Nursing Managment for Labor/Birth Flashcards
1
Q
What should you assess for Maternal status?
A
- Maternal vital signs
- Review prenatal records
- Vaginal exam
- Evaluate pain
2
Q
When can you not perform a vaginal exam on the mom?
A
When there is active bleeding
3
Q
How often will a vaginal exam be performed?
A
every 4 hours
4
Q
What is the purpose of performing a vaginal exam?
A
To assess the amount of cervical dilation, the percentage of cervical effacement, and the fetal membrane status
And to gather info on presentation, position, station, degree of flexion, and presence of skull molding/swelling
5
Q
What is used as lubricant for the initial vaginal exam?
A
water
6
Q
How is the dilation and effacement assessed?
A
The width of the cervical opening determines dilation, and the length of the cervix assesses effacement
7
Q
When the membranes rupture what should the priority focus be?
A
Assessing FHR first to identify deceleration which might indicate cord compression
8
Q
What are signs of intrauterine infection?
A
maternal fever
fetal and maternal tachycardia
foul odor of vaginal discharge
increase in white blood cells
9
Q
How is rupture of membranes confirmed?
A
Sample of fluid is taken via a nitrazine yellow dye swab to determine fluids pH
10
Q
Is vaginal fluid acidic or alkaline?
A
Acidic
11
Q
Is amniotic fluid acidic or alkaline?
A
Alkaline
12
Q
What can cause a false-positive for a nitrazine test?
A
Women experiencing large amounts of bloody show
13
Q
If the Nitrazine tets is inconclusive what other test may be performed to confirm rupture of membranes?
A
Fern test
14
Q
What do the different levels of contractions feel like when palpating?
A
Mild-tip of nose
Moderate-like the chin
Strong- like the forehead
15
Q
Leopold Maneuvers
A
method for determining the presentation, position, and lie of the fetus through the use of four specific steps
16
Q
Maneuver 1
A
What fetal part (head or buttocks) is located in the fundus?
17
Q
Maneuver 2
A
On which maternal side is the fetal back located
18
Q
Where are fetal heart tones best auscultated?
A
On the back of the fetus
19
Q
Maneuver 3
A
What is the presenting part?
20
Q
Maneuver 4
A
Is the fetal head flexed and engaged in the pelvis?
21
Q
When the membranes are ruptured what should the amniotic fluid look like?
A
Clear
22
Q
Cloudy or foul smelling amniotic fluid indicates what?
A
Infection
23
Q
What may green amniotic fluid indicate?
A
The fetus has passed meconium
24
Q
What may cause the fetus to pass meconium before birth?
A
Transient hypoxia Prolonged pregnancy Cord compression Intrauterine growth restriction Maternal hypertension/diabetes Chorioamnionitis
25
When is the passage of meconium considered normal?
When fetus is in breech position
26
Analysis of FHR is one of the primary evaluation tools for what?
Determining fetal oxygen status directly
27
What are the guidelines for assessing FHR?
- Initial 10-20 mins continuous FHR assessment on entry into labor/birth area
- Prenatal/labor risk assessment
- Intermittent auscultation q 30 mins for low risk and q 15 mins for high risk women during active labor
- During second stage q 15 mins low risk and q 5 mins for high risk women during pushing stage
28
FHR Category I (Normal)
Does NOT require intervention
- Baseline 110-160 bpm
- variability moderate
- present or absent accelerations
- present or absent early decelerations
- No late or variable decelerations
29
FHR Category II (Indeterminate)
Requires evaluation and continued surveillance
- Fetal tachycardia >160 bpm present
- Bradycardia < 110 bpm not accompanied by absent baseline variability
- Absent baseline variability not accompanied by recurrent decelerations
- Minimal or marked variability
- Recurrent late decelerations
- Prolonged decelerations > 2 mins but < 10
30
FHR Category III (Abnormal)
Requires intervention
- Fetal bradycardia < 110 bpm
- Recurrent late decelerations
- Recurrent variable decelerations-declining or absent
- Sinusoidal pattern
31
Baseline variability
irregular fluctuations in the baseline FHR, which is measured as the amplitude of the peak to trough in bpm
32
What is the most common cause of fetal death that could've been prevented?
Fetal Hypoxia
33
Continuous Electronic Fetal Monitoring
-Uses a machine to produce a continuous tracing of the FHR
| Produce a graphic record of the FHR pattern
34
What are the primary objectives of Electronic Fetal Monitoring?
- Provide info about fetal oxygenation and prevent fetal injury from impaired oxygenation
- Detect FHR changes early before they are prolonged and profound
35
What is the criteria for using continuous Internal monitoring of FHR?
- Ruptured membranes
- Cervical dilation of at least 2 cm
- Present fetal part low enough to allow placement of scalp electrode
- Skilled practitioner available to insert
36
What are the 4 Categories of Baseline Variability?
Absent
Minimal
Moderate
Marked
37
Absent
fluctuation range undetectable
38
Minimal
Fluctuation range observed at < 5 bpm
39
Moderate (Normal)
fluctuation range from 6-25 bpm
40
Marked
Fluctuation range >25 bpm
41
What is the average FHR?
110-160 bpm
42
Fetal Bradycardia
occurs when FHR is below 110 bpm and lasts 10 minutes or longer
43
What may cause fetal bradycardia?
```
Fetal hypoxia
Prolonged maternal hypoglycemia
Fetal acidosis
Analgesic drugs for mom
Anesthetic agents for mom
Maternal hypotension
Fetal hypothermia
Prolonged umbilical cord compression
Fetal congenital heart block
```
44
Fetal Tachycardia
baseline FHR > 160 bpm that lasts for 10 minutes or longer
45
What can fetal tachycardia represent?
Early compensatory response to asphyxia
46
What are other causes of fetal tachycardia?
```
Fetal hypoxia
Maternal fever
Maternal dehydration
Amnionitis
Drugs
Maternal hyperthyroidism
Maternal anxiety
Fetal anemia
Prematurity
Fetal infection
Chronic hypoxemia
Congenital anomalies
Fetal heart failure/arrhythmias
```
47
V C
E H
A O
L P
V-variability C-cord compression
E-early H-head compression
A-acceleration O-okay
L-late P-placental insufficiency
48
What category would a Sinusoidal Pattern FHR be considered?
Category 3
49
Sinusoidal Pattern
Smooth, sinewave-like undulating pattern
Cycle frequency of 3-5 bpm that persists > 20 mins
Severe hypoxia secondary to fetal anemia/hypovolemia
50
Decelerations
transient fall in FHR caused by stimulation of the parasympathetic nervous system
51
What are the classifications of decelerations?
Early
Late
Variable
Prolonged
52
Early Decelerations
Characterized by a gradual decrease in FHR in which the lowest point occurs at the peak of the contraction
-Do NOT indicate fetal distress and do NOT require intervention
53
Late Decelerations
decreases in FHR that occur after the peak of the contraction
-FHR does NOT return to baseline until well after contraction ends
54
Variable Decelerations
decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions
55
Variable decelerations are usually associated with what?
cord compression
56
Prolonged Decelerations
abrupt FHR declines of at least 15 bpm that last longer than 2 minutes, but less than 10 minutes
-usually drops to < 90 bpm
57
Pain is considered what type of experience?
universal experience
58
What are some NON-pharmacological measures for pain management?
- Continuous support
- Hydrotherapy
- Ambulation/position changes
- Acupuncture/acupressure
- Attention focusing/imagery
- Therapeutic touch/massage/effleurage
- Breathing techniques
59
What non-pharmacological measure can be done during the first stage of labor to reduce its length?
walking and upright positions
60
Effleurage
light, stroking superficial touch of the abdomen, in rhythm with breathing during contractions
61
What pharmacological measures can help with pain?
Systemic analgesia
Regional/Local anesthesia
Neuraxial analgesia/anesthesia techniques
62
Neuraxial analgesia/anesthesia techniques
use of analgesic or anesthetic, continuously or intermittently into epidural or intrathecal space
- does NOT interfere with progress of labor
- allows woman to be active participant
63
Systemic Analgesia
use of one or more drugs administered orally, intramuscularly, or intravenously; they become distributed through out the body via the circulatory system
64
What type of drugs may be used for systemic analgesia?
Opioids
Ataractics/Antiemetics
Benzodiazepines
65
Opioids
Moderate-Severe pain
- butorphanol (Stadol)
- Nalbuphine (Nubain)
- Meperidine (Demerol)
- Morphine
- Fentanyl
66
Antiemetics
Combo w/ opioids to reduce nausea, vomiting, and anxiety
- Hydroxyzine (Vistaril)
- Promethazine (Phenergan)
- Prochlorperazine (Compazine)
67
Benzodiazepines
Minor tranquilizing and sedative effects; or to stop seizures
- Diazepam (Valium)
- Midazolam (Versed)
- Lorazepam (Ativan)
68
Types of Regional Analgesia/Anesthesia
- Epidural block
- Combined spinal-epidural block (walking epidural)
- Patient controlled epidural
- Local infiltration
- Pudendal block
- Intrathecal (spinal) analgesia/anesthesia
69
Epidural Block
continuous infusion or intermittent injection; usually started when dilation > 5 cm
70
Combined Spinal-Epidural Block
"Walking Epidural"
| inserting epidural needle into the epidural space and inserting small needle into subarachnoid space
71
Patient Controlled Epidural
use of indwelling epidural catheter with an infusion of medication and a programmed pump that allows the woman to control dosing
72
Local Infiltration
injection of local anesthetic into the superficial perineal nerves to numb perineal area
-Before performing episiotomy
73
Pudendal Nerve Block
injection of local anesthetic into pudendal nerves near ischial spine
-second stage of labor, episiotomy, operative vaginal birth
74
Intrathecal (spinal) Analgesia/Anesthesia
injection with or without opioids into the subarachnoid space to provide pain relief
-elective and emergent cesarean births
75
What is general anesthesia typically reserved for?
Emergency cesarean births or woman with contraindications of use of regional anesthesia
76
How can General Anesthesia be administered?
IV injection, inhalation, or both
77
What is the common process for general anesthesia?
- First thiopental IV to produce unconsciousness
- Next muscle relaxant
- Intubation, followed by nitrous oxide and oxygen; volatile halogenated agent also possible to produce amnesia
78
First Stage of Labor: Phone Assessment
- Estimated date of birth
- Fetal movement frequency
- Other premonitory signs of labor
- Parity, gravida, and previous childbirth experiences
- Time frame in previous labors
- Characteristics of contractions
- Bloody show/membrane status
- Presence of support
79
What general measures will be taken during the first stage of labor?
- Admission history
- Results of routine lab tests and any special tests
- Ask about childbirth plan
- Complete physical assessment
- Initial contact by phone or in person
80
Maternal Physical Assessment upon admission
-Vitals, heart/lung sounds, height/weight
-Fundal height measurement
-Uterine activity: contraction frequency, duration, and intensity
-Status of membranes
-Cervical dilation/effacement
FHR, position, station
-Pain level
81
What lab tests are typically done upon admission in the first stage?
- Urinalysis
- CBC
- Syphilis screen, HbsAg screen, GBS, HIV, possible drug screen if not included in prenatal history
- Psychological status
82
How often is the moms temperature taken during the first stage of labor?
q 4 hours
83
How often is the moms temperature taken after ROM?
q 2 hours
84
How often are BP, pulse, and respirations taken during the latent phase of labor?
every hour
85
How often are BP, pulse, and respirations taken during the active and transition phases of labor?
q 30 minutes
86
How often are uterine contractions monitored during the latent phase?
q 30-60 minutes
87
How often are uterine contractions monitored during the active phase?
15-30 minutes
88
How often are uterine contractions measured during the transition phase?
q 15 minutes
89
How often should the FHR be assessed during the latent phase?
q 30-60 minutes
90
How often should FHR be assessed during active phase?
q 15-30 minutes
91
You should also assess the FHR before doing what?
ambulation
before any procedure
before administering analgesia or anesthesia to mom
92
First Degree Laceration
extends through the skin
93
Second Degree Laceration
extends through the muscles of the perineal body
94
Third Degree Laceration
Continues through the anal sphincter muscle
95
Fourth Degree Laceration
through the anal sphincter and the anterior rectal wall
96
Nursing Interventions Second Stage during Labor
- support woman and partner in active decision making
- support involuntary bearing-down efforts
- provide instructions, assistance, and pain relief
- Maternal positions to enhance descent and reduce pain
- prepare for assisting with delivery
97
Nursing Interventions with Birth
- Cleansing of perineal/vulva area
- Assisting w/ birth, suctioning newborn, umbilical cord clamping
- Providing immediate care of newborn
98
What are the 5 parameters of an APGAR score?
- heart rate
- respiratory effort
- muscle tone
- response to stimulus
- color
99
How are the parameters of the APGAR score arranged?
From most important (HR) to least important (color)
100
What is considered immediate care for the newborn?
Drying
APGAR score
Identification
101
Assessment during Third Stage of Labor
- Monitoring placental seperation
- Examining placental and fetal membranes
- Assessing for perineal trauma
- Inspecting condition of episiotomy
- Assess for perineal lacerations
102
Nursing Interventions during Third Stage
- Instructing when to push when signs of separation are apparent
- Giving oxytocin if ordered
- providing warmth
- ice to perineum if episiotomy performed
- monitor mom's physical status
- record birth statistics
- document birth in birth book
103
What does assessment during the Fourth Stage involve?
```
Vital signs
Fundus
Perineal area
Comfort level
Lochia
Bladder status
```
104
During the first hour after birth how often are vitals taken?
q 15 minutes then q 30 minutes for the next hour if needed
105
A decrease in the mom's blood pressure after birth may indicate what?
Uterine hemorrhage
106
An increase in mom's blood pressure after birth may indicate what?
Preeclampsia
107
How often should fundal height, position, and firmness be assessed after birth?
q 15 minutes during the first hour
108
Nursing Interventions Fourth Stage
- Support and info
- Fundal checks; perineal care and hygiene
- Bladder status and voiding
- Comfort measures
- Parent-newborn attachment
- Teaching
