labor 2 Flashcards
First stage of labor
begins with the onset of true labor and ends with complete dilation (10 cm).
Second stage of labor
begins with complete dilation and ends with the birth of the newborn.
third stage of labor
begins with the delivery of the newborn and ends with the delivery of the placenta.
fourth stage of labor
begins with the delivery of the placenta and ends once post-delivery recovery is completed (1-4 hrs.).
-During this time the patient is at highest risk for a postpartum hemorrhage=> assess the fundus frequently (Q15 minutes) and bleeding amount.
Stage 1 Latent -4
Contractions are Q10-30 minutes apart, lasting 30 seconds, mild-moderate by palpitation.
-This stage may last 5-8 hrs. depending on # pregnancy
Stage 1 Active -4
Contractions are 2-5 minutes apart, lasting 40-60 seconds, moderate-strong by palpitation.
-may last 2-4 hrs depending on which pregnancy this is.
Stage 1 Transition -4
Contractions are 1.5-2 minutes apart, lasting 60-90 seconds, strong by palpitation.
-may last <1-3 hrs depending on which pregnancy this is.
Stage 2 Complete dilation to delivery
Contractions are 1.5-2 minutes apart, lasting 60-90 seconds, strong by palpitation
-may last <1-3 hrs depending on which pregnancy this is.
Stage 3 Delivery of the placenta
Should last less than 30 minutes. Contractions are not being monitored at this time but instead the fundal assessment to ensure a firm fundus (less bleeding) and not a boggy (relaxed and more bleeding) one.
Stage 4 First 1-4 hours following delivery
contractions are not monitored during this time either but again the fundal assessment, last 1-4 hrs post-delivery of the placenta.
What is the importance of monitoring blood pressure
related to oxygen delivery.
-If the maternal blood pressure is low, her body will shunt to vital organs which does not include the uterus (fetus) and can compromise the fetus.
-For accurate blood pressure reading
=> avoid taking the blood pressure during contractions or while pushing as these do not reflect her true state and can skew the readings higher than they actually are.
Why does a mother have the potential to develop respiratory alkalosis
While in pain the mother may breathe to cope with her pain and accidentally hyperventilate herself and blow off too much CO2.
respiratory alkalosis treatment-2
- attend prenatal classes to prepare for birth.
- coach her through her breathing to ensure that she slows down her breathing and prevents her from hyperventilating accidentally.
What assessments need to be made during labor-5
-maternal vital signs
-fetal heart tones (rate, variability, accelerations or decelerations).
-contractions via palpitation/electronic monitor to ensure a resting period between contractions
=>too many contractions does not allow infant enough time to stay adequately oxygenated, increases risk for uterine rupture.
-progress of labor (dilation, effacement, and fetal descent)
-high risk- patient=>hemorrhage, shoulder dystocia, etc.
How do assessments differ in regards to stage and phase of labor-2
- stage 1 latent phase-patient should be at home and the nurse will not be checking on her
- active stage 1-check frequently (i.e. fetal heart tones Q15 minutes, contractions Q30 minutes, etc.
How do assessments differ in regards to high risk vs low risk labors
higher risk assess more frequently than you would a patient in the same stage of labor who is at a lower risk.
Using Leopold’s maneuvers can you identify the appropriate area to listen to fetal heart sounds
fetal back
Fetal monitoring. What is a normal baseline
110-160 bpm
What is a good variability
Moderate variability is best and falls under category I, which reflects that the infant is adequately oxygenated and neurologically intact at that moment.
Is fetal accelerations good
Yes, this reflects that the infant has enough reserve and is being active and moving around a lot which is accelerating the fetal heart rate.
What is an early deceleration?-3
- infant is moving down into the vaginal vault and delivery is getting closer.
- Due to fetal location, during contractions, the fetus is experiencing a vagal response due to the squeeze from the contraction.
- dip in fetal heart rate during the contraction (mirrors contraction).
late deceleration-4
- a concern and interventions are needed to correct
- fetus not coping well with the contractions and is not recovering well even after the contraction is over.
- cry for help that baby is under too much stress from the contraction
- related to placental perfusion problem.
What is a variable? Is this a good thing
- not a good thing and requires further investigation.
- related to the cord being compressed.
What are the appropriate nursing interventions for decrease fetal variability? Accelerations? Early decelerations? Late decelerations? Variables? -5
- accelerations-no need to intervene
- low variability- fetus is sleeping but if lasting for more than 20-30 minutes intervene
- Late decelerations and variables-not good intervene
- repositioning the patient from side to side, assessing the whole time fetal status
- bolus the LR
- stop the Pitocin infusion (if it is running) and apply oxygen via a non-rebreather mask (oxygen and Pitocin are never allowed to run at the same time)
- first interventions should still be utilized simultaneously as you move on to the next intervention - cervical check
- assess the whole picture (maternal vital signs, fetal heart strip, contractions).
- patient may go back for a STAT cesarean section if unable to resolve the symptoms (non-reassuring fetal heart tones).
- If the patient recovers quickly, still let the physician know
steps to take when assessing fetal heart tracing-2
- Assess baseline (110-160), variability (absent, minimal, moderate, marked), accelerations present (yes or no), decelerations present (yes or no, if yes, what type – early, late, episodic, variables, prolonged).
- assess for contractions. First step, are there contractions (yes, no). If yes, assess the contractions frequency, duration, and intensity, assess resting tone between contractions. This information will determine which category your patient is in, I, II, III. and continue to monitor your patient.,
Category one
fetus is adequately oxygenated at this time and neurologically intact due to the moderate variability
Category II
a wide category and you may either be monitoring more closely or intervening depending on the situation
Category III
infant is struggling a lot/dying and more than likely you are rushing back for a STAT cesarean section with anticipated need for NRP -resuscitation for the newborn
