intrapartum 2 Flashcards
admission
greet and raport, orient, informed consent, notify hcp/cnm
admission assessment
in labor? term or preterm
rf?: htn, bleed, DOPE (diabetic, obese, previous large, excessive weight gain)
ambulation or bed rest
freq of monitoring - continuous, intermittent
birth plan (env, pain mng, emergency, newborn care)
support
admission PA
all regular
ob hx: GTPAL, any problems present or past, fetal acitvities
labs = blood type, Rh, cbc, type and screen
GBS: + = start abx (PCN or clindamycin)
rubella (immune, non, equivocal)
urine (protein)
EFM
toco on fundus, US = where fetal shoulders are (loudest HB)
FSE
firm part, avoid sutures and fontanelle
not affected by moms movement
advantages: clearer tracings, provide better info about variability, nurse can place
disadvantages: infection, injury, requires ROM and sufficient dilation
EFM - US
advantages: continuous graphic recording, baseline, variability, changes in FHR, noninvasive, no rupture of membranes, nurse can place
disadvantages: interference from maternal and fetal movement, weak signal, tracing may become sketchy and difficult to interpret
EFM - toco
advantages: noninvasive, easy to place, may be used before and after ROM, can be used intermittently, permanent continuous recording, nurse can place and palpate contractions for intensity
disadvantages: must compare subjective findings with monitor, bel may become uncomfortable and require freq readjustment, mother may feel limited to move, dose not provide intensity
IUPC
when toco insufficient
intensity! want MVU sum >200 and <300 in 10 min, c <2min, <5 c in 10 min want q2-3min, resting tone should be <25mmHg
advantages: intensity, allow accurate timing of contractions, permanent record of uterine activity
disadvantages: must have ROM and adequate dilation, invasive, increase risk of infection or uterine perforation, CI with active infection, use with low lying placental can result in placenta puncture, OB or midwife place
labor status assessment
membranes intact or ruptured (SROM or AROM) - time, color (clearn, bloody, meconium), amount, odor (COAT)
c: freq, duration, intensity
vaginal exam: bimanual, 2 fingers; cervix: post, mid, ant; dilation, effacement; fetal presentation and station
fetal position: US, leopold’s maneuver
membrane status: nitrazine tape
- = yellow, urine?
+ = deep blue, alkaline amniotic fluid
membrane status: ferning test
crystalized formation
+ = ferning in amniotic fluid slide under microscope
membrane status: amnisure
swab of discharge -> solvent (1min) -> test strip (5min) -> results (<15 min)
+ = 2 lines
- = 1 line
invalid = o lines
fetal position: leopolds maneuver
help determine where to put US
1st: head (hard) or butt (soft) at fundus
2nd: arms (bumpy) or back (smooth) side of abd
3rd: presenting part at symphysis pubis, hard = head, hard to feel or soft = butt
4th: outline with palms, higher head = feel more
fetal status
baseline FHR (110-160) at least 10 min
change in FHR: accel (</>32 wk), decel (early, late, variable, prolonged, sinusoidal)
periodic = with contraction, episodic = no contraction
variability (absent, minimal, mod, marked), fetal brady (<110 for 10 min, bleeding)), fetal tachy (>160 for 10 min, temp!, med, infection) -> fetal O2
decels
VEAL CHOP
early = head compression
late = uteroplacental insuff (low bp leads to low perfusion)
variable = cord compression, abrupt (umbilical cord prolapse)
prolonged = > 2 min but <10 min, decrease greater than 10 from baseline
sinusoidal = perfect wave, acidosis, deliver
variability
absent = undetectable
minimal = <5, sleep, pain med, mgso4
mod = 6-26, good!
marked = >25
non reassuring FHR patterns
variable decel (persistent and severe), late decel, prolonged decel, no variability, sinusoidal, severe brady or prolonged tachy
category 1
normal
110-160, mod, no late or variable decel
category 2
indeterminate
minimal or marked, no accel, prolonged decl, recurrent variables or late decels with moderate variability
category 3
abn -> deliver
sinusoidal, absent, recurrent lates, variables, or brady
FHR nc
UNCOIL
change position -> L side
oxytocin with late or prolonged -> turn off
increase IVF
o2 (10L/tight non rebreathing face mask)
notify MD/midwife
toco if contracting to decrease uterine activity (terbutaline)
prep for delivery if uncorrectable (vaginal near = forceps or vacuum, vaginal remote = c/s
stage 1: latent nc
anticipatory guidance, infor and support, encourage ambulation, ice chips/fluid, VS q1, temp q4 or q2 if ROm, FHR q30-60 (risk and normality)
stage 1: active nc
palpate q15-30 or continuous, vaginal exams, void q1-2, start IV fluid infusion, auscultate FHR q15-30, VS q15-30, color, odor, amount + FHR when ruptured; change position and pads often
stage 1: transition nc
palpate q15 or continuous, vaginal exams, FHR q15-30, assess q15-30, assits with breathing, keep from pushing until fully dilated, peanut ball (epidural, rotation OP->OA)
stage 1 comfort measures
clear fluids/ice, ambulation, hydrotherapy, perineal care, relax between contractions, distract, effleurage (firm stroke with palm of hand), firm P on back or sacrum, visualization, controlled breathing, position change
stage 2 nc
vaginal exam, FHR q5-15, VS q30, support and info about labor progress, assist with push, assist with hcp or cnm with birth
stage 2 comfort measures
same as stage 1
cool cloths, rest btw, fluid/ice, reassure, assist into pushing position, assist with push
stage 2: s of imminent birth
uncontrollable urge to bear down, perineum bulge, increase bloody show
stage 3 newborn care
stimulate, warmth, VS, APGAR, identification, PA, attachment and kangaroo
stage 3 maternal care
placental delivery
doc time of delivery and intactness
stage 4 nc
vs q15 for 1st hour, temp q1, oxytocin 20U, palpate fundus q15 for 1hr (form or boggy - bleed)
assess vaginal bleed, perineum and pericare, need to void, bonding and kangaroo care, feeding, count instrument and sponge after delivery
stage 4 comfort measures
heated blanket, food.fluid, icepack to perineum, pain meds, rest
stage 4 immediate post birth danger S
hypoT, tachy, uterine atony, excessive bleed, hematoma
d/c to postpartum care
stable VS and bleeding, undistended bladder, firm fundus, return or sensation, admit baby with mom to postpartum or newborn nursery (match bracelets)
maternal adaptations following birth
BP: return to prelabor level,
pulse: slightly lower than when in labor
uterine fundus: midline at umbilicus or 1 to 2 finger breadths below the umbilicus
lochia: red (rubra), small to mod amount (from spotting on pads to 1/4 to 1/2 of pad covered in 15 min)
bladder: nonpalpable
perineum: smooth, pink, without bruising or edema
emotional state: wide variation, including excited, exhilarated, smiling, crying, fatigued, verbal, quiet, pensive, and sleepy
early decel
head compression
uniform waveform, inversely mirrors contraction
just prior to or early in contraction
consistently at or before midpoint of contraction
usually within normal range
can be single or repetitive
late decel
uteroplacental insufficiency
uniform waveform, shape reflects contraction
late in contraction
consistently after midpoint of contraction
usually within 110-130
occasional, consistent
variable decel
umbilical cord compression
variable wave form, generally sharp drops and returns
abrupt with fetal insult, not related to contraction
variable around midpoint
not usually within normal range
variable - single or repetitive
veal chop
Variable decel - cord compression
early - head
acceleration - okay
late - placental insufficiency
uncoil
UNdo what is causing the problem
Change position (left lateral)
Oxytocin off, oxygen on
Iv fluid bolus
Lower HOB
