maternity Week 2-PPT Flashcards
what is neonatal abstinence syndrome and why does it occur
when the infant is also addicted to the substance the mom is using and must go through withdrawal after brith
most illicit drugs have small molecular weight and can cross the placenta
is it better to have just one person woring with substance use mom or team approach
team
is it a good time to change drug use habits during pregnancy?
Women are more motivated to change their substance use during preg more than any other time
durin labour something very small deviates from normal what do yu do
you MUST consult with the dr
during labour how often are you doing and documenting your H2T on mum and fetus
q15 or even q5
how can you preserve personhood for complex labour/birth/preg
- try to include her birth plan as much as possible
- explain if you have time. if you dont then make sure to go back later and let her talk
- remember its ++special and important for the family
- privacy and modesty
- include their supports
how are the parts of labour divided
2 stages
- latent
- active
active stage has 4 phases 1st –labouring and dilation 2nd –pushing, descent and delivery 3rd -placenta delivers 4th -hemostasis established after delivery of baby and placenta
when a woman is in the latent phase of labour what can she still do
quality of her contractions?
how is her pain?
You can still walk
You can walk and eat light meals
Its tiring
Prevents you from going into deep sleep
The contractions have no pattern. They are all over the place
You have discomfort like menstrual cramps
consideration for those who have long latent phase of labour
they are often very tired and have less energy for active phase
how are contractions in gen during active phase
how long should they last?
Contractions should last 60 seconds
They dont go away. You cant stop them
Theyre uncomfortable to the point you cant talk through them
You need supports to get through them]wont go away with hot bath
what is the max that you want the active phase of labour to be
-what cervical dilation does this start at
8-10hrs
Starts when cervix 2-4cm dilated + thinned
what is the first stage of active labour
1st –labouring and dilation
what is the second stage of active labour and how long should it last
Pushing descent and delivery
Norm is 2hrs. Much longer and alarm bells go off
3rd stage of active labour. what occurs?
timeframe?
major risk?
3rd -placenta delivers
Hemorrhage happens at this stage
Should not take more than half an hour
If placenta hasnt been delivered after 30mins likelihood of hemorrhage is very high
4th stage of active labour and what occurs
4th -hemostasis established after delivery of baby and placenta
(i think this is when the blood vesels are clamping off in her uterus and protecting her from hemmorhage
what are the 4 ps of labor
Power ((uterine contractions))
Passenger (the fetus)
Passage (the birth canal)
Psyche (the woman and family perception of the event)
what is dystocia
a difficult labour which can arise from any of the 4 main components of the labour process
what does dystocia increase the risk of
which of these problems are most emphasized
Infection Hemorrhage Uterine rupture Fistula development Future urinary and fecal incontinence for the mother Infant mortality and morbidity Fetal anoxia
Fetal hypoxia and anoxia standout
hemmorhage and infection too
why infection from dystocia
When labour takes too long we might introduce infection by doing many exams eg vaginal/cervical exam!
when labour takes too long what problems does this pose
- uterine muscle is tired
- mum and babe very tired and inc risk of anoxia and hemmorhage
what is it called when labor is being sluggish
used to be called inertia is now called
Dysfunctional Labour
why is dysfunctional labour a risk
why does it occur
it inc risk of postpartal infect, hemmorhage, infant mortality
prolonged labor appears to result from multiple factors. most likely if lg fetus.
hypotonic and hypertonic and uncoordinated contractions all play aditional roles
risk factors for a problme with the powers
Advanced maternal age Adolescents Women with macrosomic infants Grand multiparas Multiple Gestation Full bladder and bowel Dehydration, Exhaustion, Low Sugars Narcotics used too early in labour
at what age does “advanced maternal age” occur
> 35
what is a grand multipara and why might they encounter a problem with the powers
omeone who has 5 or more children. Might not be able to cope with kids 6,7,8
how long do normal contractions last and what is the normal space betwen them
60 seconds with 4-5mins between
what are the kinds of ineffective uterine force
remember the uterus is a muscle
hypotonic
hypertonic
uncoordinated contractions
how would the contraction timing and between be for hypotonic contractions..other issue with the contraction.
what does this lead to?
risk of?
4-5mins between contractions that last around 20 seconds
the resting tone of the uterus is less than it should be
leads to prolonged labour. also risk of hemmorhage
hypotonic contractions is it painful? what stage does it occur during? what can be done? what intervention might have caused it?
not as painful as hypertonic as the uterine muscle isnt contracting all the way
occurs during the active phase
can give oxytocin to augment it
may have been caused by giving narcotic too early. this can stop or slow labour
why might hypotonic contrctions occur
tend to occur after admin of analgesia espec if cervix is not filated to 3-4 cm or if bowel or bladder distenion is preventing decent
• May also occur if uterus is overstretched by a multiple gestation, larger than usual fetus, hydramnios, or a uterus that is lax from grand multiparity
-may also be after long labour it cant mount effective contractions
what is important in first hr after birth if you had hypotonic contractions
• In first hour after birth, following a labor with hypotonic contractions important to palpate the fundus, get BP and assess amount of lochia q15 min for first hour to ensure contractions are not hypotonic postpartum
hypertonic contractions-
- timeframe of contraction and resting between
- when during labour do they likely occur
- how intense are they in comparison to hypotonic
- pain compared to hypotonic
- 60-90second contraction with 45 seconds between (occuring more frequently than hypotonic)
- likely during latent phase
- may not be any more intense than hypotonic
- likely painful and moreso than hypo
hypertonic why might it occur
ppt: May be from abruption
May be from induction of labour with prostaglandin insert (to soften and make cervix prone). Sometimes it has such a powerful effect
• Hypertonic contractions may occur bc more than one uterine pacemaker is stimulating contractions or bc the muscle fibers of the myometrium do not repolarize or relax after a contraction, thereby wiping it clean to accept a new pacemaker stimulus
what is the issue with hypertonic contractions
what might be nec for hypertonic contractions
what is good that wont work for hypotonic contractions
• Lack of relaxtion between contractions do not allow optimal uterine artery filling- can lead to fetal anoxia
• If deceleration in the FHR, abnormally long first stage of labor or lack of progress w pushing occurs, c-section may be nec.
-sedation is helpful but has no value for hypotonic
uncoordinated contractions aka ____
what is it
what often is the cause
not mentioned in class: what might be helpful
Coupling
coupling is two contractions very close together- they may be on top of each other and then have a lg period with no contraction
caused by multiple pacemakers or myometrium might be acting independently
- often from cephalopelvic dysproportion
- oxytocin admin may stim more reg contractions with better tone
why test blood sugars in relation to the powers. what else should you test?
what can hydrating help with in r/t the powers. how to do this?
- the uterine muscle needs energy
- test for ketones
hydrating helps with the pattern of contractions. often some women cant drink enough and throw up
start IV and offer her small sips after each contraction
when is it bad to give mrphine during labour. when would be a good time
By giving narcotics too soon you can stop the labour. If someones very exhausted and in latent phase 2 days then give them the morphine for a rest. If just starting then dont give
a woman has hypotonic contractions and youre considering oxytocin. what should you try first
how often should this be done
full bladder can cause hypotonic contractions
Woman in labour must urinate q2h and not any longer than that
Bowel must also be emptied
try to decrease adrenaline
The uterus doesnt like things pushing against it.
what is normal in terms of contractions length
and resting tone between what is minimum time?
after dilating to ____cm how many cm should the woman dilate/hr
3-4 contractions in 10 minutes
Last 60 seconds
60 seconds of resting tone in-between contractions—minimum! (my notes)
Dilation of 1cm/hr after 3-4 cm dilation for a multip, and dilation of 1cm/1.5hr after 3-4 cm dilation for a primip
can you rely only on a tocodynamometer?
what info does this give?
what else should you do?
when is this especially important
When woman is labouring have hands on her abdm. Dont rely on tocomanometer (it gives info of strength of contraction. its strapped to her tummy and senses the pressure of the contraction)
If woman is receiving prostaglandins, oxytocin—you MUST make sure that it is staying within the limits of normal contractions
when comparing time vs dilation on the partogram when must you take action. how would this look? what is the danger of the opposite circumstance
Once around 3 cm we want you in active phase. Then as we plot you in number of hours. If too fasst and slope is steep then there is hemorrhage risk. If slope is too flat then it takes too long to get dilated and then want to augment for oxytocin. IF too fast then stop oxytocin
cervical changes in latent vs active phase
Latent Phase-up to 3-4 cm
The cervix softens, thins, and begins to dilate
Active Phase 3-4cm to 10 cm
The presenting part descends into the pelvis, the cervix dilates.
what causes the baby to move through the birth canal?
is it P from the bab’s head
The muscles near the baby’s head retract and push the cervix down(not from force of baby)
the contractions also push the bab down
cephalopelvic dysproportion
which population is often affected by this
how might you know someone has this
Cephalopelvic dysproportion-when the head is too big for the pelvis or the way it is siting wont work
adolescents often have this
notes: It is suggested by lack of engagement at beginning of labor, prolonged first stage of labor and poor fetal descent
uterine rupture
what precedes it
how serious is this
Uterine rupture-the uterus can get very very thin and is a life-threatening thing for baby. Can tear. The warning sign feels like a little piece of rope along her belly. (a retraction ring)
The fetus struggles before you can feel this often.
emergency!! huge risk of bleeding and very serious for baby
the longer youre in labour the higher the risk of ____
infection
what are the three categoies of concern with the passenger
Prolapse of cord
Multiple Gestation
Problems with Fetal Position, Presentation, or Size
prolapse of the cord-when does this occur and why
-breech or preterm infant
Prolapse-early ROM, before head is in the pelvis (engaged head “the egg in the egg cup”).
• May occur at any time after the rupture of membranes if the presenting fetal part is nto fitted firmly into the cervix
When the waters rush out the umbilical cord can
come with it and even exit the vagina.
when the cord prolapses how quickly do you want to deliver the baby
5mins
o Premature rupture of membranes o Fetal presentation other than cephalic o Placenta previa o Intrauterine tumors preventing the presenting part from engaging o A small fetus o CPD preventing firm engagement o Hydramnios o Multiple gestation
how many layers are there to amniotic sac and what are they called.
when twins s
Twins entangled
2 layers to amniotic sac. Amnion (is inner)and chorion . If they share an amnion they may tangle or compress each others cords. Very rare. For idential twins who share an amniotic sac mono mono. They have one amnion and one chorion
what is vertex presentation
why might the baby have a longitudinal lie. can you deliver this way?
WHAT IS CONTRAINDicated
vertex is aka cephalic and head down
Longitudinal can generally be delivered
-if mum has fibroids or a growth in her uterus then the baby might lie sideways.
You cannot deliver baby if shoulder is wedged into pelvis
twins:
if the lower baby has its head down and the upper one has a breech presentation can you deliver?
what if they both have head down?
if the lower baby is a breech can you delivr?
if both babies are breech presentation can you deliver baginally?
The first baby might have head down while other one has head up. This can be delivered vaginally
If both head down they can also be delivered vaginally
But if first baby (breech presentation) and second baby head down then dont deliver vaginally. The two chins lock and both die and mum could die too
if both breech we might get away with it but we dont gamble with it. This is malpractice.
what are the 3 kinds of breech and which is most concerning
are breeches deliverable?
incomplete (hs one leg up)
complete (looks like buddha w legs crossed)
frank breech (both legs up)
Incomplete breech is most frightening-inc risk of prolapsed cord between the legs
yes all breeches can be delivered depending on the circumstances
what are the complications of a breech
what must be done
what should you not do
If breech the baby must be delivered in 5 minutes or else we have fetal anoxia/hypoxia, death, intracranial hemorrhage
Hands off the breech”-you must let the uterus contract. Put their fingers in the mouth and guide it out. Dont grab baby and pull it out
when do you know that the baby can be delivered breech (there are exceptions of course)
To deliver breech you must know her pelvis can deliver the baby-if she has hx of huge baby and the next kid is v small it is fine
what is the best fetal presentation
what presentation will cause the woman to feel pain in her back-how does this affect labour. what other physical finding will you see?
occiput anterior
ociput posterior-sunny side up-from more sedentary life-it will take longer (the pushing phase). The back of baby’s head is scraping along spine. She will talk about back pain. And you can feel the spine.
which presentations are not deliverable
Breech
Brow
Face
Asynclitic
which presentations can be delivered with hard work and risks
Occiput posterior Military Asynclitic Face Breech
what are the best and worst ways for the babes head to be positioned (what angles and what is this called)
why does the angle fo the head matter
Fetal attitudes
best: You must come into world with humble attitude with chin down.
worst (i think?)face presentation-but the chin must be at symphisis and the head gets pushed farther and farther back
as the head tilts to different parts the diameter changes
what to do when ther is shoulder dystocia? what is this?
shoulder dystocia occurs when the babies shoulder gets caught in the pelvis
HELPER!
Call for help
Episiotomy (is gen not really used d/t time)
Legs go into McRoberts-push her legs into frog position to open up pelvis
Pressure-on pelvis to wedge shoulder off
Enter-push finger into vagina to crack babys clavicle
Rotate her to hands and knees deep squat. This often happens with Diabetes mellitus
shoulder dystocia how long do you have to act
what might you see in the baby and why
Turtling and the cheeks etc are pushed up and scrunched- for normal size baby you can see lengthening around neck. This occurs with macrosomic babies
what is mcroberts maneuver
with mcroberts the legs are brought up kind of like a frog.
the pelvis tilts orienting the symphisis more horizantaly to facilitate shoulder delivery
what is normal fetal heart rate?
freq of monitoring during labour. what does this monitoring entail
Intermittent Auscultation
Q15 minutes in first stage of labour
Q5 minutes in second stage
Accelerations with fetal movement or contractions. They should last about 15 sec
Listen during the contraction and one full minute afterwards
what do you use to monitor fetal heart rate
when do you use continuous FHR monitor
stethoscope is best. if you just use the external monitor or stethoscope without checking rdial at same time then it might accidentally pick up the moms heartbeat
can use internal monitor that is small wire with tiny screw that implants into skull
Used for high risk or non-reassuring FHR on intermittent auscultation
when are you more likely to confuse moms heart beat with baby
(what conditions in mom)
Sometimes if women is anemic or she has a fever their heart rate can go up to 120
when is deceleration concerning. when is it normal
if Normal during contraction then Late deceleration (after the contraction is done)-baby is in trouble. Might be acidotic and distressed.
Early deceleration-little persons head is getting compressed. Normal and baby is likely nearing delivery. Happens with a contraction. When contraction is at highest the FHR is at lowest, mirroring the contraction
how much fetal variability is good
why is the FHR so variable
10-15 BPM
They arent neurologically stable enough. HR to be consistent, it looks like heart tracing.
loss of variability for longer than ___mins
what to do
Loss of variability for >20mins it is a worrying sign. Try to wake the baby eg give juice, but it is more likley distress
if you have less than 5BPM variability what should you query
<5 BPM variability
fetal distress?
Narcotic distress?
Sleeping?
how does a variable decel look
hey look like a V that is a dec of FHR at peak of contraction-d/t the sudden cut off of oxygenation from cord compression. Don’t worry about it too much
if a baby is macrosomic what is the most important thing to worry about
shoulder dystocia
what are the 4 kinds of pelvic types
which is best and which is worst
Gynecoid is most favourable and most common
Anthropoid and android are preferrable to platypelloid
other than bone str what can affect the “passage”
Musculature and Soft Tissues
Forceps Birth
Vacuum Extraction
does being a world class athlete make birth easier
Sometimes world calss athletes have such tough perineal muscles its difficult to deliver
cardinal movements what are they
what are the bits of the pelvis that the fetus must rotate around to get past
who are the cardinal movements important to
(i doubt these are important..)
E-engagement-The head comes into pelvis-
D-descent
F-flexion-It sinks and gets humble attitude-flexion
I-internal rotation–the maternal pelvis it has bony bits called spine-does internal rotation to get through them
E-extension–To come into the world it is humble and it does a little hello facing the bed
E-external Rotation–Then the head extends and it turns sideways
E-expulsion
The physicians use cardinal movements more than nurses
indications for forceps delivery
o Woman can’t push d/t anesthesia or spinal cord injury
o Cessation of descent in second stage of labour
o Fetus in abn position
o Fetus in distress d/t issue such as prolapsed cord
risks f fordceps delivery for infant
for mum
what sign from mum might indicate internal injury
Very common to see forceps marks. Bruising and on scalp-inspect for hematoma
has nerve trauma
For women we worry about bladder and cervical tears that we arent aware of
Normally after delivery the blood turns port wine coloured but from trauma with forceps she might have bright red trickle
• forceps Can lead to rectal sphincter tears in woman (leading to dyspareunia, incontinence)
how do forceps affect P on baby’s head
how might the baby look after its use
- Actually DECREASES P on fetal head (contrary to what you’d think), thus dec risk of subdural hem, etc
- Erythematous mark on baby fades in 1-2 days
what needs more anesthesia forceps or vacuum
what carries less risk for mums structures
forceps need more
vacuum has less risks for mom
wher is vacuum applied
how is nurse involved
risks
• Applied to posterior fontanel
Vacuum must be placed on the occiput The nurse pumps it up to within a certain zone. If it goes too high it can cause cranial trauma.
Could cause P sore and necrotic tissue, hematoma, caput (swelling of the scalp) for babe
mum might get perineal laceration
when is vacuum a bad idea
- Can’t be used if fetal scalp sampling done d/t risk of bleeding w P
- Not good for preterm infants d/t softness of skull
who gets fistulas most commonly why what happens complications of this Tx
More often seen in adolescent moms where early marriage is favoured.
labour without proper support and once head is deep in pelvis it pushes too long against her soft stissues and erodes hole between urethra, rectum, and or vagina. IF she survives such delivery she will have fecl matter and urine draining from vagina with no control.
infection !! Terrible odour
tx = Sx
powerful influences on the psyche
what can dec fear and adrenaline
Fear and Adrenaline
Support
Cultural Expectations and Customs
The Birthing Environment
family can dec adrenaline
