Intrapartum test Flashcards
First Stage (Dilation) - when does it start and end?
Longest, beginning with the first true contraction and ends with full dilation of the cervix
Latent Phase - dilation, contractions - how often and how long? (latent at 10-30)
(0-6 cm dilation). Effacement from 0 - 40%; nullipara lasts up to 20 hrs, multipara lasts up to 14 hrs; contractions every 5-10 minutes, lasting 30-45 seconds;
Active phase (6-10 cm dilation) (we’re active from 2-60)
Effacement from 40 -100%; nullipara lasts up to 6 hrs, multipara lasts up to 4 hrs; contractions every 2-5 minutes, lasting 45-60 seconds; intensity moderate to palpation
Dilation begins more rapidly and predictably; active labor generally dilates at a rate of 1.2-1.5 cm/hr
Second stage (Expulsive- active pushing) (how long are contractions?)
Begins when the cervix is completely dilated and ends with birth of the newborn. Can last from minutes to hours. Contractions typically 2-3 minutes, lasting 60-90 seconds; contraction intensity strong by palpation; strong urge to push during the later perineal phase; stage may last up to 3 hrs
Second stage (Expulsive- active pushing) - adverse outcomes (think long labor)
Longer duration of this stage of labor is associated w/ adverse maternal outcomes, such as higher rate of puerperal infections, third- and fourth- degree perineal lacerations, and postpartum hemorrhage
Second stage (Expulsive- active pushing) pain (in control on the second stage)
During this stage, mother feels more in control and less irritable/agitated
Maternal urge to push is felt when there is direct contact of the fetus to the pelvic floor; stretch receptors in the wall of the rectum, vagina, and perineum communicate the pressure of the the fetus descending the birth canal, along with increased abd pressure
Second stage (Expulsive- active pushing) - pushing?
Pushing: spontaneous (mothers urge) or directed (by caregiver)
Third stage (Placental) - how does it end?
Starts after the newborn is born and ends w/ the separation and birth of the placenta; typically expelled within 5-30 minutes
placental separation - 3rd stage
(detached from uterine wall), uterus continues to contract strongly after baby is born, causing the placenta to pull away.
placental expulsion - 3rd stage - how long does it take?
(coming outside the vaginal opening), expelled within 2-30 minutes; once expelled, the uterus is massaged briefly until firm and uterine blood vessels constrict, minimizing hemorrhage.
Fourth stage (Restorative)- fundus and lochia?
Lasts 1-4 hrs after birth; when mothers body begins to stabilize, initiates the postpartum period
Fundus should be firm and well contracted , typically located midline; lochia is red initially
What are nursing priorities at admission (3 things) (heart dilates and ruptures on admission)
Highest priority: FHR, assessing cervical dilation and effacement, and determining whether membranes have ruptured or are intact
What is are the nursing priorities immediately after a vaginal birth? What is the number one priority? (3 things - think about the birth you saw)
Placing newborn on mothers chest for skin-to-skin contact
APGAR 1 and 5 minutes
Make sure entire placenta has been delivered to prevent hemorrhage
True Labor vs. False Labor - what is the difference? (what about the cervix)
False labor is a condition occurring during the latter weeks of some pregnancies when irregular uterine contractions are felt, but the cervix is not affected. In contrast, true labor is characterized by contractions occurring at regular intervals that increase in frequency, duration, and intensity. True labor contractions bring about progressive cervical dilation and effacement.
first stage - what type of pain is it? (migraine and abby on 1st stage)
During the first stage of labor, women usually perceive the visceral pain of diffuse abdominal cramping and uterine contractions.
first stage of labor - pain
is primarily a result of the dilation of the cervix and lower uterine segment, and the distention (stretching) of these structures during contractions.
second stage of labor -pain (second pressure)
During this expulsive stage, the mother usually feels more in control and less irritable and agitated. overwhelming urge to push, rectal pressure.
fourth stage - pain (cramping at 4th base)
Her bladder is hypotonic, and thus she has limited sensation to acknowledge a full bladder or to void. The woman will be feeling cramp-like discomfort during this time due to the contracting uterus.
What is intermittent auscultation
Intermittent auscultation is a primary method of fetal surveillance in labor. It is the practice of using a handheld Doppler or fetoscope for periodic assessment of the FHR. The handheld Doppler device uses ultrasound waves that bounce off the fetal heart, producing echoes or clicks that reflect the rate of the fetal heart.Intermittent auscultation of the FHR is an acceptable option for low-risk laboring women, yet it is underutilized in the hospital setting.
intermittent auscultation - disadvantages (intermittment decelerates)
the pressure of the device during a contraction is uncomfortable and can distract the woman from using her paced-breathing patterns. it cannot detect variability and types of decelerations, as electronic fetal monitoring (EFM) can.
FHR - location
FHR is heard most clearly at the fetal back. In a cephalic presentation, the FHR is best heard in the lower quadrant of the maternal abdomen. In a breech presentation, it is heard at or above the level of the maternal umbilicus. As labor progresses, the FHR location will change accordingly as the fetus descends into the maternal pelvis for the birthing process. To ensure that the maternal heart rate is not confused with the FHR, palpate the client’s radial pulse simultaneously while the FHR is being auscultated through the abdomen.
Tachysystole (5, 10, 30)
more than 5 contractions in 10 min averaged over 30 min. Leopolds maneuver
Leopolds maneuver - 1 (start at the top)
What fetal part (head or buttocks) is located in the fundus (top of the uterus)?
Leopolds maneuver - 2 (back 2 leopolds)
On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the back of the fetus.)
Leopolds maneuver - 3 (present at 3!)
What is the presenting part?
Leopolds maneuver - 4 (4 the head flex)
Is the fetal head flexed and engaged in the pelvis?
Ballotment (bounce on ballotment)
A method of diagnosing pregnancy, in which the uterus is pushed with a finger to feel whether a fetus moves away and returns again.
External Version (move externally)
strategically placing the hands on the gravid abdomen and applying pressure to encourage the fetus to move into the vertex position. This can be attempted for fetuses in the breech, transverse, or oblique positions and has the potential to decrease cesarean delivery rates.
What are the signs and symptoms of pre-term Labor - pelvis and back (pre term is pre-low)
Pelvic pressure (pushing-down sensation)
Low, dull backache
Feeling of pelvic pressure or fullness
What are the risk factors for pre-term labor? (age, race, diabetes)
Maternal age extremes (<16 years and >40 years old)
African American race (doubles the risk)
Low socioeconomic status
Alcohol or other drug use, especially cocaine
Poor maternal nutrition
Maternal periodontal disease
Cigarette smoking
Low level of education
History of prior preterm birth (triples the risk)
Uterine abnormalities, such as fibroids
Low pregnancy weight for height
Preexisting diabetes or hypertension
Multiple pregnancy
Premature rupture of membranes
Late or no prenatal care
What is the Fetal Fibronectin test?
glycoprotein, It acts as biologic glue, attaching the fetal sac to the uterine lining.
What are indicated reasons for a C-section?
The leading indications for cesarean births are previous cesarean birth, breech presentation, dystocia, and fetal distress. specific indications include active genital herpes, fetal macrosomia, fetopelvic disproportion, prolapsed umbilical cord, placental abnormality (placenta previa or placental abruption), previous classic uterine incision or scar, gestational hypertension, diabetes, positive human immunodeficiency virus (HIV) status, and dystocia.
What are contraindications for C/S?
Placental abruption.
Prior classical hysterotomy.
Prior full-thickness myomectomy.
History of uterine incision dehiscence.
Invasive cervical cancer.
Prior trachelectomy.
Genital tract obstructive mass
Abnormal placentation (such as placenta previa, placenta accreta)
What is CPD?
Cephalopelvic disproportion isa rare childbirth complication. It occurs when your baby’s head doesn’t fit through the opening of your pelvis. It’s more likely to happen with babies that are large or out of position when entering the birth canal. The shape of your pelvis can also be a factor
HYPOTONIC LABOR (think hypo)
during active labor (dilation more than 5 to 6 cm) when contractions become poor in quality and lack sufficient intensity to dilate and efface the cervix.
HYPOTONIC LABOR- manifestations (hypo fingertip) - are contractions weak or strong?
Clinical manifestations of hypotonic uterine dysfunction include weak contractions that become milder, a uterine fundus that can be easily indented with fingertip pressure at the peak of each contraction, and contractions that become more infrequent and briefer (King et al., 2019)
HYPOTONIC LABOR - #1 complication?
The major risk with this complication is hemorrhage after giving birth because the uterus cannot contract effectively to compress blood vessels
HYPERTONIC LABOR
the uterus never fully relaxes between contractions. Subsequently, contractions are ineffectual, erratic, and poorly coordinated because they involve only a portion of the uterus and because more than one uterine pacemaker is sending signals for contraction.
Shoulder Dystocia
the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has been delivered. The incidence of shoulder dystocia is increasing due to increasing birth weight.
Shoulder Dystocia - risk factors
Postpartum hemorrhage secondary to uterine atony, vaginal lacerations, anal tears, and uterine rupture are major complications to the mother.
dystocia assessment
Assess the woman’s vital signs. Note any elevation in temperature (suggesting a potential infection) or changes in heart rate or blood pressure (potential hypovolemia). Evaluate the uterine contractions for frequency and intensity. Ask the woman about any changes in her contraction pattern, such as a decrease or increase in frequency or intensity, and report these. Assess FHR and pattern, reporting any abnormal patterns immediately. assess the woman’s fluid balance status. Check skin turgor and mucous membranes
dystocia assessment - cont
Monitor intake and output. Also monitor the client’s bladder for distention at least every 2 hours and encourage her to empty her bladder often. In addition, monitor her bowel status. A full bladder or rectum can impede descent. Continue to monitor fetal well-being. If the fetus is in the breech position, be especially observant for visible cord prolapse and note any variable decelerations in heart rate. If either occurs, report it immediately.
dystocia nursing management
The nurse should provide physical and emotional support to the client and her family. The final outcome of any labor depends on the size and shape of the maternal pelvis; the quality of the uterine contractions; and the size, presentation, and position of the fetus. Thus, dystocia is diagnosed after labor has progressed for a time, not at the beginning of labor.
Fetal Station
the relationship of the presenting part to the level of the maternal pelvic ischial spines. Measured in cm and referred to as - or + (cervix is normally 3cm)
Fetal Engagement - when is fetus engaged?
the largest diameter of the fetal presenting part (usually the head) into the smallest diameter of the maternal pelvis. Fetus is said to be engaged in the pelvis when the presenting part reaches 0 station.
Dilation: opening (0, 5 and 10)
0 cm: external cervical os is closed
5 cm: external cervical os is halfway dilated
10 cm: external os is fully dilated and ready for birth passage
Effacement: thinning(effacing in 2, 1, 0)
0%: cervical canal is 2 cm long
50%: cervical canal is 1 cm long
100%: cervical canal is obliterated
Fetal position
the relationship of the presenting part to the four quadrants of the mothers pelvis
Lie (lie on your spine)
the relationship of the spine of the fetus to the spine of the mother ex. longitudinal/vertical, transverse, oblique
Attitude (attitude w/ yourself)
the relationship of fetal parts to itself ex. General flexion (curled up: legs/arms at abd, head down), or extension (makes it difficult to push baby out)
Presenting part:
is the part of the fetal body felt first on cervical exam
Presentation (presenting the pelvis)
is the part of the body that enters the pelvic inlet first ex. Cephalic Vertex-head), breech (bottom, arms, legs), shoulder
Under what conditions are Vaginal Exams contraindicated
Avoid doing vaginal examinations in the woman with placenta previa because they may disrupt the placenta and cause hemorrhage.
Placenta Previa - and what about low lying?
Placenta previa is the complete or partial covering of the uterine internal os of the cervix with the placenta, typically identified during the second or third trimester of pregnancy. All placentas covering the os to any degree are termed placenta previa; placentas close to but not covering the os are referred to as low-lying.
placenta previa - s/sx: is bleeding painful?
Maternal signs and symptoms of placenta previa include sudden, painless bleeding (that may be heavy enough to be considered hemorrhaging), anemia, pallor, hypoxia, low blood pressure, tachycardia, soft and nontender uterus, and rapid, weak pulse.
PLACENTAL ABRUPTION:
Placental abruption refers to premature separation of a normally implanted placenta from the maternal myometrium.
UTERINE RUPTURE
Uterine rupture is a catastrophic tearing of the uterus at the site of a previous scar into the abdominal cavity.
uterine rupture - s/sx - most important symptom (rupture the baby)
Its onset is often marked only by sudden fetal bradycardia, and treatment requires rapid surgery for good outcomes. Generally, the first and most reliable symptom of uterine rupture is sudden fetal distress. Other signs may include acute and continuous abdominal pain with or without an epidural, vaginal bleeding, hematuria, irregular abdominal wall contour, loss of station in the fetal presenting part, and hypovolemic shock in the woman, fetus, or both
What are the priority diagnosis of someone with Placenta Previa
monitoring maternal vital signs, intake and output, vaginal bleeding, and physiologic status for signs of hemorrhage, shock, or infection; closely monitoring fetal heart tones for distress (e.g., bradycardia, tachycardia, baseline changes); and treating fetal distress as ordered. Administer prescribed intravenous fluids, packed red blood cells, platelets, and frozen plasma for transfusion if ordered; Rho(D) immune globulin if the client is Rh-negative; intravenous augmented oxytocin (Pitocin) to induce labor if needed; and in cases of preterm labor, tocolytics to inhibit uterine contractions and corticosteroids to enhance fetal lung maturity. Follow facility presurgical and postsurgical protocols if the woman becomes a surgical candidate (e.g., for cesarean section); reinforce presurgical and postsurgical education and ensure completion of facility’s informed consent documents; closely monitor the woman postsurgically for bleeding, infection, and other complications; assess her anxiety level and coping ability; and provide emotional support and reassurance.
What are the priority diagnosis of someone with Placental Abruption (abruptly in shock)
Monitor maternal vital signs and observe for hypotension and tachycardia, which might indicate hypovolemic shock. Assist in preparing for an emergency cesarean birth by alerting the operating room staff, anesthesia provider, and neonatal team. Insert an indwelling urinary catheter if one is not in place already. Inform the woman of the seriousness of this event and remind her that the health care staff will be working quickly to ensure her health and that of her fetus. Remain calm and provide reassurance that everything is being done to ensure a safe outcome for both.
- Typically, once the diagnosis is established, the focus is on maintaining the cardiovascular status of the mother and developing a plan to deliver the fetus quickly.
What is a prolapsed cord
rare obstetric emergency that occurs when the cord precedes the fetus out. Increased risk when the presenting part does not fill the lower uterine segment, as is the case with incomplete breech presentations, (5% to 10%), premature infants, hydramnios, and multiparous women. Cause is unclear. Perfusion decreases rapidly.
prolapsed cord - s/sx (think lack of O2)
Often the first sign of cord prolapse is a sudden fetal bradycardia or recurrent variable decelerations that become progressively more severe.Call for help immediately and do not leave the woman.
prolapsed cord - nursing interventions (just hold on)
When membranes are artificially ruptured, assist with verifying that the presenting part is well applied to the cervix and engaged into the pelvis. If pressure or compression of the cord occurs, assist with measures to relieve the compression. Typically, the examiner places a sterile gloved hand into the vagina and holds the presenting part off the umbilical cord until delivery. Changing the woman’s position to a modified Sims, Trendelenburg, or knee–chest position also helps relieve cord pressure.
