Labor & Delivery Flashcards

Question

Passenger- Placenta

Answer 1

Vena caval syndrome –If Mom on back, baby puts pressure on vena cava = poor perfusion to uterus – Possible fetal distress TX: side lying Placenta Previa: Complete, partial, marginal - Common in pts with hx of uterine scarring, multiple gestation with lg placenta, endometritis, previous low implantation, older multips - SS - intermittent, painless bleeding - usually starts about 28 weeks- can become hypovolemic - TX - NO vag exams, T&C for 2 units (on call), double set up for delivery, Marginal - can leak fluids thereby put pressure on bleeding point. Bedrest IV, frequent FHT * **If patient comes in to the emergency room with placental previa: Give patient oxygen 10L/min through mask, IV with LARGE BORE needle. Nothing smaller than an 18 guage. Previa: no pain but bleeding Abruption: Marginal, central, complete - Bleeding inside the uterus. May occur at any time in the pregnancy - SS -May have vag bleeding, fetus hyperactive at first then ceases to move, uterus is firm and tender . Pain!!! (how to differentiate from previa), change in contr, (tone>hypertonic Fierce contractions TX - Determine amt of separation and age of fetus, may treat conservatively with BR, sedatives, and observation, but if severe will need to support blood volume and do c-section. Try to get them to the OR within 5-6 minutes Acreta- placenta has invaded the uterine muscle TX May require hysterectomy

Answer 2

Prolapse: cord comes out before the baby. Babies heart rate will slow down. Need to get the pressure off the cord. Turn the woman on her side, pillows under butt. Push up on the head away from the pelvis. - occurs with ROM when head not engaged or firmly fitted against cx, with CPD, malpresentations, polyhydramnious - SS - visual or tactile dx, Deep long variable decel - TX – Position change. AROM with slow release of fluid (esp if head is high, BR if ROM & high head, If prolapses Knee chest, fill bladder etc to keep head off cord!! Compression: - Occurs when there is not enough fluid to “float” the baby - Cord around the neck - SS Deep long variable decel - TX – amniofusion, position changes

Answer 3

Polyhydramnious - >2000 cc fluid - seen by 3rd trimester - associated with fetal GI anomalies that inhibit swallowing, CNS defects, sometimes multilpe gestation, and severe diabetes - Complications = prolapsed cord, pressure symptoms - TX - Amniocenteses (draw fluid out), slow/careful ROM in labor (slowly leak membranes) , pt education (come in immediately if membrane’s break), If diabetic: Indocin to reduce fetal voids Oligohydramnios - < 500 cc fluid at term - associated with renal/GI anomalies, Maternal hypertension, vasoconstriction, IUGR, PROM - Can be life-threatening as fetus cannot move lungs, cord comression. ? Amniotic leak - TX - Amniofusion, C-section

Answer 4

PROM- no contractions SROM- contractions AROM- someone popped it PPROM- 24 hours, possibly sepsis, think antibiotics - premature, spontaneous, artificial & prolonged premature rupture of membranes ***When bag breaks: Check FHT immediately, observe for cord Note color (might have white stuff (particulate material), that’s okay. if green or yellow, means baby had BM much earlier and probably has been in trouble for a while), odor, amount, particulate material ***After bag of water breaks, temperature every 2 hours and hand out of vagina

Answer 5

Cervical: Effacement, Dilatation Vaginal: stretching, pressure Perineal: no notes?

Answer 6

contractions and bearing down of mother involuntary uterine contractions, bearing down efforts - uncoordinated Uterine dystocia - - hypotonic contractions - infrequent and/or mild in intensity, usually in active phase - R/T Analgesia, CPD, Malposition, Overdistention - TX - Rest uterus (knocks out of labor), Augmentation, evaluate glucose depletion - Hypertonic contractions - Increased frequency, increased resting tone, may see decrease in intensity due to lack of resting tone - R/T malfunction of Uterine “pacemakers” May cause fetal hypoxia, uterine rupture - TX - Medicate, support, comfort measures, evaluate fluid status & stress

Answer 7

Precipitate labor- after delivery may hemorrhage. Premature labor, may give birth right away Uterine rupture- c/o burning pain across abdomen, take care of this now, immediate c-section Inversion of the uterus- can exanguonate in 10 minutes, usually happens with delivery of placenta. Can also happen when nurse is massaging fundus, uterus must be tight, if not, you could turn it inside out. Big bleed, may need to give CPR, Call anesthesia, give tocolytic to avoid contractions Amniotic fluid embolism: Allergic reaction, blood vessels will constrict, chest pain, pale, grey, death. Clotting problem: Give heparin to stop clotting cascade, give clotting factors with plasma

Answer 8

Emergency situation Hypotonic to no contractions Burning tearing pain Hypovolemic shock Palpable fetal parts Fetal distress Can feel all of the baby body parts. Baby will be in distress, need to get them out.

Answer 9

Interventions: When this happens, causes uncoordinated contractions Can be identified by sonogram Emergency - Can cause uterine rupture, fetal death and hemorrhage if occurs in 3rd stage IV Morphine Inhalation of Amyl Nitrate Tocolytic- Mag sulfate, tribuline C- section and manual removal of placenta under anesthesia

Answer 10

fear, pain, anxiety increase catacholamines -> dereased blood flow to uterus -> weak contractions -> fetal distress -> anxiety ……… can be seen as lack of control TX - Consider preparation, culture, support, self confidence - Reassure and support

Answer 11

***KNOW THIS IN ORDER! ``` Descent Flexion Internal rotation Extension External rotation Expulsion ``` Called the cardinal moves

Answer 12

Placenta digs into the muscle of the uterus, placenta will not come out, need to have a histerectomy PC of L&D

Answer 13

Fetal - Heart rate - Meconium staining- check for meconium aspiration - Hyperactivity- may be drowning - Fetal acidosis Maternal Blood pressure Abnormal pulse Inadequate or prolonged contractions: in labor too long and the uterus is exhausted, not getting any contractions Pathologic retraction ring: PC- ruptured uterus , Abnormal lower abdominal contour Apprehension: check O2 sat KNOW S/S OF PREECLAMPSIA- headache, double vision, epigastric pain (handout)

Answer 14

``` Induction- not having contractions Augmentation – not good contractions or knocked out and restarting contractions Do this for: Post term Rh problem Prolonged rupture of membranes Small for gestational age ``` Induction of labor - Done for varied reasons - Cervical ripening: Give Prostaglandins: Luminaria - AROM - Induction with oxytocin: Monitored labor!!!!!!!, Meds on pumps - Augmentation by oxytocin If you give prostaglandins: Monitor mother and baby for at least 2 hours. N/V/D are common side effects. DO NOT GIVE IF PATIENT HAS ASTHMA, GLAUCOMA, OR HEART PROBLEMS. PC: hyper stimulation Laminaria- Piece of seaweed up into the cervix and absorbs fluid and swells to open the cervix. Can do the same thing with a foley catheter, can cause contractions. AROM- allows the uterus to contract True induction – order pytosin (oxytocin) Induction: MUST BE MONITORED, we don’t want to put too much stress on the placenta. Medications: MUST BE ON CONTROLLER OR PUMP Augmentation- stopped and restarting contractions, not having good enough contractions, on the pump, use oxytocin. MONITOR VS EVERY 15 MINUTES! With Pytosin- contractions are more painful, b/p may drop, tonic contractions and fetal distress, can cause uterine rupture, can cause water intoxication. Watch output. Contractions should not last any longer than 90 seconds. SHOULD BE 60 SECONDS IN BETWEEN CONTRACTIONS Water intoxication s/s: headache, vomiting, seizure, coma, death

Answer 15

Good monitoring of contractions and FHT ***Look for S/S of hypertonicity, uterine rupture, fetal distress, BP problems, fluid retention – water intoxication ***1st thing you are going to do STOP the PITOCIN Turn to L side- circulation to the uterus is better For Distress - Start O2 per Mask – full blast Notify Terbutaline, Mag Sulfate (safest), Ritadrine (not used often)- should stop contractions Place internals ? Prep for C/S Monitor I & O, Specific gravities, Limit fluids if possible water intoxication. Can bolus with 400 mL of NS If the patient is on mag sulfate- need calcium gluconate at the bedside Terbutaline- nervousness and chest pain. Keep beta blocker nearby.

Answer 16

First stage Latent phase Active phase Transition phase - Latent- 0-3cm dilated, lasts 4-6 hours, contractions every 5 minutes and not severe - Active- 4-7cm dilated, anxious, contractions stronger, 3-5 minutes, might start asking for pain meds, concentrated on task at hand, thin cervix, >3 hours - Transition- Irritable, loses control, leg trimmers, vomit, will start to feel like she needs to push but can’t because she’s not dilated. Have her pant to avoid pushing. Sometimes have sweat across their top lip. Second stage Period from full dilatation and cervical effacement to birth of the infant - Pushing time Third stage Placental separation Placental expulsion - Usually takes about 30-45 minutes. If it’s longer, we worry about placenta ecreta, dug into the wall of the uterus, needs to have surgery or possibly a histrectomy. Important to know the time of delivery you can time it Fourth stage- Postpartum, check fundus, check bleeding, recovery room VS 1st stage: VS every 30 minutes 2nd stage: VS every 15 minutes Problem?: VS every 5 minutes

Answer 17

- History - Physical exam: Leopold’s maneuvers, Rupture of membranes, Vaginal exam, Pelvic adequacy, VS and FHT - Laboratory analysis Blood Urine - Uterine contractions Length Intensity Frequency - Ruptured membranes in patient with history of herpes - sterile speculum exam to look at cervix - Vaginal exam: Check the fluid with pH paper (will turn blue or black), or put fluid on a slide to test if it’s ruptured membranes, could get a false positive if there is blood in the vagina 1st stage: VS every 30 minutes 2nd stage: VS every 15 minutes Problem?: VS every 5 minutes ``` Know: Anesthesia Birth plan Due date Did they have babies before and how were the labors? Medical conditions in the family? Allergies Past medical history (anemia and STDs) ``` Laboratory analysis Blood work: type and rH, H&H, if they come in anemic, when they leave they will be more anemic Urine: Protein in the urine, ketones, sugar Uterine contractions: How far apart? How long? Strength? If they are having a lot of pain, don’t expect an answer Don’t do a vaginal exam during a contraction without her permission (this can tell you how far the baby is sliding during the contraction) Amniotomy: pop bag of waters, FIRST RESPONSIBILITY AFTER RUPTRUED MEMRANES: MUST LISTEN TO BABY AFTER THE BAG IS POPPED IN CASE OF PROLAPSED CORD (HR will decrease in the case of a prolapsed cord), after amniotomy, contractions will be harder because the uterus is smaller

Answer 18

Respect contraction time Change positions If she has back pain: push on her back Voiding and bladder care: if they have an epidural, they will probably have a foley, if not, get the, to void frequently to keep the baby’s head down low and dilate faster Support: help keep concentration. If she’s in pushing stage (transition) she probably won’t pay attention to you. Keep patient informed of progress they are making. Support the support person. Particularly during transition Pain management: If they don’t want pain medication: let them know that it is okay not to want it but let her know she can still ask for it if necessary. Observe for dysfunctional labor Prolonged latent phase: might need to stop contractions and start them back up again, teach breathing exercises, time to give pain meds. TRANSITIONS IS NOT THE TIME TO GIVE PAIN MEDS BECAUSE IF IT IS A QUICK TRANSITION, THE MED WILL GO TO THE BABY. If the mom asks during the transition phase, education that it will be unsafe and ask if there is anything you can do to make her more comfortable. Protracted active phase: CPD? Baby in a bad position? Prolonged deceleration: baby is not moving down. CPD? C-section Secondary arrest of dilation: do not make progress. Probably because of a CPD which means c-section Fetal distress: Always looking for Precipitous labor: baby is coming right then and now, good to wear gloves if possible, gown, chucks Start vomiting at 7 and 8 centimeters, when in labor digestion slows down so we don’t want them to have anything major. Toast, broth

Answer 19

Pushing stage Make sure all the machinery is on and working Have things ready and be organized (Pitocin, machinary, baby bed, oxygen) Will say she has to poop, do a vaginal exam to see if she is completely dilated or if she needs to poop Positioning for birth: Squatting is the best. Beds designed to do this. Opens you up and gravity brings the baby down further. If the baby gets stuck put legs up by the ears Pushing: Want them to save air Perineal cleaning: Look at next slide. Makes patient feel better Episiotomy: To prevent a lot of pressure on the baby’s head, usually cut midline, can have mediolateral (very painful afterwards) Birth: After the whole baby is out. Cutting and clamping of the cord. Doctor often waits until the cord quits jumping. Often use the umbilical vein to give and IV, so if critical condition or primi, leave a decent amount. Must know how many vessels you have in the cord. Worton’s jelly surrounds it. ``` Observer for dysfunctional 2nd stage Make sure they don’t jerk on the cord Prolonged descent Arrest of descent Fetal Distress Inverted uterus with crede’ ```

Answer 20

Keep provider informed: no progress, too much progress Monitor for distress (maternal and fetal) Keeping glucose up: use juice or jellow Always support the patient Minimize stress Administer Meds, O2 Assist with forceps, extractor, section

Answer 21

- Advantages Little anesthesia Fewer lacerations ``` - Disadvantages Large caput- see below Tentorial tears- see below Cervical bruising tear Cannot be used on premies ``` Doesn’t touch the mother, hooks on to the baby’s head. 600 psi. Large caput: knot on baby’s head Tentorial tear: might rip the scalp away from the bone to cause bleeding. Will need to put pressure and ice. *****Cannot be used on premies

Answer 22

Outlet procedure Low forceps - head at +2 station Mid forceps – head engaged but < +2 – RARE Will usually have some type of anesthesia ``` Will usually have an episiotomy Careful monitoring to check that cord not caught - Empty bladder - Fully dilated - Membranes ruptured - No CPD ``` Shoulder dystocia- pull back on woman’s legs, called McRoberts (opens up the pelvis)

Answer 23

Cutting, clamping and examination of the cord Cord blood collection Oxytocin: Will probably get Pitocin after delivery Placental delivery: Examine and make sure the whole placenta is there Perineal repair Assessment: Is her uterus firm? Located in the middle of the belly? 1st day, 1 finger below, 2nd day, 2 fingers below, etc Do not squeeze the uterus until it is firm Aftercare: VS every 15 x4 Every 30x2 Then after an hour can go to floor Observe for complications - Inverted uterus with delivery of placenta - Hemorrhage - Problems with the baby

Answer 24

Observe for signs of separation Oxytocin to control blood loss Examine cotyledons of the placenta Foster infant attachment- give mom the baby ***make sure all of the placenta is there, must look at the maternal side

Answer 25

Pain control: Regional Pudendal block: goes near the nerve to relieve pain of pressure but NOT CONTRACTIONS Spinal block: go inside of the dura, Not in the spinal cord itself but into the dura, some of the spinal fluid will leak out could cause spinal headache, fix this by drawing blood out of the mother and putting it in the spinal cord with a clot until the body can build up the fluid in the spinal cord (called a blood patch) Epidural: outside of the dura, nerve comes out and through the epidural space, gets numbed with an epidural. MUST GIVE A FLUID BOLUS IN PREPARATION (AT LEAST 400 CC), if you don’t give the fluid, they could get hypotension, must watch the b/p after an epidural. NEVER LET THE PATIENT GET UP AND OUT OF THE BED AFTER GIVING BIRTH, THEY LOST A LOT OF BLOOD ``` Nonpharmacological pain control This can be challenging Positioning and Movement Breathing Music Relaxation ***Other attention-focusing strategies - Guided imagery - Massage and touch Hydrotherapy- whirlpool Heat/cold application Biofeedback, TENS, intradermal water block Accupressure/acupuncture ENS unit- ??? Intradermal water block ```

Labor & Delivery Flashcards

(49 cards)