Maternity week 4-1 Flashcards
Initial Assessment of Patient
Admit patient to triage
POC (point of care - bedside): Urine dip
Initiate fetal monitoring
Obtain VS
Characteristics of Labor (contractions? bleeding? leaking fluid? is your baby moving?)
Assess for VB
Assess FM: Subjective
Check for Ruptured Membranes/Dilation
Prenatal Record
Physical Exam: Including high risk s/sx
Report to provider
Admit or Send Home
Is pt in active labor?
ROM? GBS status?
Coping well?
Labor Hx?
High risk dx?
Fetal concerns?
Earlier admission= intervention
Delayed admission= Less labor augmentation, c/s, antibiotics and internal monitors.
Diagnosing Rupture of Membranes
PROM - premature rupture of membrane
PPROM - premature or prelabor before 37 weeks
SROM - spontaneous
AROM - artificial
latenent - how many cm? (latent at zero)
0-5 cm
dilation
10 cm is
complete
normal cervix is how long?
3 cm long
station is measured in
cm. minus stations are above.
Diagnosing Rupture of Membranes
Nitrazine + Pooling + Fern (pattern on strip test) Test - this means their water broke.
Speculum exam
Cervical fluid collected and viewed under microscope
Pooling:
Ferning: Crystallization of
proteins + salt
Nitrazine Testing for ROM - what pH is not ruptured? (don’t rupture before age 6.5)
ACIDIC: NOT RUPTURED Yellow = pH 5.0
Olive-yellow =pH5.5
Olive-green =pH 6.0
ALKALINE = MEMBRANES RUPTURED
Blue-green = pH 6.5
this is rupture:
ALKALINE = MEMBRANES RUPTURED 7.1 - 7.3 or 7.5
Blue-gray = pH7.0
Deep blue = pH 7.5
Assessment of Vaginal bleeding - what amount is normal?
Bloody show
Scant bleeding normal after SVE
Report any VB to MD/CNM
Closely monitor mod to heavy bleeding (pad counts/weights)
Sources of abnormal bleeding:
Placentia previa
Placental abruption
Assessment of uterine activity
Subjective assessment: questions? how often? how long? pain? (pain in lower back sign of preg)
Objective assessment
Palpation: “nose, chin, forehead”: mild, mod, strong
Observation
Tocometer
IUPC
SVE - sterile vaginal exam - do what first?
spectacle exam to get specimen before you insert something w/ bacteria
Signs of Possible
Intrapartum Complications - contractions and pressure - the numbers?
Increased IUP (intra uterine pressure?)
Contractions lasting > 90
Tachysystole: More than 5 UCs/10 min averaged over 30 min
Common intrapartum NURSING interventions
Assessments/Monitoring
Fluid intake: oral/IV
Bladder/bowel evacuations
Pain management
Ambulation & Position changes
Nutritional needs
Emotional Support
Integrating care team (includes other providers, family/friend support, doulas etc.)
Components of Nursing care: stage 1
Review: What comprises the first stage of labor?
Monitoring the labor pt: VS, screenings, assessments
Fetal assessment
Pain management/Labor support
Communication with team
Consider Maslow’s Hierarchy
Nursing care in the first stage of labor: Pain management
Part of a normal process: nothing bad is happening
Intensity increases as labor progresses
Occurs in a predictable pattern with regular respite (in a normal labor)
Ends with the birth of the baby
Sources of Pain: Stage 1 (stretch on stage 1)
Uterine Anoxia
Stretching of the cervix
Stretching of the uterine ligaments
when does baby get oxygen during labor?***
in between contractions
Sources of Pain: Stage 2 (vaginas and pressure on stage 2)
Distention of the vagina and perineum
Pressure of the baby on tissue and organs (bladder, rectum, etc)
Sources of Pain: Stage 3 (the cramps on stage 3)
Uterine Cramping
Lacerations
Factors that Influence Pain
Fear and Anxiety
Fatigue
Individual pain tolerance
Support
Cultural expression of pain
Psychosocial factors
Preparation
Previous experience (self and others)
Information/Lack of
Length of labor
Signs the patient is coping well may include: (with pain) (rocking w/ pain is good)
States they are coping well
Rhythmic activity during UCs, such as rocking, swaying
Focused inward
Rhythmic breathing
Able to relax between UC
Vocalization, such as moaning, chanting, counting
not coping with pain - signs
States she is NOT coping
Crying, tearfulness, tremulous voice
Inability to focus or concentrate
Panicked activity during contractions
Jitteriness, thrashing in bed
Tense, sweaty
Options for managing intrapartum pain
Non-pharmacologic
Pharmacologic
Center patient in decision-making process around interventions for pain.
movements.
Non-Pharmacological Management Cont’d
Hydrotherapy
Aromatherapy
Guided relaxation/breathing
Massage/Effleurage
Position Changes/Ambulation
Sacral Pressure (Counter Pressure)
Hip Squeeze
Doulas
Professional, trained birth attendant
Patients half as likely to have complications
Reduced rates of intervention
Greater client satisfaction with birth
Outcomes linked to emotional, physical support, and information given.
types of agents
Systemic Analgesics
Inhaled Analgesics
Local Anesthesia
Regional Analgesia/Anesthesia
General Anesthesia
check slide
49
Opioids: - Morphine
Morphine:
Early labor
Therapeutic effect: 4-6 hours
12-15 mg IM w/ Hydroxizine
Fentanyl
Active labor and/or severe pain
50-100mcg IVP
Therapeutic effect: 30-60 min
Hydroxyzine (hydro w/ morphine)
Hydroxyzine:
50-100mg IM
IM w/ Morphine
Potentiates opioid, antihistamine/antiemetic
Promethezine: antiemetic/antihistamine w/ opioid
Pharmacological Management Nursing Care : considerations
Assess labor progress
Assess pain and coping
Assess patient’s labor goals and expected outcomes
Assess FHR
Parenteral Route
Efficacy
Document
Narcan (naloxone)
Precautions with N20 (what about the fetus?)
Current vitamin B12 deficiency
Abnormal FHR tracing
Hemodynamic instability and/or impaired oxygenation
Observe for respiratory depression
Covid +/other respiratory illness
Contraindications to N20
Acute drug or alcohol intoxication or impaired consciousness
Inability to hold face mask
Some medical conditions, such as pneumothorax or increased intracranial pressure
EPIDURAL - how quickly does it work? (lepi takes a loooong time)
20-30 min
SPINAL ANESTHESIA (don’t use when?)
Imminent vaginal delivery or C/S, not suitable for labor
Risk of spinal (post-dural) H/A
Risk for BP
Rapid onset: full effect=5-10 min
COMBINED SPINAL-EPIDURAL (CSE)
Spinal/Epidural administered during same procedure
Provides rapid/continuous anesthesia/analgesia
Labor or C/S
DISADVANTAGES OF EPIDURAL ANESTHESIA (think decreased breathing and baby)
BP: may affect placental perfusion
Urinary retention
Limited mobility
May 2nd stage
risk of low forceps or vacuum assisted
Contraindications to regional anesthesia (clot in one spot)
Clotting disorders including thrombocytopenia
Medication allergy
Anatomical problems: scoliosis, spinal fusion/anomalies
Unable to place
pre-EPIDURAL PLACEMENT - nursing care (think of fluids)
Educate patient
Confirm consents completed
Pre-hydrate: IV bolus/prevent hypotension
Obtain medication/equipment
Position patient/place BP cuff/pulsox
Time out
Continue labor support/maintain fetal monitoring
NURSING CARE: EPIDURAL PLACEMENT
Safety
Independent double checks
Pharmacy prepared meds
Clearly label solutions and lines
Patient Monitoring
Documentation
time out (3 things - think of the OR)
Verify:
Correct pt
Correct procedure
Correct site
NURSING CARE: POST EPIDURAL PLACEMENT (change positioning?)
Assess VS
Monitor FHR/UCs
Assess pain level
Place foley catheter
Order clear diet
Change patient position q 30-60 min: lateral or tilt
General Anesthesia - when to use
Administered by Anesthesiologist (MD) or CRNA
Not for labor: C/S only!
Not routine: emergency, failed regional anesthesia, contraindication to regional anesthesia
Combination of agents may include: Fentanyl, versed, propofol, ketamine etc.
Pt recovered in PACU
Labor Stages 2-4
2nd stage: 10 cm dilation-delivery, “pushing”
3rd stage: Delivery of placenta
4th stage: After delivery of placenta until up to 4 hours after (“recovery”)
2nd Stage: Nursing assessments - how often to assess vital signs and contractions?
VS: “per protocol”, per Ricci: q-5-15
FHR: q5-15 dependent on risk level
UCs: document q5-15
Coping/pain
Fetal descent
2nd Stage: Nursing interventions
Prepare room for delivery
Communicate with providers PRN (OB, NICU etc.)
Support patient with every pushing effort
Continue comfort measures
D/C Foley
Ensure adequate hydration
Respond to abnormal assessment findings
Assist w/ delivery
3rd stage assessments - think what happens in the 3rd stage
VS: q 15
Apgars: 1 min, 5 min
Observe for placental separation
Assess fundus/lochia following delivery of placenta
bonding
it’s just the parent.
look at slide
85
3rd stage: nursing interventions
Respond to abnormal assessment findings
Administer uterotonics PRN/as ordered
Active management of the 3rd stage
Assist with BRF & Monitor NB
Post: assist w/ repair, pain meds, ice to perineum PRN
4th stage: nursing assessment (after birth, what drops?)
Fundal check/lochia assessment:
Q 15 x 4
Q 30 x 2
Vitals/Pain assessment
NB admission exam
4th stage: nursing interventions
Pain interventions prn
Hydrate/provide nutrition
Facilitate voiding ASAP
Promote rest
Assist w/ first amb/assess for readiness to amb post-anesthesia
Education
4th stage: nursing interventions Newborn (NB)
Assist w/ NB feeding
Administer NB meds
Infant security
Education
Nursing Diagnoses: Stages 2-4
Risk for injury to patient and fetus/NB
Knowledge deficit
Pain
Ineffective coping
Anxiety
Risk for infection
Risk for fluid volume deficit/excessive blood loss
Fetal assessment
Subjective: pt report, “kick counts’
Objective:
Continuous fetal monitoring
EFM
FSE
Intermittent auscultation
Assessment frequency
Stage 1
Low risk: early labor Q 1 hour, active labor Q30 min
High risk: early labor Q 30 min, active labor Q15 min
Stage 2
Low risk: Q 15 min
High risk: Q 5 min
Intermittent auscultation
Low risk patients
Assess maternal pulse
Associated with lower rate of c/s/unnecessary intervention
Equal perinatal outcomes in low risk pt
Auscultate 3-5 min through UC, one min after
Assessment frequency=cont. monitoring
Fetal Monitor Tracing Interpretation
NICHD: Standardized terminology
Visual interpretation
Identify FHR baseline
Identify variability
Identify accels/decels
Determine UC pattern
Intervene PRN
Variability
Variability:
Irregular fluctuations in baseline FHR
Sympathetic/Parasympathetic interplay
Normal variability=CNS WNL & absence of acidemia (CO2 buildup)
Absent: undetectable
Minimal: < 5 bpm
Moderate: 6-25 bpm
Marked: >25 bpm
Accelerations
Abrupt inc: 15 x 15 at 32 weeks or >
< 32 weeks: 10 x 10 ok
> 10 min= new baseline
Early decelerations - how long is onset to nadar? (30 is early)
Associated w/ Ucs
Gradual dec in baseline, mirrors UC
Onset to nadir > 30 sec
Variable decelerations (V is for variable) and what causes it?
Abrupt drop from baseline, < 30 sec onset to nadir
May occur w/out UC
“V” shaped
At least 15 x 15.
cause is cord compression.
Late decelerations (onset to nadar time - it’s 30 again) and what causes it?
Associated w/ Ucs
Gradual dec in baseline, nadir after UC peak
Onset to nadir > 30 sec
Return to baseline after UC. cause - placential insufficiency
Early decel
Early decel: head compression/vagus nerve stimulation
Late decel
Late decel: uteroplacental insufficiency, interruption in “oxygen pathway”
Accel - is normal or abnormal?
Accel: acid/base status wnl
Variable decel - causes (C causes V)
Variable decel: cord compression
FHR categories - what number is good and bad? (backwards for you)
1 is good, 3 is bad.
FHR - CAT III (the 3 are late, variable, brady and sinus)
CAT III, Includes at least one of the following:
Absent variability with recurrent late decels
Absent variability with recurrent variable decels
Absent variability with bradycardia
Sinusoidal Pattern
FHR - cat. 1 (1 cat does not decelerate)
CAT I:
FHR wnl, Accels may or may not be present
Decels are absent
Predictive of normal acid/base balance
FHR - cat 2 (2 cats just don’t fit)
CAT II:
Tracings that don’t fit in CAT I or III
Not predictive of normal acid/base balance
Indeterminate significance; cont to monitor
contractions - Tachysystole (you already know this)
Tachysystole: > 5 UCs/10 min averaged over 30 min
Nursing interventions for abnormal FHR - what drug?
Intrauterine resuscitation
Change pt position
IV fluid bolus: PL/LR
Treat hypotension
Turn of pitocin
O2 not evidenced based (listed as intervention in Ricci, 5th ed.)
Tocolytic administration:
Terbutaline: 0.25 mg SC: tachycardia, half-life=3 hours, smooth muscle relaxant
Rapid delivery PRN
Terbutaline effects - what is normal?
can cause fetal tachycardia, but it is transient. this is NORMAL.
intrapartum complications - Cat tracings
Abnormal fetal heart tracing: Cat II or III
Amniotic fluid: Meconium-stained, Cloudy, Foul-smelling
Labor dystocia (Failure to progress/FTP)
intrapartum complications - temperature - what is an abnormal temp in the mother?
Maternal Temp > 38
Foul smelling discharge,
Continuous bright red bleeding
