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OB FINAL > Intrapartum > Flashcards

Intrapartum Flashcards

1
Q

Factors that Stimulate Labor

How do we know that labor has started?

A 
Onset of Uterine muscle contractions
Oxytocin
Estrogen
Fetal Cortisol
Prostaglandins

Changes in hormones!

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2
Q

Premonitory Signs of Labor (5)

A 
Lightening
Energy spurt
“Bloody Show
Braxton Hicks contractions
Increase in clear; nonirritating vaginal secretions
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3
Q

Engagement

A 
Relationship between mom’s pelvis and the presenting part of the baby
passes the pelvic inlet
Measurements = inlet, mid-pelvis, outlet
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4
Q

False Labor

A

No cervical change occurs
Discomfort usually in lower abdomen – more annoying than painful
Contractions irregular & short in duration
Intensity does not correlate with time
Medication and activity affect contractions
Usually no bloody show

Differentiation = contractions in false labor are more commonly irregular – healed with medications
Tylenol, hot shower, varying intensity, no cervical change

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5
Q

True Labor

A

Discomfort in front and back
Frequency, duration, and intensity increase
Palpable hardening of uterus
Pinkish mucous
Cervical Changes – Effacement, Dilatation
Bulging of membranes

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6
Q

Six concepts which make labor and birth as natural as possible are:

A

labor should begin on its own, not be artificially induced
women should be able to move about freely throughout labor, not be confined to bed
women should receive continuous support from a caring other during labor
interventions such as intravenous fluid should not be used routinely
women should be allowed to assume a nonsupine position such as upright and side-lying for birth
mother and baby should be housed together after the birth, with unlimited opportunity for breast-feeding

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7
Q

5 Labor powers

A

Powers
physiologic forces

Passageway
maternal pelvis

Passenger
fetus and placenta

Passageway & Passenger
pelvis and fetus

Psychosocial (Psyche)
influences

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8
Q

Primary and secondary power forces

A

Uterine contractions—primary force
Involuntary
Dilate the cervix

Maternal pushing efforts—secondary force
Voluntary
Compress the uterus -> birth of fetus

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9
Q

Uterine Contractions - Primary

A 
Characteristics
Frequency -- 10 minutes, 5 minutes, 3 minutes
Duration
Intensity
Palpation: 
nose-chin-forehead
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10
Q

Uterine contraction graph

A

Pattern of contractions
Increment – up
Acme – peak – no blood flow to uterus
Decrement – down

Frequency – start of one contraction to start of another
Duration – start of one contraction to end of the same contraction
Intensity – how strong

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11
Q

EFM

A

Electronic fetal monitoring
to evaluate contractions
to assess fetus response to contractions

External monitor
Tocodynamometer
Electric monitor of uterine contractions

Internal monitor
Internal pressure catheter
Fetal scalp electrode – an internal fetal heart monitor
Intrauterine pressure cath – an internal contraction monitor
–> Membranes need to be ruptured

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12
Q

Maternal Pushing - Secondary

A

“Bearing down” sensation

Urge to push vs.No urge to push
10cm dilated – needs to feel urge to push
At 10cm can start encouraging to push but can become exhausted more frequently

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13
Q

Passageway

Passenger

A

Shape of pelvis can determine C/S – cephalopelvic disproportions

Fetus and fetal membranes
Fetal Head – sutures and bones can help tell provider where the baby is (occipital, frontal, parietal)
Fetal Lie – position baby is in compared to moms spine
Fetal Attitude
Fetal Presentation

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14
Q

Passenger - Fetal Lie

A

Longitudinal – can be longitudinal lie in breech position
Transverse
Oblique – diagonal

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15
Q

Fetal Presentation

A

Cephalic
Shoulder
Breech

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16
Q

Shoulder presentation

A

Fetus in transverse lie
Cannot be delivered vaginally unless rotated
Manual rotation performed by OB, CNM
Membranes must be ruptured, cervix dilated
Standard of care = C-Section

External rotation a month before
Painful; tight support strap, does not often work

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17
Q

Passenger - Presentation – BREECH

A

Breech
Complete – complete just facing the wrong way
Incomplete – butt down and one leg in air
Frank – two legs up
Footling – membranes ruptured and feel foot

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18
Q

Breech complications

A

Risk of cord prolapse
Presenting part less effective in cervical dilation
-> risk of prolonged labor
Risk of cord compression

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19
Q

Attitude

A

Flexed – want baby in this position
Vertex – 9.5

Extended
Military – 12.5
Brow –13.5
Face – 9.5

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20
Q

Passageway + Passenger

A

Fetal Position
“Landmark” = occipital bone
Landmark location vs. maternal pelvis
Back Labor

WANT LOA OR ROA – shorter labor, less pain

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21
Q

Station

A

Station – relationship of presenting part to ischial spines
Above ischial spines (–) minus station
“floating” not engaged

Ischial spines 0 station
engaged

Below ischial spines (+) plus station
“crowning” at +4 / +5
-> delivery

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22
Q

Psychosocial Influences (5th power) on Successful Labor and Delivery

A

Confidence in readiness
Educational preparedness
Cultural views of childbirth
Role transition facilitated by positive childbirth experience
Negative experience interferes with bonding and maternal role attainment

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23
Q

Stages of Labor

A

First stage
Onset of regular contractions to full dilation
First regular contraction = labor starts

Second stage
Full dilation to delivery of fetus
10cm

Third stage
Delivery of fetus to delivery of placenta
5 minutes to half hour

Fourth stage
1 - 4 hrs after delivery of the placenta (recovery

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24
Q

First Stage of Labor

A

Three phases
Latent phase 0 to 3 cm
0-30 secs, more than 5 mins

Active phase 4 to 7 cm
40-60 secs, every 2 to 5 mins

Transition 8 to 10 cm
60-90 secs, every 1 to 2 mins

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25
Q

Vaginal exams

Dilatation

A

Progress of labor
Plan interventions
Success of treatments – pitocin

If she is demonstrating changes in attitude or approach we don’t need to do a vaginal exam

26
Q

Vaginal Exams
Station of the baby
Markers to identify

A

Palpate the sagittal suture
Identify the posterior fontanel
Identify the occipital bone
Identify the the anterior fontanel

27
Q

Second Stage of Labor

A

Full dilation through birth of infant

Urge to push

Nursing interventions:
Promote effective pushing
Position of comfort

28
Q

Assessment of fetal well being

A 
Position
Abdominal palpation (early labor)
or
Vaginal examination
Ultrasound
Fetal heart sounds (FHR)
Auscultation
Doppler
or
Electronic Fetal Monitor
29
Q

Interpret FHR, EFM

A

Contractions
Frequency
Intensity

FHR
Reassuring and non-reassuring (dips, brady, tachy changes above 25 bpm)

1 full minute – comparing peak to baby HR

30
Q

Admission

A 
Establish positive relationship
Collect admission data
Initiate admission interventions
Physical assessment – mother and fetus
Psychosocial assessment
Cultural assessment
Laboratory tests
Initiate care plan in EMR
Ongoing focused assessment and interventions
31
Q

Labor Support

A 
Promote comfort
Personal hygiene
Elimination
Environment
Presence
Support relaxation

Women during labor are best supported by an RN
Shorter labors
Decreased pharmacologic use
Decreased operative vaginal or cesarean births
Decreased need for oxytocin
Increased satisfaction with birthing experience

32
Q

Labor support

5 aspects

A

Emotional: encouragement, distraction, reassurance

Physical: touch, position change, heat or cold applications

Information: provide education, coaching, interpret medical jargon

Advocacy: support decisions, let other’s know her wishes

Support family: role model support, encouragement, provide breaks

33
Q

Maternal positions in Labor

A 
Hands and knees -- back labor
Recumbent
Upright
Standing
Sitting
Side-lying -- back labor
34
Q

Imminent Birth

7

A 
Bulging of the perineum and rectum
Flattening and thinning of the perineum
Increased bloody show
Labia begin to separate
“Crowning”
Burning sensation
Intense pressure in rectum
35
Q

Umbilical Cord Clamping

A

Cord clamped by HCP or father
Collect cord blood sample for laboratory analysis – test for baby blood type, cord blood for sampling
Cord blood storage arranged by parents

36
Q

Immediate Care of Newborn

A 
Airway
Breathing
Circulation
Warmth
Appraisal—Apgar score
Identification of newborn
37
Q

Third Stage

5

A 
Birth of baby to complete delivery of placenta
Lengthening and protrusion of cord
Gush of blood from vagina
Smaller, spherical uterus
Elevation of uterus in abdomen

Nurse expects to admin oxytocin after expulsion of placenta to…
Stimulate contractions
Reduce incidence of post partum hemhorrage

38
Q

Fourth Stage (6)

A

From delivery of placenta through 1 to 4 hrs
Monitor position and firmness of uterus –> “Boggy,” soft uterus –> Initiate fundal massage
Assess bleeding – lochia
Hypotension + Tachycardia – INDICATE BLEEDING*
Facilitate bonding
Initiate breastfeeding

39
Q

Joint Commission Standards for Pain Management

A

Recognize the right: appropriate assessment and management of pain.
Screen patients: during initial assessment and reassessed appropriately.
Educate patients: pain management options and their family.

40
Q

Pain Perception and Expression

A 
Assessing pain
Physiological, psychological indicators
    Increased catecholamines
    Increased blood pressure and heart rate
    Altered respiratory pattern
Patient responses
May be intensified by fear, anxiety, fatigue…
Shaped by past experiences
Cultural competence
41
Q

Pain in Labor

A 
Complex
Multidimensional                
Pain management
Non-pharmacologic
Pharmacologic
Goal: manage pain without interruption of labor or doing harm to mom or fetus
Pain scale: Coping with Labor Algorithm
42
Q

Pain in Labor

First and second stage

A

First stage – visceral pain: deep, dull and aching, poorly localized, felt only during contractions

Second stage - somatic pain: sharp, intense, well localized, burning, or prickling caused by stretching of perineal body, distention and traction, and soft tissue lacerations.

43
Q

First Stage of Labor, Active

Pain

A

Dilatation of cervix
Stretching of the lower uterine segment
Pressure on adjacent structures
Hypoxia of uterine muscle cells during contractions

44
Q

First Stage of Labor, Transition

Pain

A

Dilatation of cervix
Stretching of the lower uterine segment
Pressure on adjacent structures
Hypoxia of uterine muscle cells during contractions

Pain is really localized; can refer down to knees – localized around perineum

45
Q

Second Stage of Labor

Pain

A

Pain
Hypoxia of uterine muscle cells during contractions
Distention of the perineum and vagina
Pressure on adjacent structures

46
Q

Non-Pharmacological

A 
Position changes and movement
Standing
Walking
Slow dancing or leaning
Rocking on hands and knees
Pelvic rocking
Side lying
Squatting
Bellydancing
Massage
Effleurage
Counter Pressure
Intuitive touch / therapeutic touch
Aromatherapy
Breathing techniques
Lamaze, Bradley
Hypnobreathing
Safety: valsava 
Compresses: warm or cold
Relaxation techniques
Visualization
Focal point
Imagery
Music 
Hydrotherapy
Immersion
Shower
Biofeedback
Tens unit
47
Q

RN vs. Doula

A 
Evidence based practice 
Meets woman at delivery
Performs clinical tasks
Consults and advocates 
Intermittent labor support
Keeps patient informed
Documents
Legal accountability
Minimal contact after delivery 
Trained, may be certified
Relationship during pregnancy
Supportive role not clinical
No communication with HCP
Provides continuous support
Informs pt using lay terms
Assists in articulating questions or concerns to the nurse or HCP
May document to share later 
Follow-ups after
48
Q

Anti-Anxiety

A

Sedatives – for anxiety – not commonly given; anxiety will slow down

Barbiturates – rarely used
secobarbital (Seconal)

Benzodiazepines
diazepam (Valium)
lorazepam (Ativan)

Antiemetics – H1 Receptor Agonists
promethazine (Phenergan)
hydroxyzine (Vistaril)
diphenhydramine (Benadryl)

49
Q

Pharmacological Pain Mgmt

A

Analgesics: Drugs that relieve pain without loss of muscle function. They lessen pain, but do not stop it completely.
RELIEF FROM PAIN

Anesthetics: Drugs that relieve pain through loss of sensation. They block all feeling.
LACK OF SENSATION

50
Q

Analgesia

A

Increase pain threshold; reduces the perception of pain
Provide maximum relief of pain with minimal risk
Help patient relax and sleep between contractions

51
Q

Analgesia Medications

A

Systemic Medications can cross the placental barrier
Analgesics used in labor:
Stadol, Nubain - 2-3 hr half-life (cross placenta, respiratory depression for baby, opioid preferred)
If given two hours before baby born – needs neonatologist

Dilaudid, Demerol - long half-life in neonate

Fentanyl, short-acting (needs repeated doses), may not cross placenta
May still cause respiratory depression

Analgesic Potentiaters
Decrease anxiety and increase effectiveness of analgesics (Phenergan, Vistaril)

52
Q

Opioid Analgesics

A

Side effects
Nausea; Vomiting
Itching
Dizziness

More serious but not likely
Loss of protective airway reflexes
Hypoxia due to respiratory depression

Psychosocial concerns
“natural” birth
Hx of addiction

53
Q

Antagonist

A 
Systemic Analgesia – Opioids
 hydromorphone (Dilaudid)
 meperidine (Demerol)
 fentanyl (Sublimaze)
 butorphanol (Stadol)
 nalbuphine (Nubain)

Opiate Antagonist
Naloxone (Narcan)
Reverses effect – if sx of respiratory depression present
Can be used for mom or baby

DO NOT GIVE TO parent who has hx of addiction
Can cause seizures and can affect baby

54
Q

Spinal and Epidural

A

Different spaces
Spinal into subarachnoid
Epidural into dura

Different locations
Spinal below L2 to avoid hitting spinal cord
Epidural into C T L spaces

Different onset
Spinal – faster acting
Epidural – slower acting

Epidural can be anesthesia and analgesia
Spinal only anesthesia

55
Q

Spinal vs. Epidural

Complications

A

Regional spinal anesthesia block

Complications: 
Maternal hypotension
Decreased placental perfusion
Ineffective breathing pattern
Spinal Headache  -> tx with autologous blood patch --> Leakage of CSF 
Regional epidural analgesia in labor, anesthesia in c/s
Complications: 
maternal hypotension
bladder distention
prolonged second stage

Contraindication: Low Platelet count for BOTH

56
Q

Epidural during Labor

Advantages and disadvantages

A 
Advantages
PCEA!
Relieves discomfort during labor
Fully awake during birth
Fewer fetal effects --> no respiratory depression
Mom rests before 2nd stage
Fetus can labor down
Access for LA morphine
Disadvantages
Maternal hypotension
    Monitor VS; respiratory 
    Bolus before insertion 
    Epinephrine available
Limited mobility
Can slow fetal descent
Less effective pushing
Urinary retention – insert foley
Blood coagulation
57
Q

Health Literacy

A

Health literacy – an interaction between system demands and people’s skills reading, writing, numeracy, listening, speaking, and conceptual knowledge

58
Q

Duration of Pregnancy

A

1st trimester = 1-12 weeks
2nd trimester = 13-27 weeks
3rd trimester = 28-40 weeks

59
Q

Gravida

Para

A

any pregnancy

delivery after 20 weeks regardless if born alive or stillborn, or how many infants

60
Q

GTPAL

A

gravida – how many times pregnant

Term – infants before 37 weeks or more

Preterm – infants born at 20-36 (6) weeks

Abortion – elective or spontaneous before 20 weeks

Living children – survived neonatal period

61
Q

Cardinal movements

A

baby turns when coming out to get head and shoulders out effectively

62
Q

Membranes ruptured…

Abnormal labs…

Emergency

A

Assess FHR/pattern
Document characteristics and notify HCP
Palpate/auscultate abdo

Intervention PRN before documenting
Further orders – call HCP and then document

Quick assessment of ABCS
initiate rapid response

OB FINAL (8 decks)

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