Intrapartum Flashcards
1
Q
Contractions are
A
coordinated and involuntary
- organized, increase frequency and intensity as term closes in
2
Q
The power of the contractions comes from
A
top of the uterus (fundus)
3
Q
Cervical changes in labor
A
Effacement
Dilation
4
Q
Effacement
A
thinning and shortening of the cervix
- estimated as % of original cervical length
5
Q
Dilation
A
opening expressed in cm
- pulled up and fetus is pushed down
6
Q
At 10 cm, the cervix is _________ felt by examiners
A
not
7
Q
Nullipara cervical changes
A
efface early in cervical dilation
8
Q
Multipara cervical dilation
A
cervix is thicker at all points of labor
9
Q
Cardiovascular during contractions
A
fondus muscles constrict on spiral arteries supplying placenta
- temp shunts 300-500 mL OF BLOOD back to mom
10
Q
VS are best assessed during what in labor
A
interval between contractions
11
Q
If the pregnant mother lays on her back it can cause
A
supine hypotension
12
Q
Respiratory system changes of labor
A
depth and RR increase
-Hyperventilation
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
14
Q
GI system changes of labor
A
mobility decrease - N/V and constipation
need calories but NPO
15
Q
Urinary system changes of labor
A
reduce sensation of a full bladder
- inhibit fetal descent
- bladder status evaluated throughput labor for distension
16
Q
Hematopoietic system changes of labor
A
blood loss vaginal birth = 500, Csection 1000mL
CLOTTING FACTORS ELEVATED
- DVT risk in postpartum
17
Q
Anything over
Vgainal 500 mL
Csection 1000 mL
of blood loss indicates
A
hemorrhage
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
19
Q
Fetal Cardiac system in labor
A
Rate or rhythm change may result from normal labor or suggest intolerance to labor stress
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
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
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
23
Q
Ferguson reflex
A
Fetus distends vagina and puts pressure on rectum
Woman feels an urge to push and bear down
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
25
Most favorable pelvis types
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
26
Least favorable pelvis types
Android: Resembles the male pelvis; found in 23% of women; heart-shaped
Platypelloid: Flat pelvis; found in 3% of women; Flat shape
27
The Four P's = Passenger
Fetal Head: bones, sutures, and fontanels
- molding and assists in fetal position
Head Diameters
Fetal lie
Fetal Attitude
Presentation
28
Fetal lie is
orientation of the long axis of the fetus to long axis of the woman
- longitudinal, transverse, oblique, breech
29
Longitudinal lie
cephalic or breech
30
Transverse lie
perpendicular
31
Oblique lie
slanted
32
Fetal Attitude
relationship of the fetal part to one another
- positioning of the head
*Tuck head to chest or extending head to the back*
33
Flexion
good
- smallest diameter part to move though the pelvis
**Tucks the head to chest**
34
Extension
head sticks out with posterior to the back
bad - can cause neck snap if birthed
35
Fetal Presentation
fetal part first entering the pelvis is the *presenting* part
- Cephalic (**vertex**, military, brow, face)
swelling of the face and difficulty passing
36
Frank breech
fetus legs are folded flat up next to head
- bottom the closest to birth canal
37
Complete breech
fetus butt is downward
- both hips and knees are flexed
38
Footling breech
the foot is the 1st thing out and moving
- also prolapsed cord possible
39
Compound presentation
the hand is on top of the head with both entering the pelvis at the same time
40
Shoulder presentation
malpresentation when the fetus is in transverse lie
- leading part of seen is the arm/shoulder/chest
41
The Four P's = Passenger
Fetal Positioning
relationship of point of reference (landmark on the fetus) on the presenting part (vertex, face,breech, shoulder) to the mom's pelvis
42
Fetal Positioning
Right or Left
[resenting part pointing to mom's right or left
43
Fetal Positioning
Occiput or Sacrum
what part coming out 1st
44
Fetal Positioning
Anterior, Posterior, or Transverse
presenting part (occipital bone or sacrum) pointing
- toward the front of mom's body (anterior)
- mom's sacrum (posterior)
- towards hip (transverse)
45
Cardinal Movements of Labor can cause the fetal position
chnage during labor as the fetus moves downward and adapts to the pelvis contours
46
Where would you put the fetal heart monitor if the fetus is facing the Right occiput posterior?
RLQ
47
Where would you put the fetal heart monitor if the fetus is facing the left occiput posterior?
LLQ
48
With antroior and posterior positioning, how do you know what to label them?
where the occipital bone is located
49
OP positioning causes
back pain
50
Pregnant Anxiety
- decrease ability to cope with labor pain
**release catecholamines - inhibit uterine contractions and placenta blood flow**
- enhance perception of pain
51
The Four P's = Psyche
- Anxiety
- Culture and Expectations (language, support, symbols, practices, and norms and restrictions
- Experience
- Support
52
Support in labor
positive effects (physical comfort, advocate, praise, reassure, and presence)
maintain calm and comfortable environment
53
Nurse's Role in Intrapartum
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
54
Factors to causing labor
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
55
Premonitory/Prodromal Signs of Labor
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
56
True Labor contractions
**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
57
True Labor discomfort
May persist as **back pain** in some women
Increasing **intensity and pain**
58
True Labor cervix
Progressive effacement and dilation (most important factor)
59
False Labor contractions
**Inconsistent** in frequency, duration and intensity
Decrease in frequency/intensity **with walking**
60
False Labor discomfort
Localized in abdomen
More annoying than truly painful
61
False Labor cervix
No significant change effacement or dilation
62
When should a patient go to the hospital or birth center?
Contractions (Nullipara = 5 minutes apart; Multipara = 10 minutes apart)
Ruptured membranes
Bright red vaginal bleeding immediately
Low or no fetal mvmt
Concerns
63
A patient SHOULD go to the hospital or birth center if they have these concerns?
severe pain, vision changes, headache, epigastric pain, feeling “something not right”
64
Labor Mechanisms
Descent of the fetal presenting part through the true pelvis
Fetal station
Engagement
65
Fetal station
descent of the fetal presenting part to ischial spines
66
Engagement is what station
0, widest part of the fetal presenting part reaches the level of the aternal ischial spines
67
Cardinal MVMT of Labor Steps
Descent
Engagement
Flexion
Internal rotation
Extension
External rotation
Expulsion
68
1st Stage of Labor is what phase
latent
69
1st Stage of Labor is the only stage with
phases
70
1st Stage of Labor begins with __________ and ends with
onset of **true**labor
complete dilation of the cervix
71
1st Stage of Labor is when what occurs in cardinal mvmt
cervical dilation and effacement
- expanding of the cervix (10 cm)
- station 0
72
What are the 3 phases of 1st stage of labor?
Latent
Active
Transition
73
Latent Phase dilates to
1-3 cm
74
Latent Phase Mother's attitude
pass **unnoticed**
**sociable and excited**
75
Latent Phase contractions
5 minutes apart with gradual intensity
75
Latent Phase average dilation
Primi
Multi
primigravida 1.2 cm/hr., Multipara 1.5 cm/hr.
76
Prolonged Latent phase
primigravida > 20 hrs., multipara > 14 hrs.
77
Active Phase starts at
4 cm and accelerates to 7 cm
78
Active Phase is when cardinal mvmt starts
internal rotation
79
Active Phase contractions
2-5 minutes apart
last 40-60 seconds
- moderate intensity
80
Active Phase Mothers attitude
discomfort increases
increasing anxiety
sense of helplessness
**inwardly focused**
81
Transition Phase starts at
8 and continues to 10 cm
82
Transition Phase cardinal mvmts
descends further into pelvis
- bloody show increases
83
Transition Phase contractions
very strong
1.5-2 minutes apart last 60-90 seconds
84
Transition Phase may feel what reflex?
Ferguson - urge to push and bear down
85
Transition Phase may have the mothers experience what else
leg tremors
N/V
86
Transition Phase ATTITUDE
irritable and lose control
easily discouraged, **overwhelmed, and panicky**
**"can't continue"**
actions are not helping anymore
87
2nd Stage of Labor is the
stage of expulsion
88
2nd Stage of Labor starts with ________ and ends with
Begins with complete dilation (10cm) and 100% effacement and ends with birth of baby
89
2nd Stage of Labor can last how long?
Primigravida is 1 hour and the Multipara is 15 minutes
90
Allow a labor down if
epidural
8-10 cm
**-1 station**
91
2nd Stage of Labor
Ferguson's Reflex signs
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**
92
Episiotomy
incision in perineum made to provide more space for presenting part
93
Mediolateral episiotomy is used for
large infants
94
Episiotomy Indications
Shoulder dystocia
Face presentation
Breech delivery
Macrosomic fetus
Vacuum or forceps-assisted births
95
Episiotomy Risk
Infection
Perineal pain
- they can still tear
96
Laceration
tears in the perineum occurring at delivery
97
1st degree laceration
perineal skin and vaginal mucous membrane
98
2nd degree laceration
skin, mucous membrane, **and fascia of the perineal body**
99
3rd degree laceration
skin, mucous membrane, muscle of the perineal body, and **extends to rectal sphincter**
100
4th degree laceration
extends into rectal mucosa **exposing the lumen of rectum**
101
3rd stage of Labor start with ______ and end with
Begins with birth of baby and ends with expulsion of placenta
102
How long does the 3rd stage of labor last?
of 5-15 minutes
103
Signs of placental separation
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**
104
How does the uterus prevent a hemorrhage
contract firmly to compress open vessels
105
Nursing Interventions for preventing a hemorrhage after expulsion of the fundus
Massage the fundus!
Administer uterotonic medications
106
If the placenta has not dropped after minutes the physician will
grab it out
107
If the uterus does not clamp down, what could occur?
postpartum hemorrhage
108
What are the 2 ways placentas are described when delivered?
Shiny Shultze (fetal side iwth membranes and cord)
Dirty Duncan (maternal with spiral arteries)
109
Uterotonic Medications
Oxytocin
Methylergonovine
Carboprost Tromethamine
Misoprostol
110
What is the 1st choice of uterotonic medications?
Oxytocin
111
Methylergonovine is used for
IV emergency only
CONTRAINDICATED for Hypertensive pts
112
Carboprost Tromethamine will cause
massive diarrhea
113
Carboprost Tromethamine CONTRAINDICATED in
asthma pts
114
4th stage of labor is
postpartum with delivery of placenta
115
Initial delivery room is now focused on
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
Nursing Responsibility for Labor
Establish a Therapeutic Relationship
Assess Maternal-Fetal Status (pregnancy hx and prenatal record, psychosocial)
117
Establish a good relationship with the patient during labor by
Interpreter (not a family member)
Obtain consents
Respect cultural values
Ask and try to complete their Birth plan
118
Imminent birth means to
obtain information from support persons and perform quick focused assessments
119
Initial Nursing Assessment
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
When assessing a GTPALM, what do you need to be cautious about asking in front of others?
Abortions
- ask in privacy for honesty
120
The pregnant laboring mother needs to have a minimum of an
INT for emergency
121
Sterile Vaginal Exam (SVE)
SINGLE STERILE GLOVE WITH WATER-SOLUBLE LUBRICANT
- no lube if just ROM
122
Sterile Vaginal Exam (SVE) used to assess
Assess for ruptured or bulging membranes
Assess cervical dilation, effacement, position and consistency
Assess for fetal station, presentation, and position
123
Sterile Vaginal Exam (SVE) performed to
Before analgesia or anesthesia
Determine labor progression and when second-stage pushing can begin
124
Sterile Vaginal Exam (SVE) frequency depends on
parity, status of membranes and speed of labor
125
You can use lubricant if the mother has done what for a SVE
MEMBRANE RUPTURES
126
SROM means
spontaneous rupture of membranes
127
SROM occurs
before or during the onset of labor
128
SROM means
Protective barrier is lost - organisms have access to the intrauterine cavity
129
SROM needs to have a delivery within
24 hours
130
If the patient has not given birth within 24 hours of SROM, then what can develop
chorioamnionitis
131
After ROM, immediate assessment of
fetal heart rate
132
What do you document when ROM occurs
date, time, color, odor, and amount of fluid after ROM
133
Polyhydramnios
- excessive amniotic fluid
Abnormalities such as TE fistula or GI obstruction (also diabetic mother)
134
Oligohydramnios
- small quantity of amniotic fluid
Placental insufficiency or urinary tract abnormalities
135
After SROM, when do you check the temperature
every 2 hours
136
With SROM is ambulation allowed?
yes, if normal FHR and fetal head is engaged
137
Normal Amniotic fluid is
clear with white flecks (vernix) with mild musty odor
138
What amniotic fluid needs to reported
Meconium-stained fluid
Foul smelling or yellow
139
Meconium-stained fluid
fetal compromise
140
Foul-smelling or yellow
chorioamnionitis
141
PROM
Premature rupture of membranes
- SROM before onset of labor
142
PPROM
Preterm premature rupture of membranes
- SROM before 37 weeks
associated with >1/3 of preterm births
143
Ruptured membrane assessments
Nitrazine paper
Fern Test (PPROM - amniotic fluid present)
Amnisure ROM test
144
Nitrazine paper
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
Fern Test
Speculum exam:** Assess for fluid in vaginal vault**
Place fluid from vagina vault on glass slide and allowed to dry
146
Amnisure ROM test
Rapid, non-invasive immunoassay lab test; ~ 99% accurate
147
Assisting with Rupturing Amniotic Fluid aka
AROM or amniotomy
- amnicot
148
Amniotomy is used fot
induction or augmentation of labor
149
Before an Amniotomy can be done, it is vital to ensure the fetal head is
engaged
150
Amniotomy allows dor
internal electronic fetal monitoring (FSE) and internal contraction monitoring (IUPC)
151
What are the risks of a ROM
PROLAPSED of the umbilical cord
152
Prolapsed cord means
Cord slips down in gush of fluid
Cord is compressed between presenting part and pelvis creating
153
Prolapse cord causes what to show up on the FHM
Variable deceleration
Prolonged decelerations
Bradycardic FHR
154
Assess the FHR for at least how long after ROM
1 MINUTE
155
Nursing Responsibilities for 1st Stage Labor
FHR every
30 min. latent,
q 15-30 min. active,
q 5-15 min transition
- continuous FHM if high risk
156
Nursing Responsibilities for 1st Stage Labor
BP and Temp
- B/P q 1hr. side-lying position, between contractions, more frequent if abnormal
- Temperature q 4 hr. until ROM, then q 1 hr.
157
Nursing Responsibilities for 1st Stage Labor
Contractions doc
frequency, duration, and intensity
158
Nursing Responsibilities for 1st Stage Labor
Urine status
Dip glucose
Urine status q 2hr., dip glucose/protein q 8 hrs.
159
Nursing Responsibilities for 1st Stage Labor
Coping
(breathing exercises, and effleurage)
Hyperventilation - breath into paper sack
160
Nursing Responsibilities for 1st Stage Labor
Comfort
Patient - oral care, peri care - frequent pad changes
Offer analgesia / anesthesia in active phase
Support persons should be included in teaching and support
161
Effleurage
muscular massages
162
Nursing Responsibilities for 2nd Stage Labor
Pain
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
Nursing Responsibilities for 2nd Stage Labor
Observe
perineal area
Bloody show, amniotic fluid color changes, bulging of perineum and anus
Visibility of fetal presenting part
164
Nursing Responsibilities for 2nd Stage Labor
Teach
Pushing positions - squatting, side-lying, high fowlers, lithotomy
**Open glottis “gentle” pushing - exhale through open mouth while pushing**
165
Nursing Responsibilities for 2nd Stage Labor
Set up for
delivery - delivery table, perineal cleansing, mirror for viewing
166
Nursing Responsibilities for 3rd Stage Labor
**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
quantitative blood loss assessment
weight of all pads minus pad weight
168
keep baby on mom's chest as long as it does not need
resuscitation
169
What are the 2 components of pain during birth?
Physiologic and psychological
170
Labor pain is not constant but
intermittent
171
Adverse effects of excessive pain
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
Pain goal is
positive birth experience, as absence of pain is unrealistic
173
Factors influencing perception or tolerance of pain
Labor **intensity**, cervical readiness
Fetal position - fetal OP position - **sacral discomfort**
Pelvic **anatomy**
Fear, anxiety, and fatigue
**Culture
Caregiver interventions**
174
Preparation childbirth classes help do what with pain
Preparation reduces anxiety and pain
Bradley; Lamaze-Woman has “tools” for labor
Support system
175
Gate Control Theory of Pain
Relaxation
**Cutaneous stimulation (effleurage)
Hydrotherapy** - (box 13.1 in book pg.326) – warm bath/shower
Mental Stimulation
176
Advantages to non-pharmacological pain management
Do not slow labor like pain meds and epidural
No side effects or risk for allergy
Only realistic option in advanced, rapid labor
177
Limitations to non-pharmacological pain management
level of control pain is not achieved
178
Breathing Techniques for Labor
Cleansing Breath
Slow-paced breathing
Modified-paced breathing
Patterned-paced breathing
Breathing to prevent pushing
179
During 2nd stage of labor, you should use what type of breathing
open glottis pushing
180
Analgesia is gven in what stage of labor
mid-active phase of labor (4-7 cm – patient goes in to focus on pain)
- 30 minutes before labor
181
If the analgesia is given too early
can slow labor
182
If the analgesia is given too late
neonatal depression
183
Anesthesia
Local - episiotomy or perineal site
Regional block - epidural, spinal - interruption of nerve impulses, cause vasodilatation and hypotension
General anesthesia: abrupt emergency
184
Pain Mgmt Assessment of Pregnant Labor
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
Intervention Before Pain Mgmt of Pregnant Labor
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
Intervention After Pain Mgmt of Pregnant Labor
**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
Onset, Peak, and Duration of IV Pain meds
5
30
1 hour
188
GIve the pain medication over
during 2 contractions
- prepare Narcan for baby depression if needed
189
Local anesthesia
injection of lidocaine in perineal body
Utilized for repair of episiotomy or lacerations
190
Pudendal block
injection of anesthetic to numb pudendal nerve
Anesthetizes the vagina and perineum
191
Pudendal block does not
block the pain from contractions
192
Pudendal block complications
Toxic reaction to the anesthetic
Rectal puncture
Hematoma
Sciatic nerve block
193
Epidural Block
epidural space outside the dura to provide infusion of medication by doctor
-combined with opioid
194
Epidural Block complications
coagulation defects, allergy, infection in injection space and hypovolemia
195
Epidural Block adverse effects
**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
Preeclampsia and clotting diseases do not get a
epidural block
- need to know BP before giving
197
Epidural nursing assessment and interventions
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
Correct maternal hypotension from epidural by
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
Subarachnoid (Spinal) Block
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
Subarachnoid (Spinal) Block adverse effects
**Maternal hypotension (most common)**
Bladder distention - requires urinary catheter placement
**Post-dural puncture headache (later)
Spinal fluid is leaking**
201
With a postdural HA, sitting up makes the HA
WORSEN
202
General Anesthesia is used for what in labor
systematic pain control with loss of consciousness
- refuse/adequate epidural/spinal
- emergency c section
203
General Anesthesia Procedure
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
The surgeon has how long to get the baby out of the mother before the effects of the anesthesia hit the baby?
3-5 minutes
205
General Anesthesia adverse effects
**Maternal aspiration of gastric contents - Cricoid pressure**
Respiratory depression in mom and baby - resuscitation equipment
Uterine relaxation - watch for hemorrhage
206
Cricoid pressure is used for
maternal aspiration
207
General Anesthesia minimizes maternal effects with
**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
General Anesthesia minimize fetal effects with
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
Induction/Augmentation is the
Artificial methods to stimulate uterine contractions
210
Inductions are associated with ______________, but waiting until ______________ reduces it
higher cesarean rate - waiting until 39 weeks - reduces cesarean rates
211
Induction Indications
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
Induction Contraindications**
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
Goal of Induction is
produce acceptable, effective uterine contractions
214
Induction Risk
Excessive uterine activity
Uterine rupture
Maternal water intoxication
Chorioamnionitis
Cesarean birth
Postpartum hemorrhage
215
____________ is determined before scheduled inductions
Bishop Score
216
The Bishop score assesses
the cervix is favorable for induction of labor status
- Dilation, Length, Consistency, Position, Head station
217
A Bishop score of 6 or less than
unfavorable cervix and successful vaginal delivery is less likely
218
Cervical Ripening
process to soften and dilate the cervix
219
Oxytocin does what tot he bladder
antidiuretic
- retain water
can lead to maternal water intoxication
220
Oxytocin is not for what health diseases?
cardiac
221
Labor augmentation
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
Complimentary Therapies for inducing labor
Herbal preparations (Evening Primrose)
Bowel stimulation - diarrhea
Nipple stimulation
Sexual Intercourse
223
The 3 Ns for induction of labor
- Neloy (bowel prep)
- Nipple Stim
- Nukkey
224
Pharmacological Method of Cervical Ripening
Dinoprostone vaginal insert
Misoprostol
225
Dinoprostone vaginal insert (Nurse does)
placed in posterior fornix
- left for 12 hours
**place recumbent with hip raised or lateral for 2 hours after insertion**
**continous monitoring**
226
Oxytocin may be started within ___-____ mins of removal of Dinoprostone vaginal insert.
30-60
227
Dinoprostone vaginal insert
gives off prostaglandin to relax and soften the cervix
228
is not recommended for women with
previous uterine scar
229
Dinoprostone vaginal insert can cause what to occur?
What do you do if it occurs?
Tachysytstole = > 5 contractions in 10 minutes
- remove insert immedaitely
230
Misoprostol
medication for abortion if used in the 1st trimester
- softens and relaxes the uterus
231
When can Oxytocin be started after last dose of misoprostol?
4 hours
232
Misoprostol at higher doses are associated with
Tachysystole
233
Misoprostol is never used with
previous uterine scar
234
Mechanical methods of Misoprostol
Transcervical balloon catheter - cause prostaglandin to increase at cervix
Membrane stripping
Hydroscopic Inserts - Laminaria
235
Laminaria
seaweed
236
Oxytocin Administration is diluted in an isotonic solution to decrease risk of
water intoxication
- Oxytocin retains water
237
Oxytocin is
synthetic oxytocin is identical to endogenous oxytocin
238
Most common drug given for induction
Oxytocin = powerful
239
Oxytocin receptor sites become
desensitized to prolonged exposure
240
Oxytocin is always administered as a
2nd IVPB by infusion pump
- most proximal port to be stopped quickly
-**start slow titrate gradual by response**
241
Oxytocin requires
continous fetal monitoring
242
Before starting Oxytocin, the nurse needs to obtain
20 minutes of baseline strip of contractions and FHR with variability
243
Oxytocin needs to be stopped if
tachysystole or abnormal fetal heart rate patterns
244
Oxytocin affects the bosy within
3-5 minutes and half-life of 10
245
Oxytocin causes the contractions to be every
3-5 minutes lasting less than 90 minutes
246
Nursing Action if the response to Oxytocin is a Category 2 OR Tachysystole
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
Nursing actions for tachysystole **with** a Category 2 or category 3 FHR pattern
**Stop OXYTOCIN**
**IUR plus consider terbutaline/Brethine**
Women’s responses are individualized
248
Oxytocin Formula
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
What assessments should be in priority for initial true labor patient
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
External Version
- turn the fetus from a breech, oblique, or transverse presentation to cephalic
251
External Version is done at and with
37+ weeks with tocolytic is given to relax uterus
US to guide manipulation
252
If te women was Rh negative, what do you give them when doing an external version
Rhogam do yo mix of the blood
253
Minimum of ___ _______ EFM with an external version
1 hour
254
Internal Version
change the position of a second twin in a vaginal birth
255
Version contraindications
Uterine malformations
Previous cesarean delivery
Placental abnormalities
CPD (Cephalopelvic disproportion)
Multifetal gestation
Oligohydramnios, ruptured membranes
256
Version risks
Umbilical cord entanglement
Placental abruption
Fetal compromise
Emergency Cesarean birth
Fetal and maternal blood mixing
257
Amnioinfusion
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
Amnioinfusion needs to _________ before infusion
warmed
- if not hypothermia
259
Avoid uterine overdistention by these assessments in amnioinfusion
Weigh under pads (also keep patient clean and dry)
Monitor for increased uterine resting tone or no relaxation
Stop infusion if overdistention occurs
260
Forceps or Vacuum Vaginal Birth is used for
shortening the 2nd stage of labor
261
Forceps or Vacuum Maternal indications
Cardiac or pulmonary disease (prevent bearing down
Exhaustion, ineffective pushing
262
Forceps or Vacuum fetal indications
Failure of presenting part to descend in the pelvis
Partial separation of the placenta, often with non-reassuring FHR patterns
263
Forceps or Vacuum contraindications
Acute maternal conditions
Severe fetal compromise
High fetal station / cephalopelvic disproportion
264
Forceps or Vacuum risk
maternal and fetal/neonatal trauma
265
Forceps
locking blades applied to fetal head
266
Vacuum extraction
cup attached to fetal head and traction applied
267
Outlet classification technique with extraction
Fetal head on perineum
268
Low classification technique with extraction
Leading edge of fetal skull at station +2
269
Mid classification technique with extraction
Leading edge of fetal skull between 0 and +2 (avoid)
270
Nursing considerations with forceps and VBAC
Prior - empty bladder, adequate anesthesia, cervix is completely dilated
Following - assess for maternal and neonatal trauma
NOT FOR CARDIAC PTS
271
C-section
Delivery of infant(s) through abdominal surgical incision
272
Factors contributing to the rise of C-sections
**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
C-sections indications
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
C-sections contraindications
**Fetus too immature to survive**
Current fetal demise
Maternal coagulation defects that could cause harm to mother during surgery
275
Maternal C-section birth risks
**Infection - endomyometritis**
Hemorrhage
Urinary tract trauma or infection
Thrombophlebitis; thromboembolism
Anesthesia complication
COPD - bruises and fractures
276
Fetal C-section birth risks
**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
Preparation for a C section
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
What 3 types of uterine incisions for C-section?
**Low transverse (safest) – bikini line**
Low vertical
Classic (vertical incision into upper uterus) – VBAC rupture
279
Nurses Responsibilities for C section
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
T/F: “Once a c/s, always a c/s”
FALSE; no longer be dictum - research does not to back it up
281
VBAC
vaginal birth after cesarean
282
VBAC is associated with
decreased maternal morbidity and decreased risk for complications in future pregnancies
283
Risk for VBAC in future pregnancies
- 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
Candidates and Requirements for VBAC
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
Mgmt for women planning a VBAC
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**
