Intrapartum 2 Flashcards
Maternal Assessment during Labor and Birth:
a vaginal examination or ultrasound assessment is performed to assess cervical dilation ONLY IF
- If there is no vaginal bleeding upon admission.
- After which it is monitored periodically as necessary to identify progress.
WHAT IS ASSESSED DURING labor/birth
- Woman-centered care
- Upon Admission
- Vital Signs: Temp, BP, HR, RR
- Pain & Response to interventions
- Vaginal Exam- Only if NO vaginal bleeding
- Assess cervical
-Dilation
-Effacement
-Position
Vaginal Assessment IS DONE every
4 hrs
Vaginal assessment includes:
- cervix: dialation 0-10cm
- effacement 0%, 50%, or 100%
- Fetal: position, station, skull
- Rupture of membranes- PRIORITY CHECK
UNRUPTURE of membranes will feel like
soft bulge
Why is Rupture of membranes important to check ?
- identify FHR deceleration indicating cord compression secondary to cord prolapse.
To confirm Rupture of membranes what test is done?
- Nitrazine yellow dye swab is used on sample of fluid from vagina.
- POS rupture = swab turns blue-green with PH 6.5 - 7.5 (amniotic fluid is more ALKALINE)
- NEG rupture = swab remains yellot to olive green with ph 5-6.
AFTER rupture of membranes, signs of intrauterine infection sinclude
- maternal fever
- fetal and maternal tachycardia
- foul odor of vaginal discharge
- increase in white blood cell count
Assessing Uterine contractions:
When PALPATIONIng uterine describe how it feels.
Place pads of your fingers on fundus & describe how it feels:
* Tip of nose (mild)
* Chin (moderate)
* **Forehead (strong) **
What intensity (in mm/Hg) is needed for cervical dialation to start
- 30 mm Hg or greater are needed for cervical dilation
- during labor: intensity reaches @ 50 to 80 mm Hg.
Maneuver 1:
soft and irregular feel on fundus is
the buttocks
Maneuver 2:
hard and smooth and round feel on fundus is
the head
Maneuver 2:
finding fetal back should feel
hard and smooth
Maneuver 3:
If presenting part in symphysis pubis is ROUND, FIRM, AND ballattable
the head
Maneuver 3:
If presenting part in symphysis pubis is soft and irregular
the buttocks.
Manuever 4:
(turn facing moms feet for this step only)
if palpate a hard area on OPPOSITE SIDE Of fetal back fetus is in
flexion - this is what we want.
hard area on opposite side of fetal back that means you have touched its chin
Manuever 4:
(turn facing moms feet for this step only)
if palpate a hard area on SAME SIDE of fetal back then fetus is in
Extension - area palpated is the occiput (back of head)
cultural considerations with pain:
- Placing a hatchet or knife under the bed – cuts pain
APPALACHIAN culture
cultural considerations with pain:
* Moms at birth
Asian, Latina, Orthodox Jew
cultural considerations with pain:
* remain quiet
Cherokee, Hmong, Japanese
MOM non-coping signs
- crying/fear
- no focus or concentrated
- panicked during contractions
- jitteriness
- clawing/biting
- tense
Coping with labor:
Nurse should observe for
- cues for 15-30 mins and throughout labor
Nonpharmacologic measures include
- Continuous Labor Support - Assisting
- hydrotherapy- tub
- ambulation and position change (q30 mins)
- acupuncture and acupressure
- patterned-paced breathing (pursed lips)
- Attentionc focus/imagery
- massage/effleurage (stroking of abdomen)
- heat or cold applications
Hydrotherpy only to be used when pt is
in active labor >6 cm dialated
Pharmacologic Measures for pain relief during labor includes
- Systemic, Regional, or Local Anesthesia
- Neuraxial Analgesia/Anesthesia - Epidural Or Intrathecal
System Analgesia
- adminsitered via: PO, IM, IV
- Most important complication respiratory depression
Systemic Analgesia:
opioids given CLOSE TO TIME OF BIRTH can cause
CNS depression in newborn
Reversal drug of Opioids
naloxone (narcan)
categories of drugs used in SYSTEMIC ANALGESIA
- Opioids: butorphanol, nalbuphine, meperidine, morphine, fentanyl
- Ataractics: hydroxyzine, promethazine, prochlorperazine
- Benzodiazepines: diazepam, midazolam
INHALED ANALGESIC
- Nitrous oxide “Laughing Gas”
- 50% nitrous oxide gas
- 50% oxygen
- using a mask or mouthpiece
- Maternal control-self administered
NITROUS OXIDE SIDE EFFECTS
- N/V, dizziness, dysphoria
- NO fetal abnormalities to its use
Regional Anesthesia is the LOSS OF PAIN SENSATIoN below
T8 - T10
- Without loss of consciousness
- With or without added opioids
DIFFERENT TYPES OF REGIONAL ANESTHESIA
- Epidural Block
- Combo – Spinal/Epidural
- Local Infiltration (ONLY on site)
- Pudendal block (in perineum)
- Intrathecal (spinal) Anesthesia/Analgesia
Type of anesthesia:
INJECTIONof a local anesthetic agent and an opioid analgesic agent INTO THE LUMBAR EPIDURAL SPACE
EPIDURAL ANALGESIA
CONTRAINDICATIONS for Epidural analgesia
- H/O spinal surgery or abnormalities
- Coagulation defects
- Cardiac disease
- Obesity
- Infections
- Hypovolemia
- On anticoagulation
type of anesthesia:
- Combines a spine and epidural anesthesia
- one needle in epidural space and other in subarachnoid space
- Opioid WITHOUT anesthesia
Combo spinal and epidural analgesia
Advantages of COMBO
- Works faster (3 to 5 mins)
- Allows ambulation “walking epidural”
- Lower incidence of urinary retention
TYPE OF ANESTHESIA:
- Local anesthetic in perineal area before an episiotomy
- Doesn’t alter pain of contractions
- Doesn’t cause side effects
Local infiltration
(numbs immediate area)
type of anesthesia:
- Local anesthetic in pudendal nerve
- Pain relief - lower vagina, vulva, & perineum
Pudendal Nerve Block
local infiltration and Pudendal nerve block INDICATIONS
- 2nd stage of labor
- Episiotomies (cut (incision) made in the tissue between the vaginal opening and the anus during childbirth. This area is called the perineum)
- Birth with forceps or vacuum extraction
- Takes 15 mins to work
- NO common maternal or fetal complications
TYPE OF ANESTHESIA:
- Anesthetic agent with or without opioids
- INTO Subarachnoid space
- INTRATHECAL- into cerebral spinal fluid
- For emergent or elective C/S
SPINAL (INTRATHECAL) ANESTHESIA
Compared to epidurals, SPINALs are
- Easy to administer
- Need smaller med. Vol.
- Rapid onset pain relief
- Less - Newborn Respiratory Depression
- NO motor blockade
ADVERSE REACTIONS TO SPINAL ANALGESIA
- HYPOTENSION
- SPINAL HEADACHE
TYpe of anesthesia:
- reserved for ER cesarian births- no time for spinal/epidurals
- OR if woman contraindicates for regional anesthesia
- RAPID loss of consciousness
GENERAL ANESTHESIA
How is GENERAL ANESTHESIA administered
- IV or inhalation
- UNCONSCIOUS followed by MUSCLE RELAXANT & INTUBATION
Complications with General anesthesia
- fetal depression
- maternal comiting & aspiration
Nursing considerations:
Antacids to administer during General anesthesia to REDUCE GASTRIC ACIDITY
-
Nonparticulate (clear) ORAL antacid: Bicitra or sodium citrate
OR - Proton pump inhibitor: protonix as ordered
Do ALL anesthetic agents cross placental barrier and affect fetus?
YES
ADmission history:
MAIN things that nurses can do during admission assessment for pregnant women.
- EDD, VS, GTPAL
- perform leopold’s
- perform vaginal exam
- assess & interpret FHR to contractions
- Fundal height measurement
Labs needed include
- UA
- Blood Type & RH
- Syphilis
- Hep B
- HIV
- Drug Screening
- Group B Strep
RX GIVEN AT ONSET OF LABOR OR ROM (rupture of membrances)
PCN (penicillin)
What is an episiotomy
a cut (incision) through the area between your vaginal opening and your anus to provide MOER SPACE to the presenting fetus heaad.
Nursing interventions:
During 1st stage of labor
- Provide clear fluids
- Maintain parenteral fluids
- Keep perineal area clean and dry
- Check on bladder status q 2 hr. & encourage voiding
- Encourage maternal movement
Nursing interventions:
During 2nd stage of labor
IF no complication= nurses dont control this stage rather empower mom
* direct mom towards effective pushing positions
* perineal lacerations occur- extent of lacerations is defined by its DEPTH.
PERINEAL lacerations: 1st degree
laceration extends through the skin
Perineal lacerations: 2nd degree
laceration extends through the muscles of the perineal body (muscles)
Perineal lacerations: 3rd degree
Through anal sphincter
muscle
Perineal lacerations: 4th degree
involves anterior rectal wall
SIGNS of 2nd stage of Labor
- incr of bloody show
- rectal or perineal pressure
- crowning ( see babys head)
2nd stage of labor begins and ends when
- Begins with cervical completion
- Ends with birth of the infant
Once fetal head emerges:
Birth attendant explores fetal neck for nuchal cord if YES
cord is slipped OVER HEAD
AFTER HEAD DELIVERY
- Birth attendant suctions mouth FIRST & nose SECOND
- umbilical cord is double clamped & cut
WHEN does 3rd stage of labor occur
delivery of baby to delivery of placenta
3 IMPORTANT HORMONES PLAY A PART IN 3RD STAGE OF LABOR
Oxytocin
endorphins (cause analgesic effect)
adrenaline
The hormone oxytocin causes
- uterine contractions
- helps the woman enact instinctive mothering behaviors such as holding the newborn close to her body and cuddling the baby.
CONTINUATION of regular contractions does what
- Leads to decrease in uterine size
- Helps with placental separation
Nurses during 3rd stage of labor need to observe s/s of placental separation which include
- Firmly contracting uterus
- Change in uterine shape from discoid to globular ovoid
- Sudden gush of dark blood from vaginal opening
- Lengthening of umbilical cord protruding from vagina
NURSES CRUCIAL ROLE IN 3RD STAGE OF LABOR
- To protect natural hormonal process by
- Ensuring unhurried & uninterrupted contact between mom & baby after birth
- Providing warmed blankets to prevent shivering
- Allowing skin-to-skin contact with initial breastfeeding.
SOFT AND WEAK UTERUS AFTER delivery
most common cause of Post-partum hemorrhage
uterine atony
(uterine tone)
Nurses during 4th stage of labor should check V/S in the 1st hour of birth every
q 15 min then
q 30 min
* BP should remain stable
* Close obsevation for hemorrhage
Baby head-to-toe VS are done every
15 mins until stable
4th stage of labor:
Assess
- perineal and vaginal area
- lochia amount: blood loss after birth
- Bladder- if full, displaces fundus to the right of midline.
4th stage of labor:
assessing fundus
- needs to remain firm= prevent excessive postpartum bleeding
- feels/size/consistency of a GRAPEFRUIT
- located in midline and below umbilicus
- if boggy- massage it until it is firm!!!!!
