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OB > Labor & Delivery > Flashcards

Labor & Delivery Flashcards

1
Q

Labor

A

Series of events by which uterine contractions and abdominal pressure expel the baby form the mother’s body.

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2
Q

***Dystocia

A

difficult, prolonged, abnormal labor (R/T passage, passenger, powers)

suspected with lack of progress in dilatation, fetal descent, altered uterine contractions

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3
Q

***CPD

A

cephalo pelvic disproportion (head cannot get through the pelvis

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4
Q

TOLAC

A

Trial of labor after C-section or VBAC - vaginal birth after C-section

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5
Q

Amniotic fluid embolism

A

Placental circulation carries amniotic fluid into venous flow

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6
Q

Version

A

Turning infant from malposition to cephalic

***Only the physician can do this!

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7
Q

Preliminary signs of labor

A

Lightening- Baby falls into pelvis
Increase in maternal activity- nesting- 24 hours in advance
Braxton Hicks contractions- start several weeks in advance
Ripening of the cervix- soft

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8
Q

Signs of true labor

A

Bloody show- can happen 2-3 days ahead of time, means you’re close

Uterine contractions

Rupture of membranes

cervical dilation

make progress

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9
Q

False Contractions vs. True Contractions

A

False Contractions
- Begin and remain irregular, felt first abdominally and remain confined to the abdomen and groin, often disappear with ambulation and sleep, do not increase in duration, frequency, or intensity, do not achieve cervical dilation

True contractions
- Begin irregularly but become regular and predictable, felt first in lower back and sweep around to the abdomen in a wave, continue no matter what woman’s level of activity, increase in duration, frequency, and intensity, achieve cervical dilation

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10
Q

Physiologic effects of labor- Cardiac

A

Cardiac output- 40-50% higher when in labor

Blood pressure- during contraction, B/P is higher because no blood is going into the placenta, B/P higher when pushing

***Pulse faster

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11
Q

Physiologic effects of labor- Hemopoietic system

A

Increased WBC because of the inflammation from labor and widening of the cervix

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12
Q

Physiologic effects of labor- Respiratory system

A

Using more oxygen during labor, her ***RR is higher throughout the entire pregnancy but definitely during labor

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13
Q

Physiologic effects of labor- Temperature regulation

A

might use up a lot of energy and get dehydrated, leading to a rise in temperature

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14
Q

Physiologic effects of labor- fluid balance

A

lose fluid through breathing, lose fluids, rising temperature

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15
Q

Physiologic effects of labor- urinary system

A

specific gravity will go up because of the dehydration, might even run albumin in urine

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16
Q

Physiologic effects of labor- Musculoskeletal system

A

joints are loose

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17
Q

Physiologic effects of labor- GI

A

will stop (inactive), might have diarrhea the day before, don’t give a lot eat during labor, will barf around 7cm

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18
Q

Physiologic effects of labor- Neurologic and sensory responses

A

May require pain medication

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19
Q

Fetal responses to labor

A

Neruologic- lower oxygen
Cardiovascular system- Not a good oxygen reserve, deceleration

Integumentary system- Bigger baby, bruising piticcui

Musculoskeletal system- flexed and pushed down into pelvis

Respiratory system- As the baby matures, the baby’s lungs will start to manufacture surfactant (makes them slippery) (happens around 35-36 weeks, starts later in diabetic baby), if the baby does not have enough surfactant, will have respiratory distress because the alveoli will stick together. C-section babies have wet lungs because they didn’t get the squeeze, make them cry.

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20
Q

***4 Components (“4P”s) of Labor

A
  1. Passenger- fetus, placenta, cord, fluid, and membranes
    - Structure & Diameter of fetal skull: Molding (overlapping of the skull bones to fit through the pelvis),
    - Fetal presentation: Attitude (position), Engagement (if the head is in the bottom of the uterus), Station, Fetal lie (is the baby up and down or sideways, relationship of long axis of fetus to long axis of mother, most common: Longitudinal)
    - Position: Relationship of presenting part to quadrants of Mom’s pelvis
    Cephalic R/L OA,OT,OP
    Chin = R/L MA, MT, MP
    Breech R/L SA, ST, SP
    - Fetal presentation types (Presenting part): Cephalic, Breech. Shoulder
  2. Passage- Pelvis, Vagina, Perineum
    - Pelvic dystocia: Pelvis too small or abnormally shaped, Inlet contraction, Outlet contraction
    - Secondary to maternal anomaly, trauma, malnutrition, low spine disorder, immature
    - leads to malpresentation, cord prolapse,
    Vagina, perineum – tears, scarring
    May do a Trial labor

Powers - Involuntary uterine contractions, bearing down efforts

Psyche – Fear, pain, anxiety

21
Q

Possible Fetal Positions

A

Relationship of fetal head/bottom/shoulder to the Mom’s pelvis

Mother Baby Mother
1st letter, side of the smooth (back)
2nd letter, where is the head
3rd letter, anterior or posterior or transverse

  • Vertex Presentation (Occiput)
    LOA, LOP, LOT, ROA, ROP, ROT
  • Breech Presentation (Sacrum)
    LSA, LSP, LST, RSA, RSP, RST
  • Face Presentation (Mentum)
    LMA, LMP, LMT, RMA, RMP, RMT
  • Shoulder Presentation (Acromion process)
    LAA, LAP, RAA, RAP

***vetex and breech will be on test!
Will not ask shoulder presentation or face presentation

22
Q

Leopold’s Maneuver

A

Determines the position of the baby so can see the points of maximum intensity of the FHT

Performed by nurses/providers

23
Q

Problems with the Passengers

A

fetus, placenta, cord, fluid, and membranes

  • **Fetal dystocia
  • size, (esp head), macrosomia
  • malpresentations include: face, brow, breech, (can try to change this with version) transverse lie, shoulder- pobably a C-section
  • malposition - most common is posterior (OP) try hands/knees position & counter pressure (back)
  • multiples - small babies, uterine dystocia, abnl presentations of twins (?surgery), anomalies

Fetal distress
S/S – Decelerations (most common), meconium stained fluids
treat: the cause –(? Overdue, Cord, placenta), with fluids, positioning, **amniofusion (put water through IV to the belly to float the baby), O2, Meds (Terbutaline, mag sulfate- slows down the birth), delivery, C/S

24
Q

Anomalies of placenta and cord

A 
Placenta
- Placenta succenturiata
- Placenta circumvallata
- Battledore placenta
- Velamentous insertion of the cord
- Vasa previa
- Placenta accreta
Cord
- Two-vessel cord
- Unusual cord length
25
Q

Passenger- Placenta

A

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

26
Q

Passenger- cord

A

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
27
Q

Passenger- fluid/membranes

A

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
28
Q

Rupture of membranes

A

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

29
Q

Passage: Cervical, vaginal, perineal changes

A

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

30
Q

Powers

A

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

31
Q

PCs: Powers

A

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

32
Q

Uterine Rupture

A

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.

33
Q

Bandl’s ring

A

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

34
Q

Psyche

A

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

35
Q

***Mechanisms of Labor

A

***KNOW THIS IN ORDER!

Descent
Flexion
Internal rotation
Extension
External rotation
Expulsion

Called the cardinal moves

36
Q

Placenta acreta

A

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

PC of L&D

37
Q

Labor Danger signs

A

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)

38
Q

Induction and augmentation

A 
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

39
Q

Interventions for pytosin

A

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.

40
Q

Stages of Labor

A

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

41
Q

Nursing Process: Assessment

A
  • 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

42
Q

Nursing care for stage 1 of labor

A

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

43
Q

Nursing care for the second stage of labor

A

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’
44
Q

Interventions for dysfunctional labor 1&2

A

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

45
Q

Vacuum Assist

A
  • 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

46
Q

Forceps

A

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)

47
Q

Nursing Care: 3rd & 4th Stage

A

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
48
Q

Nursing care for Placental delivery

A

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

49
Q

Pain control

A

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

OB (7 decks)

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