Maternity Flashcards
Stages of Labour
Full term = 37-42 weeks
Preterm = before 37 weeks
Stage 1 Labour
3 phases:
Latent Phase
Active phase
Transitional phase
Early/latent phase
longest phase client is relaxed and contractions are mild
education and encouragement
0-3cm cervix dilation
0-30% effaced
As cervix begins to stretch it trigger oxytocin release Duration 30 seconds
Closely monitor Monitor fetal heart rate
Assess for late decelerations (not enough oxygen getting to the baby)
Active Phase of Labor
Go to hospital
Breathing techniques and pain management is the focus
4-7cm dilation
100% effaced
Contractions will be stronger and longer
3-5 min
Water may break - mom all feel restless and anxious
Can provide medications:
Epidural
IV narcotics: given slowly during the peak of the contractions
A client in latent labour receiving an oxytocin infusion for labor augmentation is requesting IV pain medication.
Which nursing action is appropriate
Give the medication slowly during the peak of the next contraction?
Transitional Phase
Mom should focus and stay in control
8-10cm cervix dilation
100% effaced
Contractions are strongest and closer together
Anxiety and vomiting
Urge to have bowel movement
Strong urge to push with each contraction
Do not push until 10cm dilated (risk for cervical swelling and lacerations)
Amniotic sac ruptures “bloody show”
Assess colour of amniotic fluid (water break)
Meconium-stained fluid (dark fluid) sign of fetal distress or hypoxia
Interventions:
Emotional support and encouragement
Breathing techniques
10cm dilated - document fetal HR every 15 minutes
Avoid pushing until 10cm
What is expected during the transition phase of the first stage of labour
Vomiting
Bloody mucus
urge to have a bowel movement
A labouring client reports anxiety, vomiting and the need to have a bowel movement. What is the expected cervical examination finding?
8cm dilated, 100% effaced
Stage 2 Labor
Decent phase/pushing phase
Delivery of Baby
Cervix must be 100% effaced and 10cm dilated
Signs:
Increase in contractions and urge to push/poop
Ferguson reflex: spontaneous urge to push/bare down during labor
It occurs when the presenting part of the fetus reaches the pelvic floor
Interventions:
Position of the mother is priority
High fowlers, lithotomy, side lying
Push properly
Avoid holding breath or tightening the abdomen
Push when feeling the urge
Breathe IN deep
Breathe out slowly through the mouth and keep mouth open while pushing down
Assessments:
Fetal heart rate before, during and after the contraction
Frequency of contractions
Duration of contractions
Uterine tone between contractions
A client presents to the meergcy department wafter he water broke. She appears anxious and in pain, bearing down with each contraction. What assessment questions should the nurse ask immediately to prepare for birth? potential newborn resuscitation?
When your water broke, what was the colour of the fluid?
Dark fluid = bad sign
What is your expected due date (EDD)
How many babies are yay expecting?
Do you have any active sexually transmitted diseases?
Recently have you taken any medications, opioids or illicit drugs?
Stage 3 Labour
Placenta delivery
Uterus contracts and placenta slowly detaches from uterine wall
Must be carefully delivered
Never pull on placenta
High risk fir infection if placenta parts are not fully removed
Uterine inversion (pulling on the cord)
severe hemorrhaging (bleeding): decreased blood pressure, increased heart rate
Pitocin (oxytocin) to prevent haemorrhage
Stage 4
Post partum recovery
Goal: don’t let client bleed to death
2-4 hours after birth
Skin too skin and breast feeding
breast feeding: stimulates maternal oxytocin release helps contract uterus, provides nourishment and supports blood sugar of new born
Assessments:
Infection: temperature over 100.4
Hemorrhage: priority assessment = monitor peri pads
Fully saturated in less than 1 hour
Decreasing blood pressure, increases heart rate
Interventions:
Fundus First: soft and boggy = massage until firm (contract and stop bleeding)
Assess 3 times every 5mins then every 15min for 1 hour
Void or use catheter (in and out) full bladder can displace fundus and prevent from gully contracting to stop bleeding
Pitocin (oxytocin): IV or IM to control bleeding after childbirth
Breastfeeding: stimulate release of natural oxytocin
Uterine involution occurs: uterus returns to pre pregnancy size and location
15-21 days after delivery
Fundus Assessment
Normal:
Firm
midline
Level with umbilicus
12hours after should be 1cm above umbilicus
will resend 1-2cm every 24 hours
Not formal: displaced fundus above umbilicus or to one side = bladder distention
Intervention: void every 2-3 hours (bed pan preferred if patient has been given pain meds)
In and out catheter used if patient is unable to void or walk
Soft or soggy funds (uterine atony) = increase risk for hemorrhaging
Intervention = oxytocin infusion
Fundal massage
A client who gave birth vaginally with epidural anesthesia reports no urge to urinate 3 hours after birth. The clients fundus is above the umbilicus, but 3cm to the right. What should the nurse do?
Preform in and out catheterization
Least invasive to most invasive
A client who had a vaginal birth 1 hour ago has a boggy fundus that is deviated to the left and above the umbilicus. Which intervention should the nurse preform first?
assist the client to use the bedpan to void
The client delivered a baby 8 hours ago, the fundus is boggy and soft. Which interventions are most appropriate
Firmly massage fundus
Encourage the client to void
Administer methergine per orders
Methergin: analgesic used to treat severe bleeding after child birth
increases blood pressure
Six hours after a vaginal delivery the nurse notes the perineal pad is soaked and there is blood underneath the client buttocks. Which action does the nurse take first ?
assess the fundus
After delivery the nurse administers oxytocin this medication is used for which purpose
Stimulate firm contractions of the uterus
Profuse bleeding in a postpartum client, priority intervention?
Palpate uterus and massage if it is boggy
Which drug is used for treating a client with severe postpartum bleeding?
Oxytocin
Fourth stage of labor, early sign of excessive blood loss?
An increase pulse rate of 88-102
Fourth stage of labor, clients perineal pad saturated with blood and blood soaked into the bed linen. Which is the nurses initial action?
gently massage uterine fundus
Top tested key points of true labour
all about cervical changes
1. Bloody show “mucus and blood”
2. Water breaking - atomic sac ruptures
3. True labour contractions: increased frequency (regular and rhythmic) and increased intensity and duration cause progressive cervical changes
4. cervix
Dilation: how wide cervix is opening (goal = 10cm)
Effacement: cervix gets thinner and shorter measured in percentages 0-100%
4cm dilated and 60% effaced explain the meaning of this information
The opening of the cervix is 4cm wide and the cervical canal is 607 shorter than normal
Braxton hicks contractions
False labor contractions
Diapear with walking or position change
No dilation of cervix
False labor contractions
Decrease in intensity with ambulation
irregular contractions
Pain alleviated with rest or changing position
Cervix = no change
True labour
Regular increasing frequency duration and intensity
Pain Does not decrease with rest
cervix = Progressive change dilation and effacement
Which signs are most indicative of true labour
Pain in the lower back that moves to lower abdomen
progressive cervical effacement and dilation
Regular and rhythmic contractions that increase in frequency
Contractions become more intense with walking
Which questions would help determine if the client is in true labour
Do you feel like the contractions are getting stronger
Does anything you do make the pain eel better
Do the contractions feel the same when lying down
How frequent are the contractions
Where do you feel the contraction pain most
Back labor
Black pain “back labour”
fetus in occiput posterior position (OP)
Back of baby head is against the mothers spine = slow p progression, long labor and back pain
Can lead to labor constipation
Interventions: Apply counter pressure to the sacrum during contractions
Reposition the mother on her hands and knees with birth ball and encourage to change position every 30-60 minutes
*no position changes and remaining in bed during early labour
left lateral position with not alleviate back pain
Client reports intense back pain, fetal position is right occiput posterior. Which intervention would help alleviate the back pain during early labor?
Applying counter pressure to the sacrum during contractions
Appropriate task to delegate to the unlicensed assistive personal UAP?
Reposition an uneducated client who is in active labor onto a birthing ball
UAP can help with position changes but cannot to assessment to re-evlaution
Lochia assessment
Discharge after birth
Should become lighter in colour and amount each day
Red (rubra) bright red flow 3-4 days, small clots are expected
pink/brown (serosa) 4-10 days
White/clear (alba) 10-28 days
When to notify provider
Large clots
Foul odor
Excessive bleeding (1 pad in 15min)
Check under the client for pooled lochia
Client gave birth three hours ago a sudden gush of blood from the vagina while ambulating. Which is the most likely cause of the bleeding?
Lochia has pooled in the clients vagina
The nurse is assessing a client whoo delivered a baby 3 days ago. When assessing for lochia the nurse notes pink discharge with a serosanguinous consistency. This best described as?
Lochia serosa
A client 6 weeks postpartum which of the following findings is normal for the client?
Creamly coloured discharge with fleshy odor
Peri Care Postpartum
Cleaning: squeeze bottle with warm water
Wipe front to back
Blot perineum dry
Pain:
sitz baths
Ice packs
PharmL: opioids and NSAIDS
topical witch hazel
Laxatives and stool softeners (prevent constipation)
A client who has an episiotomy, proper perineal care?
Use a squeeze bottle with warm water to keep the sit clean
episiotmy is a cut (incision) through the area between your vaginal opening and your anus.
Which medication is appropriate for a postpartum client with perineal lacerations now experiencing constipations?
Laxatives
5ps of labor
Passenger (baby)
Baby delivery: fetal head and body size
Fetal attitude:
flexed = good
Chin to chest
Rounded beck
Flexed arms and legs
Extended = bad
Flaccid is indicative of CNS problems
Fetal lie: position of babes back in relation to moms back
Best for vaginal delivery: longitudinal lie: both baby and mothers body are parallel - spine lies along spine
High risk for breech: c- section delivery
Transverse: sideways baby
Oblique: baby is at an angle
Presentation: “presenting part”
Cephalic presentation: head first
Dimond-shaped and soft in the middle
Position of the baby
Best position: ROA - right occiput anterior
LOA: left occiput anterior
Bad position: Sunny side up
OP: occiput posterior (left or right)
OT: occiput transverse (left or right)
5Ps
Passenger
Passageway
Power
Position
Psychological response of mother
Breech Presentation
Complete breech: buttocks first with legs tucked in
Frank breech: buttocks first with legs stretched up
Footling breech: foot first
Interventions: External cephalic version (EVC)
Method of turning baby from breech too head first
if that doesn’t work a C-section used
Fetal station
Degree of fetal descent into the pelvis
-1 to - 5 pelvic inlet: baby’s head is above mom’s ischial spine. (baby is deeper inside the pelvis)
Station 0 ischial spine and engagement: baby head is level with moms ischial spine
Head is engaged and ready for labor
Station +1 - +5: Corning and emerging from vagina
Baby head is coming out “crowning” start pushing!
Vaginal examination, the nurse records: 50%, 6cm, -1. Which is a correct interpretation of the data?
The fetal presenting part is 1cm above the ischial spines
Placenta previa
Placenta blocks the cervix preventing the baby from coming out
Sudden onset of painless bleeding
Fundal height is more than expected
Bright red blood
Complete plan entails previa = c section
Abruptio Placentate
Separation. of placenta from uterine wall after 20 weeks gestation before fetus is delivered
Dark red vaginal bleeding
Uterine ridgity
abdominal pian
Signs of fetal distress
Trendelenburg to decrease pressure of fetus on placenta
Delivery of fetus as quickly as possibe
Vaginal if fetus is healthy, C-section if showing signs of fetal distress
Placenta Previa vs Abrupto placentae
Previa: painless, bright red blood, uterus soft and relaxed
Abrupto: Dark red vaginal bleeding uterine pain and uterine rigidity
Second P = Passageway
Birth canal
depends on the maternal pelvis and soft tissues
If the baby is too large for thise birth canal or the pelvis is not wide enough the baby might need to be delivered a different way such as a C-section
3rd P = Power
contractions to open the cervix
3 contractions assessment:
1. Frequency (how often - minutes)
2. Duration (how long - seconds)
3. Intensity (how strong)
Dilation: 10cm (fully open)
Avoid pushing until 10cm dilated
Effacement: 100% thin
Which are factors that accelerate dilation of the cervix
Strong uterine contractions
Pressure by amniotic fluid
Force by fetal presenting part
4th P Position
Mother should be in squat position makes labor easy:
Promotes fetal descent
5th P = Psychological response of mother
cultural considerations
Be considerate of social norms
Coping mechanisms
Fetal Heart Rate
Identify fetal well being and oxygenation during labor
abnormal reading may indicate baby is not getting enough oxygen
Normal fetal HR: 110 - 160
Bradycardia: Less than 110 for 10min or longer
Tachycardia: More than 160 for 10min or longer
External fetal monitoring
Mothers abdomen is palpated to find the point of maximal impulse - located between baby’s shoulder blades and this is the point where the baby heart rate can be heard the loudest
best place to but the heart rate sensor
Cephalic will be placed lower abdomen
Breech: will be places upper abdomen
Contraction monitor sensor
Places higher up on the abdomen
Too monitor the contractions
Internal fetal monitor: fetal scalp electrode - FSE
Used for high risk pregnancy’s
Placed on baby scalp through the cervix
Can only be used after the amitotic sac has ruptured and cervix is dilated 2cm
High risk of infection
Which of the following must be present before the nurse initiates internal fetal monitoring
Cervical dilation of at least 2 cm
Fetal Heart Rate monitoring strips
Fetal heart rate on top which we always assess first
Red lines represent 1 minute
Mothers contractions on bottom
Key terms for FHR
Baseline: normaal FHR 110-160
Variability: how jiggly or wiggly is the line? as labor progresses we expect the fetal heart rate to have wiggly lines = happy baby and neuro system is intact
Delerations: Dips form the baseline
Types of variability
Absent variability: Not jiggly = NOT good baby needs to come out asap via c-section
Minimal or decreased variability: flatter line, that looks sleepy and sad = baby is in trouble, very concerning
Moderate variability: Normal and desired finding
Marked variability: jagged jiggles = stressed baby = okay
Accelerations
Temporary increases in FHR
Indicates gerat oxygenation for the baby
Happy little mountains
Early Decelerations
Early decals = excellent
Shallow bowl shaped dips that mirror mothers contractions, indicates head compression
Variable decelerations
very concerning
Very deep “sharp V dips”
indicates cord compression
cuts of oxygen to the fetus
Change mothers position
Amitotic infusion if doesn’t improve
Late deceleration
Very bad
indicates lack of oxygen to the baby
Key terms for uterine contractions
During contractions babys will hold their breath and fetal oxygenation is impaired
4 components
frequency: measure how far apart the contractions are
2. Duration of contractions, how long the contractions last (boxes under the hill measured in seconds)
3. Intensity: rates how strong the contractions
4. Rest (tone and time): the uterus should be soft to palpation between contractions for at least 60 seconds
Normal Contractions
Rule of 60
Frequency: 2-3min apart in active labor
Duration 60 seconds
Intensity 60mmHg
Rest: 60 seconds of rest in between contractions
Tachysystole complication
Over 5 contractions in 10 minutes
Too many contractions: fetal distress, including hypoxia and reduced placental blood flow
VEAL CHOP
Variable decelerations = Cord compression
Early decelerations = Head compression
Accelerations = Okay
Late decelerations = Placental insufficiency
Interventions for late decelerations
ROADI
Reposition mom
Oxygen via facemask
Aleter HCP
Discontinue oxytocin and give tocolytics
Increase IV fluids
What happens when oxytocin levels are elevated?
Uterine contractions will increase
The nurses assesses fetal well being during labor by monitoring which factor
Response of the fetal heart rat to uterine contractions
Normal Fetal Heart rate findings
Normal baseline rate 110-160 bpm
Accelerations
Early decelerations
Not normal - indicates fetal distress
Tachycardia/bradycardia
Late decelerations
Variable decelerations
Sinusodial tracing
Normal FHR
110-160bpm
Baseline between contractions
Accelerations
Temporary increase in FHR (this is okay) indicates good oxygenation
Early Decelerations
Mirror contractions with decreased FHR during contractions = okay and expected
cause: head compression during the contractions
Interventions: prepare for delivery of the baby
Which fetal heart rate tracking characteristics are considered reassuring or normal?
Early decelerations either present or absent
Fetal tachycardia
Increase in FHR over 160/min for over 10 minutes
Early sign of fetal distress
Causes: trauma to the mother
Maternal infection or fever
Fetal anemia
Dehydration
Stimulants (cocaine)
Interventions:
Oxygen
IV fluids
Antipyretics
Client with a fractured wrist who is 36 weeks pregnant. Which of the following assessment items should the nurse prioritize
The fetal heart rate ice 210/min
While monitoring the FHR the nurse notes tachycardia. Which is a probable cause for this condition?
Early signs of fetal distress
A FHR baseline of 175bpm the nurse know that this can be caused by which factor
Fetal tachycardia
Fetal bradycardia
Decrease FHR less than 110/min for over 10 minutes
Causes
Uteroplacental insufficiency
Umbilical prolapse
Maternal hypotension
Analgesic medication
Interventions for fetal bradycardia
Reposition mom: side lying
Oxygen via facemask
Alert the HCP
Discontinue oxytocin
Increase IV fluids
Slowing of the fetal heart rate and a loss fo variability
Turn the client onto her side and give oxygen by face mask at 8-10L/min
Maternal cardiac output can be increased by factor
Change in position
Sudden drop in fetal heart rate from its baseline of 125 to 80.The nurse repositions the client, provides oxygen, increase IV… five minutes have passed and the FHR remains in the 80s. Which additional measure would the nurse take?
Notify the health care provider immediately
Abrupt and rapid fluctuation in the fetal heart rate from baseline to 90 beats per minute and back to baseline. The fluctuations in fetal heart rate occur with no relationship to the contraction pattern. Which response by the nurse is best
This is a potential problem that requires a position change first
Variable decelerations
Abrupt decreases in FHR
less than 30seconds from onset to baseline and 15bpm/min below baseline for 15 seconds - 2 min
Causes: cord compression
Critical since oxygen tube is compressed
Decreased amniotic fluid
Variable decelerations Interventions
Reposition mom: side lying
Oxygen
Alert HCP
Discontinue oxytocin
Increase IV fluids
Amnioinfusion
The installation of sterile saline into the amniotic cavity to refill the lost fluid
Done if multiple position changes have not relived the cord compression
Report immediately: indication of overfilling
Uterine resting tone that increases to 45mmHG
Can lead too uterine rupture
Late decelerations
Decreased FHR after contractions with prolonged time before retiring to baseline
Indicates oxygenation is compromised
Causes:
Placenta insufficiency
uterine tachysystolefluid
Side effects of oxytocin causing severe contractions = reduced placental blood flow and impaired fetal oxygenation
Stop oxytocin:
Over 5 contractions in 10min
Late decals
Hypotension iei also a cause
Late decelerations Interventions
Reposition mom: side lying never supine
Oxygen
Alert HCP
Discontinue oxytocin
Increase IV fluids
Prepare for C-Section
A new nurse is evaluating a fetal monitoring strip of a client in labor who is receiving an oxytocin infusion. Which of the following action should the nurse take next?
Reposition the client to left/right side
Oxygen by face mask
Initiate an IV bolus of 0.9& saline
Notify the provider and prepare terbutaline
Oxytocin induction the last five contractions the fetal heart rate has fallen below the baseline and returns to baseline in 20 to 30 seconds after the end of the contraction
What actions must the nurse take
Select all that apply
Contact the health care provider
Stop the infusion of oxytocin
Apply oxygen by facemask
Reposition the client
Fetus is experiencing distress if which heart rate pattern is observed
Late decelerations
Sinusoidal FHR
Repetitive wave-like fluctuations (hills) with no variability and no response to contractions
Requires immediate intervention
Cause:
Mother abdominal trauma (fall, motor accident)
Leading to fetal blood loss for anemia
Intervention: emergency C-section
The nurse is observing the fetal heart rate tracing for 4 clients which pattern is most concerning
Sinusoidal FHR
Gestation
Time of fertilization until date of delivery
about 280 days
Neageles Rule
subtract 3 months and add 7 days to the first day of last mensural period
Gravidity
Gravida Refers to pregnant person
Gravidity refers to the number of pregnancies
Nulligravida = person who’s never been pregnant
Primigravida = person pregnant for the first time
Multigravida = at least second pregnancy
Parity
Parity is the number of births (not number of fetuses) carried past 20 weeks of gestation whether or not the fetus was born alive
Nullipara = not has a birth at more than 20 weeks gestation
Primipara = had one birth that occurred after 20 weeks
multipara = person had two or more pregnancies to the stage of fetal viability
GTPAL
G: number of pregnancies including the present one
T: term births the number born at term (longer than 37 weeks)
P: Pre term births before 37 weeks
A: is abortions or miscarriage
L: number of current living children
Fundal Height
measured to evaluate the gestational age of the fetus
Weeks 18-30: fundal height iim cm = fetal age in weeks + 2cm
