise/tear cervix; exhaustion ensues

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14
Q

Pushing Causes Fetal Head to Descend to Pelvic Floor

A

Head meets perineal structure; pressure causes it to thin from 5 cm thick to 1 cm
Thin = less blood = natural physiologic anesthesia
Anus everts, exposing internal rectal wall

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15
Q

Premonitory Signs of Labor: Lightening

A
  1. Fetus settles into inlet (becomes “engaged”)
  2. Uterus seems to move downward (“dropped)
    Breathe easier
    More pelvic pressure
    More leg cramps/pain
    More venous stasis
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16
Q

Premonitory Signs of Labor: Braxton-Hicks Contractions

A

Irregular, intermittent contractions
Experienced throughout pregnancy
Pain in abdomen or groin
Can become uncomfortable
Purpose: cervical ripening

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17
Q

Premonitory Signs of Labor: Cervical Ripening

A

Ripe cervix: soft, anterior, slightly effaced and dilated
Non-pregnant: cervix feels like tip of nose
Pregnant: like lower lip
Ripe: like pudding
Ripening important re: induction decisions (unlikely to be successful if unripe)
Bishop Score: Cervical Ripening

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18
Q

Cervical Ripening Balloon

A

No drugs needed ( mechanical pressure)
Eliminates side effects
Silicone balloons adapt to cervical contour
Easily placed & removed ( foleys can be used)

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19
Q

Premonitory Signs of Labor: Bloody Show

A

Mucus plug expelled; exposed capillaries bleed
Consistency: bloody mucus
Watery bleeding NEVER normal
Labor usually begins 24-48 hours
Confusion if recent vaginal exam

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20
Q

Premonitory Signs of Labor: ROM (Rupture of Membranes)

A
  1. SROM: Spontaneous Rupture of Membranes
  2. AROM: Artificial Rupture of Membranes, via amniotomy
    Most common L & D procedure
    No pain endings in BOW (bag of water)
    Additional terms:
  3. PROM: Premature Rupture of Membranes;
    >1 hour from ROM to labor onset
  4. PPROM: Preterm, Premature Rupture of Membranes
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21
Q

Prolonged ROM

A

anytime ROM >24 hours; increased risk of ascending infection
Chorioamnionitis: infected BOW; fever, tenderness, foul-smelling & cloudy amniotic
fluid

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22
Q

Sterile Speculum exam:

A

to check if BOW broke

rests ½ hour
Pooling, nitrazine, ferning

Normal fluid: clear, bloody streaks; not meconium-stained or port wine color

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23
Q

Umbilical Cord Prolapse

A

Major OB emergency
R/O: after ROM, check FHTs; if low, suspect prolapse
Glove hand, insert into vagina, push upward; place patient in Trendelenburg or hands &
knees (relieve pressure on cord)

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24
Q

Premonitory Signs of Labor: “Nesting Instinct”

A

Sudden burst of energy
24 – 48 hours prior to labor
Cause unknown
Woman “feathers her nest”
Warn not to over-exert

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25
Q

Premonitory Signs of Labor: “Other”

A
  1. Weight loss of 1-3 #
    Fluid & electrolyte shifts
    “progesterone deprivation theory”
  2. More backache & sacroiliac pressure
    Relaxin influencing pelvis
  3. N/V, diarrhea
    More room in pelvis
    Clear liquid absorption unchanged; may vomit solids (aspiration risk)
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26
Q

True Labor

A
  1. Cervix progressively effaces/dilates
  2. Contractions regular, become closer, longer, stronger over time
  3. Pain begins in back, radiates to abdomen
  4. Ambulation intensifies
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27
Q

False Labor

A
  1. No progressive effacement/dilation
  2. Contractions irregular, do not become closer, longer, stronger
  3. Pain chiefly lower abdomen or groin
  4. Ambulation relieves
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28
Q

Stages of Labor & Birth

A
  1. First Stage - True labor until 10 centimeters dilation
  2. Second Stage - Complete dilation thru birth of neonate
  3. Third Stage - Birth of neonate thru birth of placenta
  4. Fourth Stage - First 1-4 hours after delivery
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29
Q

Critical Factors in Labor: The 5 P’s (traditional)

A
  1. Passageway (pelvis)
  2. Passenger (fetus)
  3. Powers (contractions)
  4. Psyche (mental status of the woman)
  5. Position (…of the woman)
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30
Q

Additional Critical Factors

A

Philosophy (low tech, high touch)
Partners (support persons)
Patience (respect for the natural timing of birth)
Patient Preparation (knowledge base)
Pain Management (comfort care)

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31
Q

Passageway: Pelvis

A

True pelvis: bony birth canal; must be adequate size, shape
False pelvis: nothing to do with OB; holds up abdominal contents
3 planes
Inlet (linea terminalis)
Midpelvis (ischial spines)
Outlet (ischial tuberosities)

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32
Q

1933, Caldwell-Malloy Pelvic Types: Inlet Shape

A
  1. Gynecoid: “female” pelvis, 50% women; all diameters adequate for birth
  2. Android: “male” pelvis, 20% women; OP (occiput posterior), long labors, C/S
  3. Anthropoid: OP, but usually adequate; long AP diameter compensates
  4. Platypelloid: flat pelvis, rare, inadequate for birth
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33
Q

Getting an OP to Rotate to OA

A 
Occiput Posterior (OP) sunny side up
 Occiput Anterior (OA)

  1. Hands+knees
  2. Lunging
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34
Q

Gynecoid pelvis measurments

A
  1. Inlet

Clinical Pelvimetry: measure diagonal conjugate (11.5 cm)

  1. Midpelvis

Clinical Pelvimetry: ischial spines blunt, pelvic sidewalls straight, sacrum hollow (curved),
coccyx freely-movable

  1. Outlet

Bi-ischial diameter: 8 cm or >

Pubic arch: at least 90 degrees

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35
Q

Passenger (Fetus)

A
  1. Must fit through bony pelvis
    Most are head-first
    Largest part
    Least compressible
    If head delivers, delivery of body rarely delayed

Fetal head molds to accommodate pelvis

Diameters of Fetal Skull:

  1. Biparietal Diameter (BPD)
  2. Suboccipitobregmatic Diameter
    Vertex: Most Common
    Suboccipitobregmatic diameter presents to pelvis
    Head well-flexed; chin onto chest
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36
Q

Fetal Lie

A

Relationship of fetus to long axis of mother
Normal lie: longitudinal
Fetus’ long axis in line with mother’s long axis
Abnormal lies: transverse & oblique
Oblique is unstable

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37
Q

Fetal Attitude

A

Refers to posturing of joints & relation of fetal parts to one another
Normal attitude: flexion
Deflexed = larger diameters of fetus meet pelvis

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38
Q

Fetal Presentation: “Presenting Part”

A

Part of fetus closest to internal os
At term:
Cephalic (head), 96-97%
Breech (buttocks), about 3%
Arm or shoulder, <1%
Transverse lie

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39
Q

Risks: Vaginal Breech Delivery

A

Few trained in methods
After-coming head
Increased risk hypoxic events/cerebral palsy
Increased risk umbilical cord prolapse
Preemie breech should never be delivered vaginally

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40
Q

Compound Presentation:

A

More than 1 part presenting, i.e. baby’s hand on top of head
Larger diameter to fit through pelvis

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41
Q

Malpresentation:

A

Anything other than cephalic presentation
Can lead to difficult labor & birth

*ECV External Cephalic Version

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42
Q

Relationship of Fetus to Pelvis

A
  1. Engagement: widest diameter of presenting part reaches or passes through inlet
    Confirms adequacy of inlet
    2 weeks before term in primigravida
    Can happen before or during labor in multipara
  2. Station: relationship of head to ischial spines
    Confirms adequacy of midpelvic plane
43
Q

Forceps/Vacuum Extraction

A

Can only be done if fetus descends to “0” station
Otherwise, C/S
Mother must be completely dilated

44
Q

Forceps/Vacuum Extraction Reasons

A

Fetal distress #1 reason
Maternal exhaustion
Maternal cardiac disease
Poor pushing (epidural)/prolonged 2nd stage

45
Q

Forceps

A

MD only
Open or closed blades
Different types
Preemies
Breeches
Term vertex
Usually with vaginal delivery, but also C/S
Pulling sensation; good anesthesia needed
More room; episiotomy needed

Like big “spoons”: 2 curves
1 fits around head
Other conforms to shape of pelvis/birth canal
Must know landmarks to avoid injury to baby
Mother still pushes
Gentle traction
Deliver head to perineum or fully deliver

46
Q

Vacuum Extraction Delivery

A

CNMs can also perform
Same reasons & usage as forceps, but less precise landmarks
Must use safe amount of suction

47
Q

LOA - left occiput anterior - most common

A
48
Q

LOT - left occiput transverse

A
49
Q

LOP - left occiput posterior

A
50
Q

ROA - right occiput anterior

A
51
Q

ROT - right occiput transverse

A
52
Q

ROP - right occiput posterior

A
53
Q

The Powers (Contractions)

A

Intermittent shortening of muscle
Propel fetus through birth canal
Involuntary; action independent of mother’s will & extrauterine nervous control

Phases of Contraction - increment, acme, decrement

54
Q

Dystocia

A

“dys-” = difficult or painful
“-tocia” = birth
Abnormal labor patterns can lead to dystocia
Hypertonic: uterus doesn’t relax sufficiently between contractions
Hypotonic: uterus doesn’t contract strongly enough to be effective
Friedman Labor Curves: Ideal Labor
Friedman Labor Curve: Effect of Station

55
Q

Catecholamines

A

Stress hormones; released in response to anxiety & fear
Constrict blood vessels, including those to uterus
Uterine muscle anoxic, causing pain (#2 cause of pain in labor)
High catecholamine levels block release of oxytocin and may prolong labor

56
Q

Endorphins

A

Morphine-like substances; come from pituitary gland & brain
Laboring women have higher levels than non-pregnant
Relaxation, touch, massage, activity can raise levels
Goal: minimize catecholamines, maximize endorphins
Decrease anxiety, use comfort measures, walk

57
Q

Position (…of the woman)

A

Primary consideration: don’t lie on back in labor
Vena cava compression worse in labor
If cardiac output falls, can’t perfuse uteroplacental unit
Alternate positions frequently; use upright & lateral positions
Contractions more intense, but not more painful
Fetal head descends quicker (gravity)
Labor may be shorter
Fetal diameters correspond better to pelvic diameters

58
Q

First stage - Latent Phase (early labor)

A

Onset of regular contractions until 3 cm
Nullipara: 8.6 hours, no >20 hours
Multipara: 5.3 hours, no >14 hours
Contractions: every 10-20 minutes x 15-20 seconds, mild—become every 5-7 minutes x
30-40 seconds, moderate
Average 40 mm Hg; resting tone 10 mm Hg
Good time to review CB preparation

59
Q

Latent Phase - Pain control

A

Gate control theory of pain relief:
Stimulate peripheral nerves, message of pain can’t reach brain
Examples: TENS units, effleurage, distraction, relaxation techniques, massage
Alternative Pain Relief
Aromatherapy

Hydrotherapy

Massage

60
Q

Latent Phase -
Breathing patterns:

A

rhythmic chest breathing
Slow rate 8/min
Modified rate 16-20/min

61
Q

Latent Phase - Nursing care

A

Time contractions
Support efforts
Monitor breathing/relaxation
Conserve energy (many are excited, talkative)
Clear fluids/empty bladder every 2 hours

62
Q

Latent Phase - vitals

A

Maternal VS hourly, except T every 4 hours
If ROM, T hourly with pulse
FHT auscultation
Hourly if low-risk
 ½-hourly if high-risk
Note fetal activity
Note uterine contraction pattern every ½ hour
Labor pain: #1 cause is cervical changes

63
Q

Medications in Latent Phase

A

Labor not well-established
Narcotics/epidurals can slow labor down
Can’t give po meds
Options:
1. Vistaril 50 mg IM (sedative)
2. Inhalation analgesia (nitrous oxide)

64
Q

Active Phase (accelerated phase)

A

Labor well-established
Dilates from 4-7 cm
Nullipara dilates 1.2 cm/hr
Multipara dilates 1.5 cm/hr
Descent is progressive
Contractions: every 2-3 minutes x 60 seconds, strong
If ROM, increase in strength

65
Q

Active Phase Breathing

A

Breathing patterns: combined, rhythmic chest or shallow (“he-he-hoo”)
“count down” contractions
Remind her that labor is intermittent

66
Q

Active Phase - nursing care

A
  1. Mouth care
  2. Stroke arms and legs
  3. Encourage efforts
  4. Intake/output; full bladder impedes descent
67
Q

Active Phase
Medications:

A

Labor well-established, so unlikely to diminish
Narcotics “take the edge off” pain:
Nubain (nalbuphene) 10 mg IM or IV every 3-6 hours
Inhalation anesthesia
Nitrous oxide
Regional anesthesia
Epidural most common
 60-80% in major city hospitals

68
Q

Epidural Anesthesia: The Good

A

Relief of labor pain
Allows for rest
Decreases catecholamines
Can be awake if C/S
Partner may prefer this method

69
Q

Epidural Anesthesia: The Bad, part 1

A

#1: ↓ BP due to peripheral vasodilation
Inadvertent spinal + possible headache
Immobility, unless “walking epidural”
May ↓ contractions → more pitocin
May ↑ length of 2nd stage → forceps/vacuum
? ↑ OP babies, ? ↑ C/S

70
Q

Epidural Anesthesia: The Bad, part 2

A

Unable to void; may need catheter
“Spotty” blocks
Mild itching
May ↓ neonate’s ability to breastfeed
Maternal fever → blood cultures/antibiotics in neonate

71
Q

Epidural Anesthesia: The Ugly (Contraindications)

A

Bleeding disorders/anticoagulants
Mother low volume (PIH)
Thrombocytopenia
Infections near site (i.e., herpes)

72
Q

Other Regional Anesthetics

A

Spinal
Injected inside dura
Uses less medicine & works faster than epidural
More likely than epidural to decrease BP
Used for C/S, not labor
Pudendal
Local anesthetic injected into pudendal nerve, near ischial spine
Usually given 2nd stage
Relieves pain around vagina/rectum
Good for forceps, prolonged repairs
Paracervical
Local anesthetic injected into the cervix, during labor
Can cause FHT to drop
Could accidentally inject fetus

73
Q

Active Phase - vitals

A

Check maternal VS hourly; T every 4 hours, unless ROM (hourly, with pulse)
Check FHT every 30 minutes in low-risk; every 15 minutes high-risk
Note uterine contraction pattern every 30 minutes

74
Q

Transition Phase

A

Patient dilates from 8-10 cm
Contractions strong and close together: every 1 ½ - 2 minutes, lasting 60 seconds or more
Short phase
Nullipara: no >2 hours
Multipara: no >1 hour
Descent progressive
Nullipara: 1 cm/hour
Multipara: 2 cm/hour

75
Q

Transition Phase - breathing and nursing care

A

Breathing patterns: pant-blow during contractions & rhythmic chest breathing in-between
Head descends; urge to push
Patient irritable, discouraged, over-whelmed
Give specific instructions
Remind her that baby is almost here
Encourage her
Remain with her

76
Q

Transition Phase - special considerations

A

Physical sensations: N/V, belching, chills, trembling, sweating, difficulty relaxing
Special considerations:
Hyperventilation: tingling, dizzy, light-headed
Rebreathe exhaled air between contractions
Back labor: small of back, difficult to relax, increase in tension
Warm or cold compresses
Counterpressure to small of back
Increase in bloody show

77
Q

Transition Phase - Vitals

A

Check maternal VS every 30 minutes
Check FHT every 30 minutes low-risk; every 15 minutes high-risk

78
Q

Second Stage of Labor

A

Nullipara: 48-174 minutes, 66 average
Multipara: 6-66 minutes, 24 average
“precip. packs”
Prolonged second stage = >2 hours
Pushing sensation: pressure of fetal head on sacral & obturator nerves
Woman feels relieved; birth near & actively involved
Some fight pushing; fear, loss of control

79
Q

Second Stage of Labor
Coach efforts:

A

open glottis pushing
Physical sensations: vaginal fullness, rectal pressure, burning, stretching
Instruct to stop pushing at birth of head; use pant-blow

80
Q

Second Stage of Labor- Vitals

A

Check maternal VS every 15 minutes
Check FHT every 5-15 minutes (most RNs check after each contraction)
Check delivery equipment; O2, suction, Code Pink Team/Code Pink Box, turn on warmer

81
Q

Second Stage: Crowning

A

Ring of fire ; episiotomy performed

82
Q

Cardinal Movements (Mechanisms) of Labor

A
  1. Engagement
  2. Descent
  3. Flexion
  4. Internal rotation
  5. Extension
  6. External rotation/restitution
  7. External rotation/shoulder rotation
  8. Expulsion
83
Q

Extension (4., 5.):

A

: head meets resistance of pelvic floor + mechanical
movement of vulva anterior & forward;
head passes under pubic bone &
occiput, then brow, then face emerge

84
Q

External rotation/restitution (6.):

A

head
rotates 45 degrees

85
Q

External rotation/shoulder rotation (7.):

A

head rotates additional 45 degrees; head & shoulders lined up

86
Q

Expulsion (7., 8.): anterior shoulder

A

meets underside of pubic symphysis
& slips under it; delivery attendant lifts
baby up & posterior shoulder born; body flexes laterally

87
Q

Third Stage of Labor

A

Baby born, uterus contracts: less surface for placental attachment, hematoma forms
between placenta & decidua
Signs of separation usually 5 minutes after birth; 30 minutes or > = retained placenta
Globular shape to uterus
Fundus rises
Gush of blood
Amount of cord lengthens

88
Q

Third Stage of Labor - placenta delivery

A

Patient bears down; attendant aids with gentle traction

Always check to see if placenta complete

> 30 min - manual removal of placenta

89
Q

Fourth Stage of Labor

A

1-4 hours after delivery
BP returns to prelabor level
Pulse slightly lower than labor
FF @ U or below, midline
No evidence of PPH
Variation in emotional state
Hungry, thirsty, shaking chills, hypotonic bladder

90
Q

Interview/Risk Assessment

A

Why in L & D: labor? EDC?
Contracting: when began? Pain?
Fluid leakage or bleeding?
Problems during pregnancy? Medical problems? Any surgeries? Recent exposure to illness ?
Problems during pregnancy? Medical problems? Any surgeries? Recent exposure to
illness?
Take any medications? Allergies to meds.?
Baby moving normally?
Last ate and drank?

91
Q

Admission Care - VS

A

Get VS
Elevated BP suggests pre-eclampsia
Elevated T suggests infection
Pulse >100 suggests hypovolemia
Urine Dipstick
1+ proteinuria or > suggests pre-eclampsia
1-2+ glycosuria or > suggests diabetes
CBC, Type & Screen
Leopold’s Maneuvers
Check FHT/place external monitors

92
Q

Admission Care

A

Time frequency/duration of contractions
Check fundus for strength of contractions
If likely ROM, Nitrazine & prepare ferning slide
Some settings: check cervical dilation & effacement
Start IV or place heplock

93
Q

EFM in Low-Risk Women

A
  • *>85% low-risk have EFM**
    1. Does not decrease # perinatal deaths
    2. Does not decrease # with CP
    3. Does not decrease # admitted to NICU
  • *Continuous monitoring**
    1. Increases risk of Vacuum or forceps delivery
    2. Increases risk of C/S
    3. Increases risk of infection
94
Q

External monitoring (indirect)

A

2 belts
Tocodynanometer (“toco”); placed over fundus, picks up contractions
Ultrasound transducer; placed over baby’s chest or back, opening/closing of valves of
heart read as FHTs
More subject to artifact
Can use on anyone

95
Q

Internal Monitoring (direct)

A

2 types, placed inside uterus; must have ROM & be dilated at least 2 cm
IUPC: intrauterine pressure catheter; goes between fetus’ head & wall of uterus,
squeezed during contractions, transducer picks up strength in mm Hg
FSE: fetal scalp electrode; internal spiral electrode, attaches to fetus’ head & picks up
electrical activity of heart, reads it as FHT
Less subject to artifact

96
Q

Basics of EFM: “Dr. C. Bravado”

A
  1. Determine Risk
  2. Contractions
  3. Baseline
  4. Rate
  5. And
  6. Variability
  7. Accelerations (periodic change of FHR)
  8. Decelerations (periodic change of FHR)
    Early
    Late
    Variable
  9. Overall impression
97
Q

Determine Risk

A

Interpret tracing within context of clinical circumstances

Patterns change over time; regular re-evaluation needed

98
Q

Contractions

A

# in 10 minute period averaged over 30 minute period
Normal < or = 5/10 minutes
Tachysystole > 5/10 minutes

Duration, intensity, rest between also important

99
Q

Baseline Rate

A

Mean FHR rounded to increments of 5 bpm over 10 minutes, excluding accelerations,
decelerations, marked variability
Bradycardia: baseline < 110 bpm
Tachycardia: baseline > 160 bpm

100
Q

Baseline Bradycardia

A

Baseline <110
#1 cause: fetal hypoxia
Other causes uncommon: congenital heart block, maternal use of beta blockers

101
Q

Baseline Tachycardia

A

Baseline >160
#1 cause: maternal/fetal fever
Other causes: infection, fetal hypoxia, tocolytic drugs (Terbutaline)

102
Q

Variability

A

Baseline fluctuations, irregular in amplitude & frequency
Peak-to-trough in bpm, seen over 10 minutes
Parasympathetic/sympathetic nervous system

103
Q

Categories of Variability

A

Absent: amplitude range undetected
Minimal: range < 5 bpm use

Moderate: range 6-25 bpm

Marked: range > 25 bpm

104
Q
A

Nursing - OB (9 decks)

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