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Maternal/Child > Lecture 3 - Intrapartum Care > Flashcards

Lecture 3 - Intrapartum Care Flashcards

1
Q

How does estrogen effect oxytocin receptors on the uterus?

A

Estrogen induces oxytocin receptors on the uterus

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2
Q

How does oxytocin effect the placenta and uterus during labour?

A

Stimulates uterus contraction direction

Stimulates placenta to release prostaglandins which also stimulate vigorous contractions of the uterus

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3
Q

How do contractions of the uterus effect oxytocin and placenta prostaglandin release?

A

Increases both –> Positive feedback loop

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4
Q

A rupture of membranes before labour occurs in what percent of pregnant individuals? When must an induction occur following ROM?

A

8%
–> Induction will occur 12 hours following ROM

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5
Q

What is meant by “bloody show”?

A

A loss of mucous plug in combination with small amount of pinkish/blood tinged discharge. Associated with cervical effacement.

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6
Q

How does increased and high stress effect oxytocin release?

A

Excessive stress can decrease its release
–> Reduces the amount of contractions and the progression of labour

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7
Q

When does a surge of catecholamines occur labour? What is their role?

A

During 2nd stage of labour
–> Increases strength provide energy/motivation

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8
Q

Relaxin is released by what and has what role during pregnancy?

A

Released by placenta
–> Relaxes pelvic ligaments and joints and plays role in cervical ripening

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8
Q

What is the role of endorphins in labour?

A

To ease pain and provide sense of calm

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9
Q

How can true labour contractions can be differentiated from Braxton-Hicks or pre-labour?

A

True labour contractions will progress cervical dilation and effacement
–> True labour contractions are regular and will not subside, will increase with walking

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10
Q

What are the four stages of labour?

A

Stage 1
–> Onset of regular contractions that result in cervical changes and ends with complete effacement and dilation
2 Phases
–> Latent: 0-3 cm
–> Active: 4-10 cm

Stage 2
–> Begins with full dilation and effacement and ends with the baby’s birth
2 Phases
–> Passive: Not yet pushing
–> Active: Pushing

Stage 3
–> Starts with birth of the baby and ends with expulsion of placenta

Stage 4
–> Begins with the expulsion of the placenta and lasts until the birthing person is stable in the immediate postpartum period. Usually first 2 hours.

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11
Q

When is it recommended that a person comes to the hospital to be assessed during labour?

A

5-1-1 Rule
–> Contractions are 5 minutes (or less) apart, and are lasting 1 minute, and have been continuing in this pattern for an hour.

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12
Q

What are the two phases of stage 1 of labour? How long do they last?

A

Latent: 0-3 cm
–> Variable

Active: 4-10 cm
–> 0.5-1 cm dilation/hour (3-6 hours)

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13
Q

What are the two phases of stage 2 of labour?

A

Passive: Not yet pushing

Active: Pushing

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14
Q

When does latent labour begin?

A

The onset of regular contractions
–> q 5-30 mins, lasting 30-45 seconds.

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15
Q

How long does latent labour last?

A

6-8 hours, very variable

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16
Q

What are the Lamaze International 6 healthy birth practice?

A
  1. Let labour begin on its own
  2. Walk, move, change positions throughout
  3. Bring loved one, friend, doula for continued support
  4. Avoid interventions that are not medically necessary
  5. Avoid giving birth on your back and follow body’s urges
  6. Keep dyad together
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17
Q

What happens to the cervix during the latent phase of labour?

A

Lasts for first 1-3 cm dilation
–> More effacement than dilation during this phase

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18
Q

Why is it recommended that someone stay home during the latent phase of labour?

A

More comfort, less stress

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19
Q

If a person is admitted during latent labour, what nursing interventions should be done?

A

–> Minimize interruptions.
–> Offer fluids and light snacks.

–> Encourage rest and distraction and offer reassurance.
E.g., watch movie, go for a walk, take a shower or bath to relax, snooze between contractions

–> Remind the birthing person to void.

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20
Q

How frequent are uterine contractions during the active phase of stage 1 labour?

A

Contractions q 2-5 mins, lasting 40-90 seconds
–> Contractions should be moderate to very strong

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21
Q

How long does the active phase of stage 1 of labour last?

A

3-6 hours
–> Longer in primapara

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22
Q

What happens to the cervix during the active phase of stage 1 labour?

A

Dilates from 4-10 cm and effaces to 100%

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23
Q

What assessment must be done during phase 2 of stage 1 (active) labour?

A

Review OPR, interview.

Systems review, VS, fetal wellbeing, labour progress

Labs and diagnostics

Expressed psychosocial and cultural factors

Birth plan

Notify family and physician/OB

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24
Q

How is labour progress assessed?

A

Uterine activity, vaginal exam for dilation, ROM, bleeding

Minimize invasive assessments as much as possible, no more than every 2 hours unless otherwise indicated

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25
Q

What blood work will be done when a person is admitted in active labour?

A

CBC, T&S

GBS, HSV
–> May have already been done

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26
Q

What antibiotics are given for GBS+?

A

Penicillin G
–> q4h

Can also use clindamycin, baby will not be considered covered.

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27
Q

What are the key components of a FHR assessment?

A

Baseline FHR (not during contractions)

Accelerations and decelerations
–> Accelerations are a good sign
–> Decelerations may occur simultaneously with contractions

Uterine activity

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28
Q

How often is FHR monitored during labour?

A

On admission
–> qh

Active phase
–> q15-30 mins

Stage 2
Passive: q15 min
Active: q5 min/after contractions

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29
Q

When is electronic fetal monitoring recommended over intermittent ausculation?

A

For pregnancies at risk of perinatal outcomes

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30
Q

What are the five factors affecting the process of labour and birth?

A

Passenger (fetus & placenta)
Passageway
Powers (contractions)
Position (of mother)
Psychological response

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31
Q

What is fetal presentation? What are the most common kinds?

A

The part of the fetus that enters the pelvic inlet first and will therefore lead through the birth canal

–> 96% cephalic
–> Breech 3-4%
–> Shoulder <1%

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32
Q

How can the presenting fetal part be assessed?

A

Through cervical/vaginal examination

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33
Q

What are the different kinds of breech presentations?

A

Complete
–> knees tucked to chin

Frank
–> Legs extended upward

Single/double footling
–> Descended leg

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34
Q

What is fetal lie?

A

The relationship of the spine of the fetus to the spine of the mother
(longitudinal, transverse)

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35
Q

What is fetal attitude?

A

The relation of fetal parts to each other - attitude of flexion or extension

Generally, we want an attitude of flexion (fetal position) because extension can make delivery more challenging.

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36
Q

What factors affect the passenger during labour?

A

Fetal head
–> skull is not yet fused

Fetal Presentation (part)

Fetal Lie

Fetal Attitude

Fetal Position
–> Station
–> Engagement

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37
Q

What shape is the anterior fontanelle? When does it close?

A

Diamond
-> 18-24 months

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38
Q

What shape is the posterior fontanelle? When does it close?

A

Triangle
–> 6-8 weeks

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39
Q

What is vertex presentation?

A

Cephalic presentation with occiput as presenting part
–> ideal

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40
Q

Why is a footling breach the most challenging vaginal delivery?

A

Cervix may dilate enough for foot/legs to descend, but not enough for the hips and head to descend.
–> Mechanism for dilation is interrupted

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41
Q

What is the suboccipotobregmatic diameter?

A

9.5 cm
–> Smallest part of the head descending first is deal (with vertex presentation)

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42
Q

What military presentation?

A

Attitude of moderation extension with occipitofrontal diameter as presenting part
–> 12cm descending

43
Q

What is meant by fetal position?

A

The relationship of the presenting part of the fetus to the 4 quadrants of the mother’s pelvis

44
Q

Fetal presentation is described with what three letter system?

A
  1. Right/Left
  2. What is the part?
  3. Direction part is facing (anterior, posterior, transverse)
45
Q

What is meant by Direct OA?

A

A direct occipito-anterior positioning of the fetus (not left/right)
–> Ideal for vaginal delivery

46
Q

What is the station of the fetus?

A

A measure of the degree of descent of the presenting part in cm
–> The presenting part’s location to the ischial spines

Station 0 is at the ischial spine

47
Q

What is engagement?

A

When the largest diameter of the presenting part has passed the pelvic inlet and entered the true pelvis.

The presenting part of engaged with is it at station 0.

48
Q

When does engagement occur?

A

Usually 2 weeks before term in nulliparas and just before labour in multiparas

49
Q

What are the false and true pelvis?

A

The false pelvis is everything before the inlet.

The true pelvis is everything below the pelvis.
–> Includes inlet, ischial spine, and outlet.

50
Q

What hormones contribute to the softening of soft tissues in the birth canal?

A

Progesterone and Relaxin

51
Q

How does the active segment of the uterus change during labour?

A

During the second stage of labour the active segments thickens and stops accommodating the fetus.

52
Q

What are the powers of labour?

A

Primary: Uterine contractions
Secondary: Bearing down - pushing

53
Q

How are contractions described?

A

Frequency
–> 5 contraction/10 mins in active labour/pushing

Duration
–> 1-1.5 mins

Intensity
–> Maternal perception and examiner palpation. not EFM.

Resting Tone

54
Q

How long is an ideal resting period between contractions during active labour?

A

At least a minute
–> Risk of hemorrhage after birth

55
Q

When do we want a person to begin using secondary powers during labour?

A

After the cervix has fully dilated, because otherwise can cause edema and enlarging.

Most effective once the urge to push is felt and during a contraction.

56
Q

What position is best when the fetus is in negative station?

A

Trying to open the inlet
–> External rotation of femur head (toes and knees out)

57
Q

What position is best when the fetus is in positive station?

A

–> Internal rotation of femur head (toes and knees in)

58
Q

What is the usual length of the 2nd stage, passive phase of labour?

A

60-70 minutes for nulliparous

20-30 minutes for multiparound

59
Q

How can we support someone in the second stage, passive phase of labour?

A

Assist with positioning
–> promote fetal descent with position changes, pelvic rock, ambulation, showering

Encourage relaxation

60
Q

What are two common kinds of pushing?

A

Open-glottis pushing
Closed-glottis pushing

61
Q

What is open-glottis pushing?

A

Not holding breath while pushing
–> Facilitates maternal-fetal circulation, less maternal fatigue, protects pelvic organs from undue pressure, decreased incidences of perineal tears

62
Q

What positions are best during the pushing phase of stage 2?

A

Upright and side-lying positions

63
Q

What is closed glottis pushing?

A

Person holds breath while pushing
–> Increased intrathoracic and CDV pressure, decreased cardiac output and blood flow.
–> Increased fatigue
–> Cephalgia

For fetus, alterations in perfusion, pH. Can tighten pelvic floor muscles and limit fetal rotation and descent.

Not recommended.

64
Q

What are the position changes of the fetus during vaginal delivery?

A
  1. Engagement
  2. Descent
  3. Flexion
    –> Resistance from soft tissues and musculature causes attitude of flexion
  4. Internal Rotation
    –> Fetal head fits into widest diameter of pelvic cavity
  5. Extension
    –> Extension of fetal head passes under symphysis pubis - brow and face emerge
  6. Restitution and external rotation
    –> Head realigns with back and shoulder and anterior shoulder extends under symphysis, followed by posterior
  7. Birth
    –> Trunk of baby is born
65
Q

What are some risks of EFM?

A

May limit ambulation, increase rates of cesarean and instrumental vaginal births

66
Q

What are the risks of using epidural anaesthesia?

A

Increased oxytocin administration
Increases length of 2nd stage
Increased need for assisted vaginal births

67
Q

How can perineal trauma be prevented during delivery?

A

Warm compresses and upright positioning

68
Q

What are the four degrees of perineal lacerations?

A

1st - Mucosal tear
2nd - Perineal muscles involved
3rd - Anal sphincter involved
4th - Rectum mucosa involved

69
Q

How long does stage 3 of labour last? How does the length of this stage effect risk of hemorrhage?

A

5-30 minutes
–> Risk increases as length of this stage increases

After 30 minutes, the placenta is considered retained.

70
Q

How to we prophylactically treat/prevent the risk of retained placenta?

A

Prophylactic oxytocin administered after birth of anterior shoulder
–> IV rate as ordered
–> IM 10 units

71
Q

How long will we wait for cord clamping in a term baby?

A

60 seconds

72
Q

What are the priorities of care for the birthing person during stage 4?

A

Promote bonding, rest and relaxation, shower and clean clothes, fluids and food.

Continue to asses VS q15x1 then once during 2nd hour. Assess lochia, fundus, bladder, perineum, pain. Treat pain.

73
Q

What are the priorities with the newborn during stage 4 of the labour?

A

Promote bonding, prevent cold stress, observe for complications.

Vit k, weight, ID bands.

74
Q

Skin-to-skin causes a lower risk of jaundice. Why?

A

Increased breastfeeding to promote excretion of bilirubin + thermoregulation

75
Q

What are the four essential elements of labour support?

A

Physical, emotional, and informational support

Advocacy

76
Q

When is continuous labour support most effective?

A

When it is provided by someone outside the mother’s social circle, who is not a member of hospital staff, and who has a moderate amount of training, such as a doula.

77
Q

What is the acronym for labour pain?

A

Purposeful
Anticipated
Intermittent
Normal

78
Q

What causes visceral pain during labour during the first stage?

A

Caused my uterine contractions, stretching of cervix
–> Ischemia, pressure and traction on adjacent tissues

79
Q

What kind of referred pain will be felt during the first stage of labour?

A

Pain the radiated from uterus to the abdominal wall, Lumbosacral area, iliac crests, gluteal area, thighs, and lower back.

80
Q

What kinds of pain are most felt during the first stage of labour?

A

Visceral and referred

81
Q

What kind of labour pain is felt most during the second stage of labour?

A

Somatic pain
–> intense, sharp, burning
–> Caused by distension and traction on peritoneum and utero-cervical supports during contractions.

82
Q

What spinal nerves are involved in pain perception during the first stage of labour?

A

T10-L1
–> Related to visceral and referred pain

83
Q

What spinal nerves are involved in pain perception during the second stage of labour?

A

S2-S4
–> Somatic pain

84
Q

How does informed choice differ from informed consent?

A

Informed consent - offers opportunity to say yes or no

Informed Choice - Available options are presented

85
Q

What is the gate control theory of pain?

A

The idea that a gate open/closes to allow pain impulses through

Small diameter fibers carrying pain can be blocked by large diameter fibers activated by non-painful stimuli - such as counterpressure, massage, temperature

86
Q

When can cleansing breaths be effective for pain releif?

A

Before and after a contraction

87
Q

What is slow paced breathing?

A

Breathing in through nose and out through mouth - about half of regular resp rate

88
Q

What is modified paced breathing?

A

Easy, rhythmical breathing with a frequency of approximately twice your normal respiratory rate.

89
Q

What are the Rs of labour support?

A

Relaxation, rhythm, ritual

90
Q

What can relieve trembling in late active labour?

A

A warm blanket

91
Q

What is effleurage?

A

Light, rhythmic stroking touch

92
Q

What are some benefits of using a peanut ball during labour?

A

Reduced length of stage 1 and 2 of labour, reduced C-section rates

Increased patient satisfaction with no adverse neonatal effects

93
Q

How does the use of hydrotherapy prevent pain during labour?

A

Softens perineal tissues and promotes circulation, release of endorphins

Related to gate-control theory

94
Q

What are two things to keep in mind when using hydrotherapy during labour?

A

Wait until 5cm or more dilated (active labour)
–> Can slow labour in early labour

Water temp should not exceed 37°C (prof disagrees)
–> Decrease risk of hyperthermia and fetal tachycardia

95
Q

How much SWFI is infected for intradermal water block? What gauge needle is used? What four location are used?

A

0.5-1 ml with 25g into four areas surround sacrum

96
Q

How long does ISWB last?

A

2 hours
–> First accompanied by 20-30 seconds of intense stinging

97
Q

Why is ISWB effective?

A

May be gate-control or counter-irritation

98
Q

What is entonox?

A

A 50:50 blend of oxygen and nitrous oxide - self administered by mask

CNS depressant + anxiolytic
Peaks in 50 seconds and quickly dissipated

99
Q

What are some common side effect of entonox?

A

N&V, light-headedness

100
Q

Why are systemic opioids not recommended close to delivery?

A

Risk of respiratory depression in the newborn

Variability in fetal heartrate will also decrease

101
Q

What is a common side effect of Nubain (nalbuphine)?

A

Nausea
–> Often administered with Gravol

102
Q

How long does it take a pudendal nerve block to take effect? How long does it last?

A

2-10 minute onset with 1 hour duration

103
Q

What is an epidural?

A

A cath placed epidurally between 4th-5th lumbar vertebrae

104
Q

What is spinal analgesia?

A

A cath (smaller than for epidural) placed in the subarachnoid space, Not continuous.
–> Used for planned c/s

105
Q

What kind of pain does an epidural relieve during labour?

A

Relieves pain of contractions but not the pressure of fetal descent in the pelvis.

106
Q

What are the different kinds of epidurals?

A

Intermittent
Continuous
PCEA
–> Continuous with PC pump

Maternal/Child (4 decks)

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