L&B 6b/Third stage of Labor/Nursing Interventions Flashcards
Third stage of Labor/Maternal Assessment/Vital Signs
1) How often?
1) BP, HR and RR q5mins
Hogan 164
Third stage of Labor/Maternal Assessment/Uterine Fundus
The uterine fundus maintains ___1___ and ___2___ pattern to delivery placenta by ___3___ and ___4___ from uterine wall.
1) Uterine fundus maintains TONE
2) CONTRACTION pattern
3) Decreasing surface volume of uterus
4) Shearing placenta from uterine wall
(Hogan 165)
Third stage of Labor/Maternal Assessment/ Placental separation s/s Hints: 1) abd 2) shrinks, gush 3) expelled 4) umbilical cord 5) Shape of uterus
NOTE: (London list this as 4 stage of labor pg 418)
1) Uterus rises upward in abd
2) Uterine volume shrinks from contractions, creating a gush/sudden trickle or spurt of blood vaginally
3) Uterine contents are expelled
4) During this process UMBILICAL CORD protrudes further from the vagina as the placenta moves downward the umbilical cord lengthens (? appears to lengthen)
5) Shape of uterus changes from flat (discoid) to round (globular).
(Hogan 165)
Third stage of Labor/Fetal Assessment/Apgar Score
1) What does this assessment tell you?
2) How soon after birth is this done?
3) What are the five criteria?
4) What are the possible scores for each criteria?
NOTE: (London list this as 4 stage of labor pg 415)
1) Assess fetal status after birth
2) 1-5 mins after birth
3) Color, HR, Reflex irritability, muscle tone and respiratory effort
4) 0, 1, 2
(Hogan 165)
Third stage of Labor/Fetal Assessment/Apgar scores of 8 or greater indicate?
NOTE: (London list this as 4 stage of labor pg 415)
Newborn needs minimal intervention (nasopharyngeal suction and oxygen near face)
(Hogan 165)
Third stage of Labor/Fetal Assessment/Apgar score of 4 to 7 indicates? (3) possible interventions
NOTE: (London list this as 4 stage of labor pg 415)
Newborn needs intervention through
1) oropharyngeal suctioning
2) Tactile stimulation
3) oxygen administration
Third stage of Labor/Fetal Assessment/Apgar scores of 3 or less indicates?
NOTE: (London list this as 4 stage of labor pg 415)
Need for resuscitation
Third stage of Labor/Fetal Assessment/Respiration
Normally 30 to 60 may be irregular
Third stage of Labor/Fetal Assessment/Apical pulse
110-160 maybe irregular and may increase to 180 transietly while crying
Third stage of Labor/Fetal Assessment/Temperature
Skin temp above 97.8 F (36.5)
Third stage of Labor/Fetal Assessment/Umbilical cord
Normally two arteries and one vein (note 1 artery with 1 vein can occur)
Third stage of Labor/Fetal Assessment/Gestational age
Consistent with expected date of delivery
Third stage of Labor/Fetal Assessment/Physical
Abbreviated exam to detect presence of visible congenital anomolies
Third stage of Labor/Implementation and Collaborative Care
1) Mother
2) Immediate care of newborn (4)
1) Encourage rest/relax
2) Placing in a modified Trendelenburg position
3) Suctioning nose and oropharynx
4) Provide warmth
5) Begin attachment parent hold newborn
Third stage of Labor/Documentation/Placenta
Hint:
1) Tick tock
2) How does it look?
3) Is it firm, loose/falling apart?
4) How did it separate from uterine wall?
5) Average blood loss?
NOTE: (London list this as 4 stage of labor pg 418)
1) Time of placenta delivery
2) Placenta appearance
3) Intactness of placenta
4) Mechanism of placental expulsion
5) Estimated delivery blood loss (average 250-500ml)
(Hogan 165)
Third stage of Labor/Documentation/Placenta/Mechanism of expulsion
1) dirty Duncan mechanism of delivery
NOTE: (London list this as 4 stage of labor pg 418)
1) Placenta separates from edge progressing toward center and rough maternal side of placenta is visible
Third stage of Labor/Documentation/Placenta/Mechanism of expulsion
1) shiny Schultz mechanism of delivery
NOTE: (London list this as 4 stage of labor pg 418)
1) Placenta separates from center progressing outward and membrane-covered fetal side of placenta is visible
Third stage of Labor/Documentation/Medication
1) What med/agent is often used to assist with expulsion of placenta?
1) Oxytocic agent
Third stage of Labor/Documentation/Cultrual disposal of Placenta
1) Assess and get biohazard bag? or container?
Third stage of Labor/Evaluation Mother and newborn
Evaluate if mother and newborn experience a safe labor ad birth
Third stage of Labor/Fetal Assessment/Apgar Score 0 points Color (Appearance) HR Reflex Irritability (Grimace) Muscle Tone (Activity) Respiratory Effort (Respirations)
0 points Color (Appearance): Blue, pale HR: Absent Reflex Irritability (Grimace): Absent Muscle Tone (Activity): Absent Respiratory Effort (Respirations): Absent
(Hogan 165)
Third stage of Labor/Fetal Assessment/Apgar Score 1 points Color (Appearance) HR Reflex Irritability (Grimace) Muscle Tone (Activity) Respiratory Effort (Respirations)
1 points
Color (Appearance): Blue extremities, pink body
HR: <100
Reflex Irritability (Grimace): Grimace
Muscle Tone (Activity): Some flexion of extremities
Respiratory Effort (Respirations): Slow irregular
Third stage of Labor/Fetal Assessment/Apgar Score 2 points Color (Appearance) HR Reflex Irritability (Grimace) Muscle Tone (Activity) Respiratory Effort (Respirations)
2 points
Color (Appearance): Completely pink
HR: >= 100
Reflex Irritability (Grimace): Vigorous cry
Muscle Tone (Activity): Active motion
Respiratory Effort (Respirations): Good cry
Third stage of Labor/Maternal Assessment/ Placental separation while observing for s/s of placenta separation
palpate the uterus to check for ?
1) Ballooning caused by uterine relaxation and subsequent bleeding into uterine cavity.
Third stage of Labor/Maternal Assessment/ Post-Placental separation
1) HCP inspects (2)
2) HCP repairs
1) Vagina and cervix of lacerations
2) lacerations and episiotomy repair
Third stage of Labor/Newborn ID
1) Place on newborn’s wrist and ankle before leaving birthing room and parents receive their matching bands
