labor and complications Flashcards
True labor (3)
- UC: regular, stronger, longer, closer, more intense if walking, more moaning, may not be able to breathe or talk
- cervix: effaces, dilates, anterior position
- fetus becomes engaged (in the pelvic inlet)
False labor (3)
- UC: irregular or regular temporarily, may stop with position change
- cervix: no change in effacement or dilation
- fetus: not usually engaged
Premonitory signs of labor (6)
- cervical changes (cervical softening, possible cervical dilation)
- lightening: settled into pelvis, dropped down
- increased energy level (nesting)
- bloody show: bloody discharge, not bleeding just mixed with mucus
- braxton hicks
- srom
Critical factors affecting labor and birth, 5 P’s (5)
- passageway (birth canal shape-pelvis and soft tissues)
- passenger (fetus and placenta)
- powers (contractions)
- position (maternal)
- psychological response (emotionally prepared, lamaze classes, interior factors that can predict good labor outcome or not)
Passenger (7)
- fetal skull: info about the baby based on which part can be felt
- fetal attitude: in the pelvis
- fetal lie: direction of baby in the pelvis
- fetal presentation: what presenting part is nearest the internal cervical os
- fetal position: three letter abbreviation for id using presentation and lie
- fetal station: where baby is located to zero station in between the pelvic inlets of mom
- fetal engagement
Passenger: fetal skull (4)
- largest and least compressible structure
- sutures: allow for overlapping and changes in shape (molding), help identify position of fetal head
- fontanels: intersections of sutures, help in identifying position of fetal head and in molding
- diameters: occipitofrontal, occipitomental, suboccipitobregmatic, and biparietal
Dimensions of the skull (4)
- occiput: back
- sinciput: front
- vetex: middle
- biparietal: sides
Fetal lie (2)
- longitudinal lie (up and down)
- transverse lie (side to side), can’t deliver vag
Fetal presentation: Cephalic/vertex (4)
-Cephalic (vertex): baby head down in the pelvis, arms over chest, knees flexed,
:military: same as general flexion but back is straight
:brow: the brow is presenting first
:face: the face is presenting first
Fetal Presentation: Breech (4)
-Breech: high-risk preg
:frank arms crossed, head down, legs straight up
:full or complete: general flexion but upside down, legs crossed
:footling or incomplete: general flexion with one foot sticking out straight
Fetal Position (5)
Landmarks:
: occipital bone (o): vertex presentation
: chin (mentum (m)): face presentation
: buttocks (sacrum (s)): breech presentation
: scapula/shoulder (acromion process (a)): shoulder presentation
-three-letter abbreviation for identification: ROP, LOT, LMA, RST, etc
Fetal Station (4)
- assessed through sterile vagina exam and use 3 number abbrev for dilation, effacement of cervix (% how thin), fetal station of passenger ex: 5/80/-1
- how far the baby is in the pelvis nearing the 0 station
- above zero is negative 1-4
- below zero is positive 1-4
Fetal engagement (2)
- presenting part reaching 0 station
- floating: no engagement, presenting part freely movable about pelvic inlet
Cardinal movements
-normal birth movements
Powers (5)
-Uterine contractions (primary power)
-intra-abdominal pressure (from mother pushing and bearing down)
-contractions: involuntary–> thin and dilate cervix
-three parameters: frequency, duration, intensity
:intensity-uterus feels like
: mild: tip of nose
: moderate: tip of chin
: severe: tip of forehead
Position (5)
-nonmoving, back-lying positions during labor are usually not healthy
-maternal position can influence pelvis size and contours:
: changing position, walking–> facilitate fetal descent and rotation
: squatting, inc pelvic outlet by 25%
: kneeling (hands and knees), –> removes pressure on maternal vena cava, helps fetal rotation (posterior to anterior)
Benefits of maternal positions (9)
- dec length of first stage labor
- dec duration of second stage labor
- dec number of assisted deliveries (vacuum and forceps)
- dec episiotomies and perineal tears
- contribute to fewer abnormal fhr patterns
- inc comfort dec requests for pain med
- enhance a sense of control by mom
- alter the shape and size of pelvis, assisting in descent
- assist gravity to move the fetus downward
Psychological response (7)
factors influencing a positive birth experience
- clear info on procedures
- support, not being alone
- sense of mastery, self-confidence
- trust in staff caring for her
- positive reaction to pregnancy
- personal control over breathing
- preparation for childbirth experience
Physiologic responses to labor (9)
- inc heart rate, cardiac output, blood pressure (during contractions)
- inc white blood cell count
- inc respiratory rate and 02 consumption
- dec gastric motility and food absorption
- dec gastric emptying and gastric ph
- slight temp elevation
- muscle aches/cramps
- inc BMR
- dec blood glucose levels
Fetal physio responses to labor (5)
- periodic FHR accelerations and slight decelerations
- dec in circulation and perfusion
- inc in arterial CO2 pressure
- dec in fetal breathing movements
- dec in fetal oxygen pressure, dec in partial pressure of oxygen
Stages of Labor: 1 and 2 (6)
-First stage: true labor to complete cervical dilation (10 cm)
: Longest of all stages
: three phases
1) latent phase: 0-3 cm
2) active phase: 4-7 cm
3) transition phase: 8-10 cm
-Second stage: cervix dilated 10 cm to birth of baby
Stages of labor: 3 and 4 (4)
- Third stage: birth of infant to placental separation
- placental separation
- placental expulsion
- Fourth stage: 1-4 hours following delivery
Nursing care management of labor (6)
-General measures
: obtain admission hx
: check results of routine lab tests and any special tests
: ask about childbirth plan
: complete a physical assessment
-initial contact either by phone or in person
Admission assessment (8)
-maternal health history
-physical assessment (body systems, vital signs, heart and lung sounds, ht and wt)
: fundal ht measurement
: uterine activity, including contraction freq, duration, and intensity
: status of membranes (intact or ruptured)
: cervical dilation and degree of effacement
: fetal heart rate, position, station
: pain level
Continuing assessment (8)
- woman’s knowledge, experience, and expectations
- vital signs
- vaginal examinations
- uterine contractions
- pain level
- coping ability
- FHR
- amniotic fluid: color (clear), odor, consistency
Nursing interventions during labor (5)
- supporting woman and partner in active decision making
- supporting involuntary bearing down efforts, encouraging no pushing until strong desired or until descent and rotation of fetal head well advanced
- providing instructions, assistance, pain relief
- using maternal positions to enhance descent and reduce pain
- preparing for assisting with delivery
Nursing care during labor and delivery (9)
1) Assessment
- placental separation
- placenta and fetal membranes examination
- perineal trauma: episiotomy, lacerations
2) Interventions
- instructing to push when separation is apparent
- giving oxytocin if ordered
- assisting woman to comfy position, providing warmth, applying ice to perineum if episiotomy
- explaining assessments to come
- monitoring mom’s physical status
- recording birth statistics, documenting birth in birth book
Interventions with birth (6)
-cleansing of perineal area and vulva
-assisting with birth, suctioning of newborn (amnio fluid), and umbilical cord clamping
-providing immediate care of newborn
: drying
: apgar score: color, resp, crying, muscle tone, reflex
: identification
Nursing care after delivery (12)
1) Assessment
- vital signs
- fundus
- perineal area
- comfort level
- lochia
- bladder status
2) Interventions
- support and info
- fundal check; perineal care and hygiene
- bladder status and voiding
- comfort measures
- parent-newborn attachment
- teaching
Placenta Previa (10)
-complete, partial, or marginal from implantation in lower uterus causing placenta to grow in front of uterus Sx: -painless bleeding -uterus is soft, non-tender Care: -stabilize mother and fetus -VS,IV,CBC -monitor FHR -no vag exams -ultrasound -bedrest -unstable-> deliver infant
Abruptio Placenta (15)
-can be partial or complete, concealed or apparent hemorrhage
-placenta is pulling away from uterus, only 10% are viable
Sx:
-bleeding
-tenderness to pain
-backache
-abdominal firmness, rigidity, “boardlike abdomen”
-uterine hypertonicity: strong, long duration, frequent
-contractions
-shock
Care:
-stabilize mother and fetus
-VS, IV, CBC
-no vag exams
-monitor FHR, UC, observe
-unstable—> deliver c/s
-labs: prothrombin time (PI), activated partial thromboplastin (aPTT)
DIC: disseminating intravascular coagulation (4)
- precipitating events
- thromboplastin release
- fibrin clot formation
- fibrinogen and platelet depletion
DIC sx, lab, care (10)
-secondary to something else that caused it SX -bleeding gums, nosebleed, petechiae, bruising with injections and venipuncture -tachycardia -diaphoresis LAB -low platelets -low fibrinogen -prolonged PT, PTT Care -correct underlying problem (need to deliver) -volume/blood/blood product replacement -oxygen
Hypertension Classifications (7)
- Pregnancy induced HTN (PIH): onset after 20 weeks, no proteinuria
- Transient htn: isolated episode
- preeclampsia
- ecclampsia
- chronic htn: had htn before pregnancy
- chronic htn with superimposed preeclampsia
- chronic htn/ecclampsia
Pre-eclamspia (5)
- htn: 140/90 or increase 30/15
- proteinuria: 350 mg or more in 24 hours, +1 or higher on dipstick
- edema
- sx: blurry vision, starry eyes, dizziness, HA, epigastric pain
- labs: elevated LFT, AST, ALT
Pre-eclampsia etiology (3)
- unknown
- risk
- young, primigravida, over 35, grand multigravida, multiple pregnancy, diabetes, severe obesity
Patholophysiology of pre-eclampsia (3)
- change endothelial cells
- vasospasm of arteries
- dec blood flow to organs
HELLP SYndrome (6)
H: hemolysis EL: elevated liver enzymes LP: low platelets -can be caused by pre-eclampsia -hepatic disfunction -thrombocytopenia
Management of PIH (2)
-assessment: early dx
-observation for edema
1+= 2mm 2+=4mm 3+=6mm 4+=8mm, pitting or dependent
Evaluation CNS-DTR and Clonus (3)
- check for deep tendon reflexes and clonus
- brisk response isn’t good as sign of CNS stimulation when can mean impending seizure
- clonus: foot relaxed and dorsiflex and release, should go back to place in a smooth manner, if stoccato count the beats/jerks
Ecclampisa 3)
- stop infusion of plasma and pitocin if seizing
- stop meds, and use seizure precautions (pad bed rails, report, monitor, side laying position)
- after use 02 via face mask
Care of PIH (4)
- bedrest, dec activity, dec CO
- frequent prenatal visits and fetal assessments
- self-care
- diet
Care for severe preeclampisa/eclampsia HELLP syndrome (6)
- dx
- hospital
- bestrest/stabilization/delivery
- seizure precautions
- anticonvulsants
- fetal monitoring/assessment
Anti-convulsant: Magnesium Sulfate (8)
- Pharmacology: blocks neuromuscular transmission and decreasing the amount of acetylcholine liberated at the end-plate by the motor nerve impulse
- depressant effect on the central nervous system, but it does not adversely affect the woman
- bp: 160/110
- lower bp, stops/depresses uterine contractions
- antidote is calcium gluconate
- loading dose 4g, maintenance rate 2g/hr
- relaxes muscle, bladder, uterine muscle (can increase bleeding so pitocin is also given)
- dec LOC
Monitor for MgSO4 toxicity (5)
- bp
- urine output
- loc
- dec reflexes
- respiratory depression
Postpartum preeclampisa (5)
- continue MgSO4 for 24 hrs
- sx dec rapidly
- diuresis
- risk of hemorrhage
- continue seizure precautions
Hemorrhagic complications/spontaneous abortion (7)
- threatened: slight bleeding, not aborted, cervix closed
- inevitable: going to happen, cervix open, lots of bleeding
- incomplete: placenta, fetal tissue, still there, cervix still open
- complete: fetal tissue expelled, common before 12 weeks, cervix closed
- missed: baby died but not expelled–> TAB cervix opened here
- recurrent: 3 or more abortions, often related to genetic disorders
- septic: mom is infected and has abortion
Management of hemorrhage (5)
- threatened: bedrest
- inevitable, incomplete: D&C
- missed: if no SAB, then D&C
- second trimester abortion: D&E
- septic abortion: D&C, antibiotics
D&C
D&E
D&C: dilation, currettage: dilate cervix with med, surgical instrument to scrape uterus contents
D&E: dilation, evacuation with vacuum, because the fetus is too big
Cervical insufficiency (7)
: premature dilation
- cerclage: sew cervix closed, 12-13 wk
- monitor UC, FHR
- observe for R/M
- bedrest, activity restrictions
- tocolytics: anti-contraction meds
- education re: labor
Tocolytic: terbutaline (9)
-B2 adrenergic receptor agonist
-side effects:
: uterine relaxation, bronchodilation, vasodilation, muscle glycogenesis
: CNS: dizzy, drowsy, HA, restlessness
: BP: widening pulse pressure
: HR: palpitations, tachycardia, chest pain
: GI: N/V
: Resp: SOB, cough, PEdema
: Metabolic: maternal hyperglycemia
: Fetal: tachycardia, hypoglycemia
Postpartum hemorrhage (4)
- definition: loss of blood following a delivery resulting in hypovolemia or otherwise causing the pt to become symptomatic
- ebl or qbl
- vaginal delivery: 500 ml
- c/s: 1000 ml
Oxytocin (pitocin) (5)
- IV, IM
- hormone normally stimulate labor, post pit
- used for PPH
- bolus or maintenance rate
- side effects: not common, anaphylactic reaction, pelvic hematoma, cardiac arrhythmia, subarachnoid hemorrhage, hypertensive episodes, nausea, rupture of the uterus, vomiting
Misoprostol (cytotec) (4)
- misoprostol to soften their cervix or induce contractions to begin labor
- cause mild contractions
- misoprostol is sometimes used to decrease blood loss after delivery of a baby
- these uses are not approved by the FDA
Methergine (3)
- smooth muscle constrictor, acts mostly on uterus
- commonly used to prevent or control excessive bleeding
- contraindication: pt with htn
- postpartum only for pph
Cesarian birth (3)
- vertical no longer done here
- horizontal is the most common form, low transverse
- less risk of bleeding, infection, uterine antony
C/S pre-op care (5)
- include support person
- anesthesia visit, informed consent
- foley, abdominal prep
- antacid is standing order, sodium citrate
- discuss post-op care
C/S post-op care (4)
- treat her like a mother who has given birth
- major surgery: IV, foley, incision
- complications: atelectasis/pneumonia, urinary retention/infection, wound infection, GI complications, hemorrhage
- postpartum care-continue
Fetal assessment via electronic fetal monitoring (2)
- non-stress test-NST, 20 mins
- contraction stress test: given pitocin to see if baby can tolerate it
Non-stress test (2)
- evaluate fhr during movement on monitor
- reactive= normal= acceleration of fhr equal to or greater than 15 bpm over baseline and lasting 15 sec and 2 or more accelerations with movement in 20 mins
Contraction stress test (3)
- evaluate fhr with uterine contractions
- negative=normal=no decelerations of fhr with 3 uc’s (lasting 40-60 sec) in 10 mins
- positive=abnormal=decels with 50% or more of uc’s
Absent variability
- flatline, ominous sign
Minimal fluctuation
<6 bpm
Moderate fluctuation
<6-25 bpm
-ideal
Marked variability
> 25 bpm
Veal Chop
v: variable decel
e: early decel
a: acceleration
l: late decel
c: cord compression
h: head compression
o: ok
p: placental insufficiency
Early decel
Late decel
Variable decel
Early: mirror image of contractions and decel
Late: repetitively after contraction
Var: abrupt decel with contraction
