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Module 6 (Labor And Delivery) > Intrapartum > Flashcards

Intrapartum Flashcards

1
Q

Contractions are

A

coordinated and involuntary
- organized, increase frequency and intensity as term closes in

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2
Q

The power of the contractions comes from

A

top of the uterus (fundus)

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3
Q

Cervical changes in labor

A

Effacement
Dilation

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4
Q

Effacement

A

thinning and shortening of the cervix
- estimated as % of original cervical length

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5
Q

Dilation

A

opening expressed in cm
- pulled up and fetus is pushed down

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6
Q

At 10 cm, the cervix is _________ felt by examiners

A

not

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7
Q

Nullipara cervical changes

A

efface early in cervical dilation

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8
Q

Multipara cervical dilation

A

cervix is thicker at all points of labor

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9
Q

Cardiovascular during contractions

A

fondus muscles constrict on spiral arteries supplying placenta
- temp shunts 300-500 mL OF BLOOD back to mom

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10
Q

VS are best assessed during what in labor

A

interval between contractions

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11
Q

If the pregnant mother lays on her back it can cause

A

supine hypotension

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12
Q

Respiratory system changes of labor

A

depth and RR increase
-Hyperventilation

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13
Q

If the laboring mother is experiencing hyperventilation, what should the nurse instruct

A

May feel tingling of her hands and feet and numbness and dizziness
Nurse should help slow breathing through relaxation techniques
Breathe into paper bag or into cupped hands

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14
Q

GI system changes of labor

A

mobility decrease - N/V and constipation
need calories but NPO

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15
Q

Urinary system changes of labor

A

reduce sensation of a full bladder
- inhibit fetal descent
- bladder status evaluated throughput labor for distension

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16
Q

Hematopoietic system changes of labor

A

blood loss vaginal birth = 500, Csection 1000mL
CLOTTING FACTORS ELEVATED
- DVT risk in postpartum

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17
Q

Anything over
Vgainal 500 mL
Csection 1000 mL
of blood loss indicates

A

hemorrhage

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18
Q

Placental circulation

A

Placental exchange occurs during the interval between contractions
Exchange of oxygen, nutrients, and waste products occur in the intervillous spaces

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19
Q

Fetal Cardiac system in labor

A

Rate or rhythm change may result from normal labor or suggest intolerance to labor stress

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20
Q

Fetal Pulmonic system in labor

A

lungs fluid to allow normal airway development which decrease near term
Compression of the fetal thorax at birth clears lung fluid for normal breathing after delivery

  • surfactant and amniotic fluid - keep lungs lubed
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21
Q

What are the 4 components of birth?

A

Power - contractions and pushing effort
Passage - pelvis and soft tissue
Passenger - fetus
Psyche - response to labor influenced by anxiety, culture, expectations, experiences, and support

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22
Q

The Four P’s = Powers

A

Uterine contractions
- The primary force that moves the fetus through the maternal pelvis
Maternal pushing efforts
- 2nd stage of labor: contractions continue to propel the fetus through the pelvis
- Ferguson Reflex
- Crowning

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23
Q

Ferguson reflex

A

Fetus distends vagina and puts pressure on rectum
Woman feels an urge to push and bear down

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24
Q

The Four P’s = Passage

A

True pelvis - inlet for fetus to pass through
- Bones and joints do not readily yield to forces of labor
- Relaxin softens cartilage linking pelvic bones near term
Cervix and vagina

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25
Q

Most favorable pelvis types

A

Gynecoid: Most common; found in 50% of women; round shape big diameter

Anthropoid: Resembles pelvis of anthropoid apes; found in 24% of women; oval shape

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26
Q

Least favorable pelvis types

A

Android: Resembles the male pelvis; found in 23% of women; heart-shaped

Platypelloid: Flat pelvis; found in 3% of women; Flat shape

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27
Q

The Four P’s = Passenger

A

Fetal Head: bones, sutures, and fontanels
- molding and assists in fetal position
Head Diameters
Fetal lie
Fetal Attitude
Presentation

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28
Q

Fetal lie is

A

orientation of the long axis of the fetus to long axis of the woman
- longitudinal, transverse, oblique, breech

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29
Q

Longitudinal lie

A

cephalic or breech

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30
Q

Transverse lie

A

perpendicular

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31
Q

Oblique lie

A

slanted

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32
Q

Fetal Attitude

A

relationship of the fetal part to one another
- positioning of the head
Tuck head to chest or extending head to the back

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33
Q

Flexion

A

good
- smallest diameter part to move though the pelvis
Tucks the head to chest

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34
Q

Extension

A

head sticks out with posterior to the back
bad - can cause neck snap if birthed

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35
Q

Fetal Presentation

A

fetal part first entering the pelvis is the presenting part
- Cephalic (vertex, military, brow, face)
swelling of the face and difficulty passing

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36
Q

Frank breech

A

fetus legs are folded flat up next to head
- bottom the closest to birth canal

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37
Q

Complete breech

A

fetus butt is downward
- both hips and knees are flexed

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38
Q

Footling breech

A

the foot is the 1st thing out and moving
- also prolapsed cord possible

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39
Q

Compound presentation

A

the hand is on top of the head with both entering the pelvis at the same time

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40
Q

Shoulder presentation

A

malpresentation when the fetus is in transverse lie
- leading part of seen is the arm/shoulder/chest

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41
Q

The Four P’s = Passenger
Fetal Positioning

A

relationship of point of reference (landmark on the fetus) on the presenting part (vertex, face,breech, shoulder) to the mom’s pelvis

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42
Q

Fetal Positioning
Right or Left

A

[resenting part pointing to mom’s right or left

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43
Q

Fetal Positioning
Occiput or Sacrum

A

what part coming out 1st

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44
Q

Fetal Positioning
Anterior, Posterior, or Transverse

A

presenting part (occipital bone or sacrum) pointing
- toward the front of mom’s body (anterior)
- mom’s sacrum (posterior)
- towards hip (transverse)

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45
Q

Cardinal Movements of Labor can cause the fetal position

A

chnage during labor as the fetus moves downward and adapts to the pelvis contours

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46
Q

Where would you put the fetal heart monitor if the fetus is facing the Right occiput posterior?

A

RLQ

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47
Q

Where would you put the fetal heart monitor if the fetus is facing the left occiput posterior?

A

LLQ

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48
Q

With antroior and posterior positioning, how do you know what to label them?

A

where the occipital bone is located

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49
Q

OP positioning causes

A

back pain

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50
Q

Pregnant Anxiety

A
  • decrease ability to cope with labor pain
    release catecholamines - inhibit uterine contractions and placenta blood flow
  • enhance perception of pain
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51
Q

The Four P’s = Psyche

A
  • Anxiety
  • Culture and Expectations (language, support, symbols, practices, and norms and restrictions
  • Experience
  • Support
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52
Q

Support in labor

A

positive effects (physical comfort, advocate, praise, reassure, and presence)
maintain calm and comfortable environment

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53
Q

Nurse’s Role in Intrapartum

A

Advocate for the laboring woman and her support person
Increase their sense of control and mastery of labor
Reduces anxiety and fear
Achieve their desired birth

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54
Q

Factors to causing labor

A

Changes in ratio of maternal estrogen to progesterone
Fetal membranes release prostaglandin
Prostaglandins prepare uterus for oxytocin stimulation
Increased secretion of natural oxytocin
Oxytocin receptors in the uterus increase markedly
Large quantities of cortisol released by fetal adrenal glands
Stretching, pressure and irritation of the uterus and cervix

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55
Q

Premonitory/Prodromal Signs of Labor

A

Braxton Hicks contractions
Lightening (easier breathing and baby on bladder)
Increased vaginal mucous secretions
Cervical softening and slight effacement
Bloody show or loss of “mucous plug”
Energy Spurt or “Nesting instinct”
Weight Loss (slight)
Diarrhea, nausea

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56
Q

True Labor contractions

A

Consistent increase in frequency, duration, and intensity
Increase in frequency/intensity with walking
Starts in the lower back and moves around to the lower abdomen

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57
Q

True Labor discomfort

A

May persist as back pain in some women
Increasing intensity and pain

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58
Q

True Labor cervix

A

Progressive effacement and dilation (most important factor)

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59
Q

False Labor contractions

A

Inconsistent in frequency, duration and intensity
Decrease in frequency/intensity with walking

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60
Q

False Labor discomfort

A

Localized in abdomen
More annoying than truly painful

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61
Q

False Labor cervix

A

No significant change effacement or dilation

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62
Q

When should a patient go to the hospital or birth center?

A

Contractions (Nullipara = 5 minutes apart; Multipara = 10 minutes apart)
Ruptured membranes
Bright red vaginal bleeding immediately
Low or no fetal mvmt
Concerns

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63
Q

A patient SHOULD go to the hospital or birth center if they have these concerns?

A

severe pain, vision changes, headache, epigastric pain, feeling “something not right”

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64
Q

Labor Mechanisms

A

Descent of the fetal presenting part through the true pelvis
Fetal station
Engagement

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65
Q

Fetal station

A

descent of the fetal presenting part to ischial spines

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66
Q

Engagement is what station

A

0, widest part of the fetal presenting part reaches the level of the aternal ischial spines

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67
Q

Cardinal MVMT of Labor Steps

A

Descent
Engagement
Flexion
Internal rotation
Extension
External rotation
Expulsion

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68
Q

1st Stage of Labor is what phase

A

latent

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69
Q

1st Stage of Labor is the only stage with

A

phases

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70
Q

1st Stage of Labor begins with __________ and ends with

A

onset of truelabor
complete dilation of the cervix

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71
Q

1st Stage of Labor is when what occurs in cardinal mvmt

A

cervical dilation and effacement
- expanding of the cervix (10 cm)
- station 0

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72
Q

What are the 3 phases of 1st stage of labor?

A

Latent
Active
Transition

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73
Q

Latent Phase dilates to

A

1-3 cm

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74
Q

Latent Phase Mother’s attitude

A

pass unnoticed
sociable and excited

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75
Q

Latent Phase contractions

A

5 minutes apart with gradual intensity

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75
Q

Latent Phase average dilation
Primi
Multi

A

primigravida 1.2 cm/hr., Multipara 1.5 cm/hr.

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76
Q

Prolonged Latent phase

A

primigravida > 20 hrs., multipara > 14 hrs.

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77
Q

Active Phase starts at

A

4 cm and accelerates to 7 cm

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78
Q

Active Phase is when cardinal mvmt starts

A

internal rotation

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79
Q

Active Phase contractions

A

2-5 minutes apart
last 40-60 seconds
- moderate intensity

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80
Q

Active Phase Mothers attitude

A

discomfort increases
increasing anxiety
sense of helplessness
inwardly focused

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81
Q

Transition Phase starts at

A

8 and continues to 10 cm

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82
Q

Transition Phase cardinal mvmts

A

descends further into pelvis
- bloody show increases

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83
Q

Transition Phase contractions

A

very strong
1.5-2 minutes apart last 60-90 seconds

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84
Q

Transition Phase may feel what reflex?

A

Ferguson - urge to push and bear down

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85
Q

Transition Phase may have the mothers experience what else

A

leg tremors
N/V

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86
Q

Transition Phase ATTITUDE

A

irritable and lose control
easily discouraged, overwhelmed, and panicky
“can’t continue”
actions are not helping anymore

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87
Q

2nd Stage of Labor is the

A

stage of expulsion

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88
Q

2nd Stage of Labor starts with ________ and ends with

A

Begins with complete dilation (10cm) and 100% effacement and ends with birth of baby

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89
Q

2nd Stage of Labor can last how long?

A

Primigravida is 1 hour and the Multipara is 15 minutes

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90
Q

Allow a labor down if

A

epidural
8-10 cm
-1 station

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91
Q

2nd Stage of Labor
Ferguson’s Reflex signs

A

May feel need to have a bowel movement or say “the baby is coming” or “I have to push”
Voluntary pushing efforts augment involuntary contractions
Vulva distends as fetus descends into pelvis
Crowning of fetal head, may cause a stretching or splitting sensation
Allow to “labor down”
Woman often regains a feeling of control

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92
Q

Episiotomy

A

incision in perineum made to provide more space for presenting part

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93
Q

Mediolateral episiotomy is used for

A

large infants

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94
Q

Episiotomy Indications

A

Shoulder dystocia
Face presentation
Breech delivery
Macrosomic fetus
Vacuum or forceps-assisted births

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95
Q

Episiotomy Risk

A

Infection
Perineal pain
- they can still tear

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96
Q

Laceration

A

tears in the perineum occurring at delivery

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97
Q

1st degree laceration

A

perineal skin and vaginal mucous membrane

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98
Q

2nd degree laceration

A

skin, mucous membrane, and fascia of the perineal body

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99
Q

3rd degree laceration

A

skin, mucous membrane, muscle of the perineal body, and extends to rectal sphincter

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100
Q

4th degree laceration

A

extends into rectal mucosa exposing the lumen of rectum

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101
Q

3rd stage of Labor start with ______ and end with

A

Begins with birth of baby and ends with expulsion of placenta

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102
Q

How long does the 3rd stage of labor last?

A

of 5-15 minutes

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103
Q

Signs of placental separation

A

Uterus rises in abdomen as placenta descends into vagina and pushes fundus upward
Cord descends (lengthens) from the vagina
Gush of blood appears from vagina as blood trapped behind placenta is released

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104
Q

How does the uterus prevent a hemorrhage

A

contract firmly to compress open vessels

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105
Q

Nursing Interventions for preventing a hemorrhage after expulsion of the fundus

A

Massage the fundus!
Administer uterotonic medications

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106
Q

If the placenta has not dropped after minutes the physician will

A

grab it out

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107
Q

If the uterus does not clamp down, what could occur?

A

postpartum hemorrhage

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108
Q

What are the 2 ways placentas are described when delivered?

A

Shiny Shultze (fetal side iwth membranes and cord)
Dirty Duncan (maternal with spiral arteries)

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109
Q

Uterotonic Medications

A

Oxytocin
Methylergonovine
Carboprost Tromethamine
Misoprostol

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110
Q

What is the 1st choice of uterotonic medications?

A

Oxytocin

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111
Q

Methylergonovine is used for

A

IV emergency only
CONTRAINDICATED for Hypertensive pts

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112
Q

Carboprost Tromethamine will cause

A

massive diarrhea

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113
Q

Carboprost Tromethamine CONTRAINDICATED in

A

asthma pts

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114
Q

4th stage of labor is

A

postpartum with delivery of placenta

115
Q

Initial delivery room is now focused on

A

Assessment and interventions to assist with uterine involution and prevent postpartum hemorrhage
Comfort measure - ice pack to episiotomy or lacerations, warm blanket for chills
Newborn delivery room care
Promotion of maternal-infant bonding, skin-skin care, breastfeeding, and family adaptation

116
Q

Nursing Responsibility for Labor

A

Establish a Therapeutic Relationship
Assess Maternal-Fetal Status (pregnancy hx and prenatal record, psychosocial)

117
Q

Establish a good relationship with the patient during labor by

A

Interpreter (not a family member)
Obtain consents
Respect cultural values
Ask and try to complete their Birth plan

118
Q

Imminent birth means to

A

obtain information from support persons and perform quick focused assessments

119
Q

Initial Nursing Assessment

A

Gravida, Para - Term, Preterm, Abortions, Multiples and Living if indicated
Gestational age
Fetal Heart Rate (FHR) and Maternal vital signs
Contractions - frequency, duration and intensity
Sterile vaginal exam and membranes (intact or ruptured)
Dip urine for glucose and protein
Comfort level
Labor and delivery preparation of patient and support person (childbirth classes)
Notify provider
Obtain informed consents
IV access and laboratory test

120
Q

When assessing a GTPALM, what do you need to be cautious about asking in front of others?

A

Abortions
- ask in privacy for honesty

120
Q

The pregnant laboring mother needs to have a minimum of an

A

INT for emergency

121
Q

Sterile Vaginal Exam (SVE)

A

SINGLE STERILE GLOVE WITH WATER-SOLUBLE LUBRICANT
- no lube if just ROM

122
Q

Sterile Vaginal Exam (SVE) used to assess

A

Assess for ruptured or bulging membranes
Assess cervical dilation, effacement, position and consistency
Assess for fetal station, presentation, and position

123
Q

Sterile Vaginal Exam (SVE) performed to

A

Before analgesia or anesthesia
Determine labor progression and when second-stage pushing can begin

124
Q

Sterile Vaginal Exam (SVE) frequency depends on

A

parity, status of membranes and speed of labor

125
Q

You can use lubricant if the mother has done what for a SVE

A

MEMBRANE RUPTURES

126
Q

SROM means

A

spontaneous rupture of membranes

127
Q

SROM occurs

A

before or during the onset of labor

128
Q

SROM means

A

Protective barrier is lost - organisms have access to the intrauterine cavity

129
Q

SROM needs to have a delivery within

130
Q

If the patient has not given birth within 24 hours of SROM, then what can develop

A

chorioamnionitis

131
Q

After ROM, immediate assessment of

A

fetal heart rate

132
Q

What do you document when ROM occurs

A

date, time, color, odor, and amount of fluid after ROM

133
Q

Polyhydramnios

A
  • excessive amniotic fluid
    Abnormalities such as TE fistula or GI obstruction (also diabetic mother)
134
Q

Oligohydramnios

A
  • small quantity of amniotic fluid
    Placental insufficiency or urinary tract abnormalities
135
Q

After SROM, when do you check the temperature

A

every 2 hours

136
Q

With SROM is ambulation allowed?

A

yes, if normal FHR and fetal head is engaged

137
Q

Normal Amniotic fluid is

A

clear with white flecks (vernix) with mild musty odor

138
Q

What amniotic fluid needs to reported

A

Meconium-stained fluid
Foul smelling or yellow

139
Q

Meconium-stained fluid

A

fetal compromise

140
Q

Foul-smelling or yellow

A

chorioamnionitis

141
Q

PROM

A

Premature rupture of membranes
- SROM before onset of labor

142
Q

PPROM

A

Preterm premature rupture of membranes
- SROM before 37 weeks
associated with >1/3 of preterm births

143
Q

Ruptured membrane assessments

A

Nitrazine paper
Fern Test (PPROM - amniotic fluid present)
Amnisure ROM test

144
Q

Nitrazine paper

A

SVE performed without lubricant – inserting piece of nitrazine tape into vagina
Amniotic fluid is alkaline (7.5); paper turns blue-green to deep blue if positive
Bloody show or semen being present can skew results

145
Q

Fern Test

A

Speculum exam:** Assess for fluid in vaginal vault**
Place fluid from vagina vault on glass slide and allowed to dry

146
Q

Amnisure ROM test

A

Rapid, non-invasive immunoassay lab test; ~ 99% accurate

147
Q

Assisting with Rupturing Amniotic Fluid aka

A

AROM or amniotomy
- amnicot

148
Q

Amniotomy is used fot

A

induction or augmentation of labor

149
Q

Before an Amniotomy can be done, it is vital to ensure the fetal head is

150
Q

Amniotomy allows dor

A

internal electronic fetal monitoring (FSE) and internal contraction monitoring (IUPC)

151
Q

What are the risks of a ROM

A

PROLAPSED of the umbilical cord

152
Q

Prolapsed cord means

A

Cord slips down in gush of fluid
Cord is compressed between presenting part and pelvis creating

153
Q

Prolapse cord causes what to show up on the FHM

A

Variable deceleration
Prolonged decelerations
Bradycardic FHR

154
Q

Assess the FHR for at least how long after ROM

155
Q

Nursing Responsibilities for 1st Stage Labor
FHR every

A

30 min. latent,
q 15-30 min. active,
q 5-15 min transition
- continuous FHM if high risk

156
Q

Nursing Responsibilities for 1st Stage Labor
BP and Temp

A
  • B/P q 1hr. side-lying position, between contractions, more frequent if abnormal
  • Temperature q 4 hr. until ROM, then q 1 hr.
157
Q

Nursing Responsibilities for 1st Stage Labor
Contractions doc

A

frequency, duration, and intensity

158
Q

Nursing Responsibilities for 1st Stage Labor
Urine status
Dip glucose

A

Urine status q 2hr., dip glucose/protein q 8 hrs.

159
Q

Nursing Responsibilities for 1st Stage Labor
Coping

A

(breathing exercises, and effleurage)
Hyperventilation - breath into paper sack

160
Q

Nursing Responsibilities for 1st Stage Labor
Comfort

A

Patient - oral care, peri care - frequent pad changes
Offer analgesia / anesthesia in active phase
Support persons should be included in teaching and support

161
Q

Effleurage

A

muscular massages

162
Q

Nursing Responsibilities for 2nd Stage Labor
Pain

A

Labor is stressful for both patient and support person
Involuntary need to push
Additional force of uterine contraction, rapid fetal descent, enhances cardinal movements

163
Q

Nursing Responsibilities for 2nd Stage Labor
Observe

A

perineal area
Bloody show, amniotic fluid color changes, bulging of perineum and anus
Visibility of fetal presenting part

164
Q

Nursing Responsibilities for 2nd Stage Labor
Teach

A

Pushing positions - squatting, side-lying, high fowlers, lithotomy
Open glottis “gentle” pushing - exhale through open mouth while pushing

165
Q

Nursing Responsibilities for 2nd Stage Labor
Set up for

A

delivery - delivery table, perineal cleansing, mirror for viewing

166
Q

Nursing Responsibilities for 3rd Stage Labor

A

Palpate fundus of uterus for firmness and location below the umbilicus
Administer Oxytocin as order following delivery of the placenta
obtain quantitative blood loss assessment
Newborn care on mom’s abdomen for heat and bonding
Repair lacerations
Clean perineal area, place an ice pack, and apply two sterile perineal pads from front to back
Remove both legs simultaneously from stirrups
Provider clean gown and warm blanket
Assist mother into a comfortable position for breastfeeding
Allow siblings and family members once the mother and support person are ready

167
Q

quantitative blood loss assessment

A

weight of all pads minus pad weight

168
Q

keep baby on mom’s chest as long as it does not need

A

resuscitation

169
Q

What are the 2 components of pain during birth?

A

Physiologic and psychological

170
Q

Labor pain is not constant but

A

intermittent

171
Q

Adverse effects of excessive pain

A

Increases maternal fear and anxiety resulting in an increase maternal metabolic rate and oxygen demand
Poorly managed pain can interfere with bonding, create unpleasant memories effecting future births
Creates feels of inadequacy, helplessness, and frustration for the support person

172
Q

Pain goal is

A

positive birth experience, as absence of pain is unrealistic

173
Q

Factors influencing perception or tolerance of pain

A

Labor intensity, cervical readiness
Fetal position - fetal OP position - sacral discomfort
Pelvic anatomy
Fear, anxiety, and fatigue
Culture
Caregiver interventions

174
Q

Preparation childbirth classes help do what with pain

A

Preparation reduces anxiety and pain
Bradley; Lamaze-Woman has “tools” for labor
Support system

175
Q

Gate Control Theory of Pain

A

Relaxation
Cutaneous stimulation (effleurage)
Hydrotherapy - (box 13.1 in book pg.326) – warm bath/shower
Mental Stimulation

176
Q

Advantages to non-pharmacological pain management

A

Do not slow labor like pain meds and epidural
No side effects or risk for allergy
Only realistic option in advanced, rapid labor

177
Q

Limitations to non-pharmacological pain management

A

level of control pain is not achieved

178
Q

Breathing Techniques for Labor

A

Cleansing Breath
Slow-paced breathing
Modified-paced breathing
Patterned-paced breathing
Breathing to prevent pushing

179
Q

During 2nd stage of labor, you should use what type of breathing

A

open glottis pushing

180
Q

Analgesia is gven in what stage of labor

A

mid-active phase of labor (4-7 cm – patient goes in to focus on pain)
- 30 minutes before labor

181
Q

If the analgesia is given too early

A

can slow labor

182
Q

If the analgesia is given too late

A

neonatal depression

183
Q

Anesthesia

A

Local - episiotomy or perineal site
Regional block - epidural, spinal - interruption of nerve impulses, cause vasodilatation and hypotension
General anesthesia: abrupt emergency

184
Q

Pain Mgmt Assessment of Pregnant Labor

A

Acute pain level
Birth plan** expectations**
Decreasing coping or increase anxiety
Assess patient
Vital signs and FHR
Labor/cervical progression
Last time and amount of ingestion
Labs - Hbg., Hct., and clotting time
Hydration status
Sign and symptom of infection

185
Q

Intervention Before Pain Mgmt of Pregnant Labor

A

Determine patient/family desire for analgesia
Assess phase and stage of labor
Baseline vital sign and FHR
Obtain order for medication
Butorphanol, Fentanyl, Meperidine, Nalbuphine
Explain purpose of medication
Administer IVP slowly at start of contraction
Constricted uterine blood flow - less to fetus
Opioid antagonists - Naloxone (Narcan)
Reverses opioid-induced respiratory depression
Adjunctive drugs – antiemetic (Phenergan and Zoloft)

186
Q

Intervention After Pain Mgmt of Pregnant Labor

A

Assess response
FHR & contractions
Q 15 minutes VS for one hour
DISTRACTIONS and pee q 2h
Monitor for bladder distension
Decrease environmental distractions
Darken room, TV off, reduce visitors
Note time of between medication and delivery
Delivery time during peak absorption time
Obtain order for Naloxone (Narcan) for infant
Be prepared to resuscitate infant

187
Q

Onset, Peak, and Duration of IV Pain meds

188
Q

GIve the pain medication over

A

during 2 contractions
- prepare Narcan for baby depression if needed

189
Q

Local anesthesia

A

injection of lidocaine in perineal body
Utilized for repair of episiotomy or lacerations

190
Q

Pudendal block

A

injection of anesthetic to numb pudendal nerve
Anesthetizes the vagina and perineum

191
Q

Pudendal block does not

A

block the pain from contractions

192
Q

Pudendal block complications

A

Toxic reaction to the anesthetic
Rectal puncture
Hematoma
Sciatic nerve block

193
Q

Epidural Block

A

epidural space outside the dura to provide infusion of medication by doctor
-combined with opioid

194
Q

Epidural Block complications

A

coagulation defects, allergy, infection in injection space and hypovolemia

195
Q

Epidural Block adverse effects

A

Maternal hypotension is caused by vasodilation below block
Bladder distention - often requires catheterization
Cather migration
Prolonged second stage (pushing)
Cesarean births
Maternal fever
Pruritus

196
Q

Preeclampsia and clotting diseases do not get a

A

epidural block
- need to know BP before giving

197
Q

Epidural nursing assessment and interventions

A

Preload with 500 to 1000 ml of warmed LR or NS
bedside continuously
blood pressure (q 2-5 min) for 30 min
fetal heart rate (Late or prolonged stop)
Metallic taste, ringing in the ear - possible injection into the bloodstream

198
Q

Correct maternal hypotension from epidural by

A

Left later position
Fluid bolus ( additional bolus if 1st is unsuccessful)
Medication - Ephedrine 5-10 mg IV - remain alert, hypotension can recur at any time

199
Q

Subarachnoid (Spinal) Block

A

Performed just before birth primarily for cesarean births - dense block lasts about 2 hrs.
Local anesthetic combined with an opioid to provide about 24 hrs. of relative comfort

200
Q

Subarachnoid (Spinal) Block adverse effects

A

Maternal hypotension (most common)
Bladder distention - requires urinary catheter placement
Post-dural puncture headache (later)
Spinal fluid is leaking

201
Q

With a postdural HA, sitting up makes the HA

202
Q

General Anesthesia is used for what in labor

A

systematic pain control with loss of consciousness
- refuse/adequate epidural/spinal
- emergency c section

203
Q

General Anesthesia Procedure

A

OR table with hip wedge (right hip) or table tilt
Urinary catheter placed
Surgical site prep
Patient safety straps are applied, and patient is draped
Patient breathes oxygen for 3-5 minutes via mask

204
Q

The surgeon has how long to get the baby out of the mother before the effects of the anesthesia hit the baby?

A

3-5 minutes

205
Q

General Anesthesia adverse effects

A

Maternal aspiration of gastric contents - Cricoid pressure
Respiratory depression in mom and baby - resuscitation equipment
Uterine relaxation - watch for hemorrhage

206
Q

Cricoid pressure is used for

A

maternal aspiration

207
Q

General Anesthesia minimizes maternal effects with

A

Clear fluids or NPO if surgery is expected
Use cricoid pressure to block esophagus during intubation
Administer drugs to speed gastric emptying, raise gastric pH making secretions less acidic

208
Q

General Anesthesia minimize fetal effects with

A

Reduce time from anesthesia to clamping of umbilical cord
Minimal use of anesthetics and sedation until the cord is clamped
Deeper into sleep after clamp

209
Q

Induction/Augmentation is the

A

Artificial methods to stimulate uterine contractions

210
Q

Inductions are associated with ______________, but waiting until ______________ reduces it

A

higher cesarean rate - waiting until 39 weeks - reduces cesarean rates

211
Q

Induction Indications

A

SROM at or near term without labor
Post term pregnancy
Chorioamnionitis - infection
Gestational hypertension
Placental abruptions that are small
Maternal medical conditions
Fetal demise (IUFD) – deterioration stillborn

212
Q

Induction Contraindications**

A

Cephalopelvic disproportion (CPD) – anatomy of pelvis can not deliver or huge baby
Placenta previa or vasa previa
Abnormal fetal presentation - breech, brow, face
Active genital herpes or diagnosis of HIV
Overdistended uterus - multifetal pregnancy
Maternal conditions – heart disease, severe hypertension
Previous uterine surgery - classical cesarean incision

213
Q

Goal of Induction is

A

produce acceptable, effective uterine contractions

214
Q

Induction Risk

A

Excessive uterine activity
Uterine rupture
Maternal water intoxication
Chorioamnionitis
Cesarean birth
Postpartum hemorrhage

215
Q

____________ is determined before scheduled inductions

A

Bishop Score

216
Q

The Bishop score assesses

A

the cervix is favorable for induction of labor status
- Dilation, Length, Consistency, Position, Head station

217
Q

A Bishop score of 6 or less than

A

unfavorable cervix and successful vaginal delivery is less likely

218
Q

Cervical Ripening

A

process to soften and dilate the cervix

219
Q

Oxytocin does what tot he bladder

A

antidiuretic
- retain water
can lead to maternal water intoxication

220
Q

Oxytocin is not for what health diseases?

221
Q

Labor augmentation

A

Stimulation of ineffective Uterine Contractions after onset of spontaneous labor to manage labor dystocia
Lower doses oxytocin are required because cervical resistance is lower
Same precautions apply as with induction of labor

222
Q

Complimentary Therapies for inducing labor

A

Herbal preparations (Evening Primrose)
Bowel stimulation - diarrhea
Nipple stimulation
Sexual Intercourse

223
Q

The 3 Ns for induction of labor

A
  • Neloy (bowel prep)
  • Nipple Stim
  • Nukkey
224
Q

Pharmacological Method of Cervical Ripening

A

Dinoprostone vaginal insert
Misoprostol

225
Q

Dinoprostone vaginal insert (Nurse does)

A

placed in posterior fornix
- left for 12 hours
place recumbent with hip raised or lateral for 2 hours after insertion
continous monitoring

226
Q

Oxytocin may be started within ___-____ mins of removal of Dinoprostone vaginal insert.

227
Q

Dinoprostone vaginal insert

A

gives off prostaglandin to relax and soften the cervix

228
Q

is not recommended for women with

A

previous uterine scar

229
Q

Dinoprostone vaginal insert can cause what to occur?
What do you do if it occurs?

A

Tachysytstole = > 5 contractions in 10 minutes
- remove insert immedaitely

230
Q

Misoprostol

A

medication for abortion if used in the 1st trimester
- softens and relaxes the uterus

231
Q

When can Oxytocin be started after last dose of misoprostol?

232
Q

Misoprostol at higher doses are associated with

A

Tachysystole

233
Q

Misoprostol is never used with

A

previous uterine scar

234
Q

Mechanical methods of Misoprostol

A

Transcervical balloon catheter - cause prostaglandin to increase at cervix
Membrane stripping
Hydroscopic Inserts - Laminaria

235
Q

Laminaria

236
Q

Oxytocin Administration is diluted in an isotonic solution to decrease risk of

A

water intoxication
- Oxytocin retains water

237
Q

Oxytocin is

A

synthetic oxytocin is identical to endogenous oxytocin

238
Q

Most common drug given for induction

A

Oxytocin = powerful

239
Q

Oxytocin receptor sites become

A

desensitized to prolonged exposure

240
Q

Oxytocin is always administered as a

A

2nd IVPB by infusion pump
- most proximal port to be stopped quickly
-start slow titrate gradual by response

241
Q

Oxytocin requires

A

continous fetal monitoring

242
Q

Before starting Oxytocin, the nurse needs to obtain

A

20 minutes of baseline strip of contractions and FHR with variability

243
Q

Oxytocin needs to be stopped if

A

tachysystole or abnormal fetal heart rate patterns

244
Q

Oxytocin affects the bosy within

A

3-5 minutes and half-life of 10

245
Q

Oxytocin causes the contractions to be every

A

3-5 minutes lasting less than 90 minutes

246
Q

Nursing Action if the response to Oxytocin is a Category 2 OR Tachysystole

A

Maternal repositioning – left lateral
IV fluid bolus of at least 500ml of LR
Administer oxygen at 10L/min by non-rebreather
Decrease rate of oxytocin by half
Stop OXYTOCIN if no response and pattern persists

247
Q

Nursing actions for tachysystole with a Category 2 or category 3 FHR pattern

A

Stop OXYTOCIN
IUR plus consider terbutaline/Brethine
Women’s responses are individualized

248
Q

Oxytocin Formula

A

units/mL x 100 = milliunits/mL
Take the desired mu/min x 60 = mu/hr
Divide the desired mu/hr by the mu/min from the bag(have) = mL/hr needed

249
Q

What assessments should be in priority for initial true labor patient

A

fetal heart rate,
perform vaginal exam (SROM, dilation, effacement, presentation, station),
uterine contraction with frequency, duration, and strength,
VS, pain level, and birth plan

250
Q

External Version

A
  • turn the fetus from a breech, oblique, or transverse presentation to cephalic
251
Q

External Version is done at and with

A

37+ weeks with tocolytic is given to relax uterus
US to guide manipulation

252
Q

If te women was Rh negative, what do you give them when doing an external version

A

Rhogam do yo mix of the blood

253
Q

Minimum of ___ _______ EFM with an external version

254
Q

Internal Version

A

change the position of a second twin in a vaginal birth

255
Q

Version contraindications

A

Uterine malformations
Previous cesarean delivery
Placental abnormalities
CPD (Cephalopelvic disproportion)
Multifetal gestation
Oligohydramnios, ruptured membranes

256
Q

Version risks

A

Umbilical cord entanglement
Placental abruption
Fetal compromise
Emergency Cesarean birth
Fetal and maternal blood mixing

257
Q

Amnioinfusion

A

Instillation of isotonic fluid through an IUPC into uterus to restore amniotic fluid volume-used to decrease incidence of variable decelerations
pump 120-180 mL/hour

258
Q

Amnioinfusion needs to _________ before infusion

A

warmed
- if not hypothermia

259
Q

Avoid uterine overdistention by these assessments in amnioinfusion

A

Weigh under pads (also keep patient clean and dry)
Monitor for increased uterine resting tone or no relaxation
Stop infusion if overdistention occurs

260
Q

Forceps or Vacuum Vaginal Birth is used for

A

shortening the 2nd stage of labor

261
Q

Forceps or Vacuum Maternal indications

A

Cardiac or pulmonary disease (prevent bearing down
Exhaustion, ineffective pushing

262
Q

Forceps or Vacuum fetal indications

A

Failure of presenting part to descend in the pelvis
Partial separation of the placenta, often with non-reassuring FHR patterns

263
Q

Forceps or Vacuum contraindications

A

Acute maternal conditions
Severe fetal compromise
High fetal station / cephalopelvic disproportion

264
Q

Forceps or Vacuum risk

A

maternal and fetal/neonatal trauma

265
Q

Forceps

A

locking blades applied to fetal head

266
Q

Vacuum extraction

A

cup attached to fetal head and traction applied

267
Q

Outlet classification technique with extraction

A

Fetal head on perineum

268
Q

Low classification technique with extraction

A

Leading edge of fetal skull at station +2

269
Q

Mid classification technique with extraction

A

Leading edge of fetal skull between 0 and +2 (avoid)

270
Q

Nursing considerations with forceps and VBAC

A

Prior - empty bladder, adequate anesthesia, cervix is completely dilated
Following - assess for maternal and neonatal trauma
NOT FOR CARDIAC PTS

271
Q

C-section

A

Delivery of infant(s) through abdominal surgical incision

272
Q

Factors contributing to the rise of C-sections

A

Inductions with 1st baby, greater risk for primary C-section, leads to repeat C-section
Women having children later - older women more likely to have C-section
Increasing body mass index
C-section birth may be chosen for breech presentation
High threat of litigation
Maternal request for elective C-section

273
Q

C-sections indications

A

Labor dystocia or CPD (Cephalopelvic disproportion)
Hypertension, if prompt delivery is indicated
Conditions labor not advised (diabetes, heart disease etc.)
Active genital herpes or HIV (with high viral load)*
Previous uterine incision*
Persistent indeterminate/abnormal FHR pattern
Prolapsed umbilical cord
Fetal malpresentations – breech, transverse
Placental abruption or previa
Maternal request

274
Q

C-sections contraindications

A

Fetus too immature to survive
Current fetal demise
Maternal coagulation defects that could cause harm to mother during surgery

275
Q

Maternal C-section birth risks

A

Infection - endomyometritis
Hemorrhage
Urinary tract trauma or infection
Thrombophlebitis; thromboembolism
Anesthesia complication
COPD - bruises and fractures

276
Q

Fetal C-section birth risks

A

Injury - laceration, bruising, fractures or other trauma
Inadvertent preterm birth
Transient tachypnea of the newborn – no thoracic squeeze – need suction
Persistent pulmonary hypertension
Lung immaturity (consider lung maturity test)
Amniocentesis for L/S ratio

277
Q

Preparation for a C section

A

Labwork - blood available for transfusion if the mother at risk for hemorrhage
Informed consent - C-Section, anesthesia, support person attendance
Notify - Anesthesiologists, Nursery/NICU team, Pediatrician/Neonatologist
Prophylactic (SCIP) antibiotic - IV dose of ampicillin/cephalosporin given within 30 min of incision
Pubic hair clipped from about 3 inches above the mons pubis along with fronts of upper thighs
Spinal, epidural, or combined is commonly used; general anesthetic for emergencies
Wedge under the hip for left tilt - prevent supine hypotension and promote placental blood flow
Indwelling catheter inserted after regional block established but before surgery
Emergency or general anesthesia catheter must be done before induction
Sterile abdominal prep is done just before sterile draping
Position support person at the head of the bed by mother

278
Q

What 3 types of uterine incisions for C-section?

A

Low transverse (safest) – bikini line
Low vertical
Classic (vertical incision into upper uterus) – VBAC rupture

279
Q

Nurses Responsibilities for C section

A

personnel for mother and baby
- skin to skin as quickly as possible
Care of the Mother
- Observe for hemorrhage
- VSq 5-15 min in PACU
- Assess bladder and fundus
- promote comfort (narcotics)
- Postoperative care (TCDB, TURN, AMBULATION)
Care of the baby
- RN for each baby - care is transition care

280
Q

T/F: “Once a c/s, always a c/s”

A

FALSE; no longer be dictum - research does not to back it up

281
Q

VBAC

A

vaginal birth after cesarean

282
Q

VBAC is associated with

A

decreased maternal morbidity and decreased risk for complications in future pregnancies

283
Q

Risk for VBAC in future pregnancies

A
  • Failed TOLAC (trial of labor after cesarean) - associated with more complications than a repeat c/s
  • VBAC - associated with small but significant risk of uterine rupture
  • Women must make decision about VBAC with all available information including risks
  • Cesarean births - risks including infection and abnormal placental placement in future pregnancies
284
Q

Candidates and Requirements for VBAC

A

with one previous low transverse uterine incision and absence of other uterine scars
Pelvis that is clinically adequate for estimated fetal size
Immediate availability of physician/anesthesia during active labor if emergency C-section is needed
No other contraindications for a vaginal delivery

285
Q

Mgmt for women planning a VBAC

A

Epidural analgesia and anesthesia may be used
Induction and augmentation of labor with oxytocin may be done (NO Misoprostol)
Most authorities recommend continuous electronic fetal monitoring
Nurse must intervene immediately for signs of fetal distress, abruption or uterine rupture

Module 6 (Labor And Delivery) (7 decks)

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