OB Bootcamp Flashcards
Stage 1 of labor
The stage of cervical dilation. Begins with the onset of regular contractions and ends when complete. Includes Latent, Active, and Transitional phases
Stage 2 of labor
Expulsion. Begins with complete cervical dilation and ends with delivery of the fetus
Stage 3 of labor
Placental stage. Begins immediately after the fetus is born and ends with the delivery of the placenta
Stage 4 of labor
Maternal homeostatic stabilization. Begins after the delivery of the placenta and continues for 1-4 hours after delivery.
Latent Phase
Dilation 0-3 CM
UC q 15-30 minutes
mom usually happy/excited
Part of stage 1
Active Phase
Dilation between 4-7cm UC 5-8 minutes UC last 45-60 seconds mom gets anxious. starts to feel more pain Part of stage 1
Transition Phase
Dilation between 8-10 cm UC 1-2 minutes apart uc last 45-90 seconds -Duration of strong intensity. Part of stage 1
when shouldn’t you use external fetal monitoring
-if the fetus is dead
-mom refuses monitoring
-dr did not order
do not use continuously is the fetus is less than 23 weeks.
Clue for contractions. What the DIF??
D- Duration (how long)
I- Intensity (how strong)
F- Frequency (hoe often)
Disadvantages and risks of Internal Uterine monitoring
Disadvantages: membranes must be ruptured, must nbc inserted by skilled care provider.
RISKS: abruption, lower uterine segment perforation, infection, contraindicated with HIV and active herpes
what is the duration on a contraction
from the beginning of one contraction to the end of that same contraction
What is the Frequency of a contraction
beginning of one contraction to the beginning of the next contraction.
Tachysystole (hyperstimulation)
more than 5 UC in 10 minutes, over a 30 minutes or any single contraction lasting longer than 120 seconds
Causes for decreased FHR variability
hypoxemia, drugs, CNS depression, fetal sleep cycles, congenital anomalies, extreme prematurity, nueologic anomaly
ACTION: evaluate cause, stimulate fetus (scalp stimulation, vibroacoustic stimulation, trans abdominal halogen light), oxygen by mask, notify MD
EFM TERMS: Variability Accelerations Decelerations (early, late, variable)
variability: beat to beat variation. (Absent, mild: less than 5 bpm, Moderate: 6-25 ppm, Marked: greater than 25 bpm,
Bradycardia FHR: less than 110 bpm
Tachycardia FHR: greater than 160 bpm
Accelerations: Increase in FHR 15 beats for 15 seconds, good-reassuring.
Deceleration: EARLY: vagus nerve response to head compression- usually reassuring-appears with UC
LATE: utero placental insufficiency - always bad. appears during and after UC concludes
VARIABLE: cord compression, sharp deceleration with rapid return
What if the fetal HR drops below 55-60 bpm?
THINK HYPOXIA
VEAL CHOP
Variable. Cord
EARLY. HEAD
ACCELERATION. OK
LATE PLACENTA
FHR range
110-160 beats per min
FHR categories
1- WNL
2- Prblamatice patterns
3- Pathologic patterns
Prolonged decelerations
variable in shape and onset
often associated with rebound tachycardia and loss of variability
frequently an isolated event
CAUSES: cord compression or prolapse, tachysystole, maternal hypotension, rapid fetal descent, sustained maternal valsalva, SVE or FSE applications, maternal voiding or cvomiting
Nursing actions with late decelerations
SVE to r/o cord prolapse or rapid decent. Change maternal position oxygen 10 LPM by mask IVF bolus notify MD terbutaline PRN stop oxytocin sterile vag exam correct maternal hypotension
POINTS
P Position O O2 I IV - open wide open N Notify DR T. Terbutaline S. STOP Pitocin & STERILE vag exam
SINUSOIDAL PATTERN
rare but ominous pattern associated with high rates of morbidity and mortality
Appears as regular, smooth, undulating form of a sine wave with frequency of 2-5 cycles per minute and amplitude of 5-25 BPM.
Indicates severe fetal anemia or severe fetal hypoxia
Cardinal Movements
Engagement- head at station 0
Descent- head moving out of pelvis
Flexion- chin to chest
Internal rotation: head rotation to midline
Extension: chin up as head passes symphysis pubis
External Rotation: Head transverse to allows holders to pass
Explusion: Head out
POSTPARTUM ASSESSMENT
BUBBLE HE Breasts Uterus Bowels Bladder Lochia Episiotomy/laceration/C Section Hemmorhoids & Hemmorhage Emotions
Evaluation of Episiotomy heeling
REEDA Redness Edema Eccymosis Drainage, Discharge approximation
LATCH
LATCH (0=to sleepy, 1=repeated attempt, holds nipple in mouth, have to stimulate to suck. 3=grasps breast, lounge down, lips flanged, rhythmic sucking) AUDIBLE SWALLOWING (0=none, 1=few wth stimulation, 2=spontaneous and intermittent if more then 24 hours old. spontaneous and frequent if over 24 hrs old TYPE OF NIPPLE (0=inverted, 1=flat, 2=everted) COMFORTof breast/nipple (0=Engorged, cracked, bleeding, blisters, bruising. 2=Filling. reddened/small blisters or bruises. mild to moderate discomfort. 3 Soft, contender. HOLD /positioning. (1=Full assist-staff hold infant at breast. 2=minima. assist-elevate head of bed, place pillow for support, teach one side and mom does other. 3=no assist from staff. mom able to position infant.
What is eyes and thighs
Eyes get erythromycin, Vitamin K (left thigh), Hep B(right thigh)
Station
the measurement of the progress of descent in centimeters above or below the midplane from the presenting part to the ischial spines. Station 0: at ischial spine. Minus station: above ischial spine. Plus station: below ischial spine.
Effacement
shortening and thinning of the cervix during the first stage of labor
Before you apply External fetal monitoring you should?
Complete maternal-fetal assessment
-Urinalysis, palpate fetal movement, Vital signs, labor assessment, leopards maneuver, maternal fetal hx, educate on EFM, detect contraindication
uterine contractions
- Uterine contractions controlled by alpha receptors in uterine muscle cells
- Begin in uterine fundus and proceed symmetrically down toward cervix
- Pressure >50 mm Hg = no oxygen to fetus
- Influenced by maternal hydration status and fear
- –Fear= Catecholamines = PAIN
Fetal Bradycardia
Less than 120 beats per min
-Change position of the mother and administer oxygen as prescribed. The physician is notified
Fetal Tachycardia
greater than 160 BPM.
-Change position of the mother and administer oxygen as prescribed. The physician is notified
Variability (fetal)
a change in the baseline FHR in response to sleep, wake states, medications and hypoxia. A FHR that fluctuates 6-25 BPM at the baseline indicates a well-oxygenated functioning central nervous system
Acceleration (fetal)
transient rise in FHR of more than 15 beats per minute for more than 15 seconds. May or may not be related to uterine contractions. Marked acceleration (more than 180 BPM) may be related to prematurity, maternal fever, hypoxia, fetal infection, or medications.
Deceleration (Fetal)
transient decrease in the FHR. Early deceleration: decrease in the FHR below baseline. Can be due to head compression
Variable deceleration
an abrupt decrease in FHR that is variable in duration, intensity, and timing. Can be due to cord compression.
Late deceleration
decrease in the FHR below baseline. Due to uteroplacental insufficiency.
Hyperstimulation
increasing resting tone or peak contraction pressures. Implementation for altered patterns: the physician is notified. Check for cord prolapse. Maintain the client in the left lateral position. Administer oxygen as prescribed. Oxytocin infusion is discontinued as prescribed. Fetal scalp pH is done to determine a blood pH value. IV fluids are increased as prescribed. Monitor and maintain blood pressure if hypotension occurs. Prepare the client for cesarean delivery as prescribed.
Transducers
used to pick up the uterine contractions
Where is the best place to listen to baby heart sounds in utero
where the babies back is
Disadvantages for internal fetal monitoring
- membranes must be ruptured
- must be inserted by health care provider
Risks for internal fetal monitoring
- Abruption
- Lower uterine segment perforation
- Infection
- Contraindicated with HIV, active herpes
Montevideo Units
Used to evaluate contractions in relation to labor progress.
FORMULA: MVU= the sum of the intensity of contractions in a 10 minute period
contractions
DURATION
beginning to end of one contraction
contractions
FREQUENCY
beginning of one contraction to the beginning of the next
MONITORING
Where is the fetal heart rate displayed?
Where is Uterine activity displayed?
Fetal heart rate on top pane and uterine contractions in bottom pane
how can contractions be measured?
From peak to peak
Normal Uterine contractions
<5 contractions in 10 minutes averaged over 30 minutes
Tachysystole (hyperstimulation) Uterine contractions
> 5 uterine contractions in 10 minutes, over 30 minutes OR any single uterine contraction lasting longer than 120 seconds
Hypertonus uterine contractions
an elevated resting tone >20 mm Hg when on IUPC is in place (not possible to evaluate with a toco.)
causes of Maternal Tachycardia
Fever, Anxiety, Medications (betasympathomimetrics, illicit drugs, OTC drugs)
Causes of Fetal Tachycardia
Hypoxemia Fetal anemia/heart failure Amnionitis Fetal arrhythmia SVT
Causes of Maternal Bradycardia
Hypothermia Medications Connective tissue disease (SLE) Hypotension Position
Causes of Fetal Bradycardia
Occiput posterior or transverse position Fetal heart block Fetal compromise: --Hypoxemia --Decompensated fetus
Causes of decreased FHR Variabilty
Hypoxemia Drugs CNS depressants Fetal sleep cycles Congenital anomalies Extreme prematurity Neurologic anomaly
Nursing Actions for decreased FHR Variability
Evaluate cause Stimulate fetus --Scalp stimulation --Vibroacoustic stimulation --Transabdominal halogen light Oxygen by mask Notify MD
types of variability
Absent Mild: <5 bpm Moderate: 6-25 bpm Marked >25 bpm Bradycardia FHR < 110 Tachycardia FHR>160
types of decelerations
-Early : vagus nerve response to head compression-usually reassuring
Appears with contraction
-Late: utero placental insufficiency Always NON reassuring
Appears during and after contraction concludes
-Variable: Cord compression “shoulder”
Sharp deceleration with rapid return
Why doesn’t a variable deceleration go below 55 to 60 bpm?
When the fetal parasympathetic nervous system is activated fully by cord compression of the umbilical arteries, it drops the fetal heart rate to what would be equivalent to a complete heart block with the recorded heart rate being the ventricular rate. If the fetal heart rate is below 55 to 60 bpm, think hypoxia!
Early Decelerations
Reassuring, Waveform consistently uniform. Just prior to or
early in contraction. Consistently at or before midpoint of contraction. Usually within
normal range of 120-160 bpm. Can be single or repetitive
Late Decelerations
Always nonreassuring, Waveform uniform, shape reflects
contractions. Late in contraction. Consistently after midpoint of contraction. Usually
in normal range with a high baseline (120-130 bpm); when severe may drop to 60
bpm. Occasional, consistent gradually increase.
variable decelerations
Can be nonreassuring, Waveform variable, generally shape
drops and returns. Immediate with fetal insult; not related to contraction. Variable
around midpoint. Usually in normal range, can drop low. Variable, single or repetitive
Category 1 -within defined limits
Baseline Fetal Heart Rate between 110-160
With one of the following variability patterns present:
-Minimal Variability with accelerations
-Minimal variability without accelerations for less than 90 minutes or for unknown time
-Moderate variability
With one of the following deceleration patterns present
-No decelerations
-Early decelerations
-Variable decelerations with abrupt decrease and abrup return to baseline (<2 minutes)
-Variable decelerations without slow return to baseline or overshoot
Benign Sinusoidal Pattern (e.g. narcotic induced)
Nurses role with Category 1 WDL
-Continue to observe client
Document
-Notify physician “Routine”
Category II: Problematic Patterns
Minimal Variability for more than 90 minutes with no deceleration and no accelerations
Variability or accelerations are present with one of the following:
Recurrent Late Decelerations
Recurrent Variable decelerations with one of the following:
Overshoot
tachycardia
Decreased Variability
Slow return to baseline
Single Prolonged Deceleration with Return to baseline
Within a 12 hour period
Tachycardia
Low baseline heart rate on initial EFM
Prolonged deceleration Characteristics
- Variable in shape and onset
- Often associated with rebound tachycardia and loss of variability
- Frequently an isolated event
prolonged decelerations causes
- Cord compression or prolapse
- Tachysystole
- Maternal hypotension
- Rapid fetal descent, sustained maternal valsalva, SVE or FSE application
- Maternal voiding or vomiting
Prolonged deceleration nursing actions
- SVE to r/o cord prolapse or rapid descent
- Change maternal position
- Stop oxytocin
- Correct maternal hypotension
- IVF bolus
- Oxygen10 LPM by mask
- Terbutaline prn
- Notify MD, charge nurse
Nurses role in Category II - Problematic Pattern
Recognize and document Institute IR Notify Physician Request Physician Eval Document Physician response Document observations, actions, fetal/client response Update physician Anticipate potential to cat III
Intrauterine resuscitation
Increase uterine perfusion by:
Lateral maternal positioning Correct maternal hypotension IV fluid bolus (200-300ml LR) Administration of ephedrine Modified trendelenberg position
Intrauterine resuscitation
Increase Oxygen Transfer by
Provide supplemental oxygen at 10 LPM
Intrauterine resuscitation
Reduce Uterine activity by:
Discontinue oxytocin/cytotec/
prostaglandin
Administer terbutaline 0.25 mg SQ
Intrauterine resuscitation
Promote Umbilical Blood flow by:
Maternal position change
Change pushing pattern
Amnioinfusion
Intrauterine resuscitation
Increase fetal cerebral blood flow
Change pushing pattern
POINTS
P -Position 0 - O2 I - IV- Open wide open N - Notify physician T - Terbutaline S - Stop Pit
Category III: Pathological Problems
Absent variability and absent accelerations: With one of the following: No deceleration or Unknown decelerations Late decelerations Recurrent Variable decelerations with one of the following: Slow return to baseline Overshoot Tachycardia Tachycardia Prolonged deceleration > 1 Bradycardia (was previously normal) Sinusoidal Pattern Marked Variability (Saltatory) Fetal heart Block on initial EFM
Category III: Pathological Problems
Nurses Role
Recognize and document Institute IR Notify attending Physician Require On site assessment Document physician response Prepare for delivery Activate C/Section team Prep Pt for delivery Call for OB/General surgeon Document observations, actions, fetal and maternal response
SINUSOIDAL PATTERN
Rare but ominous pattern associated with high rates of morbidity and mortality
Appears as regular, smooth, undulating form of a sine wave
Frequency of 2 to 5 cycles per minute and amplitude of 5 to 15 BPM.
True pattern indicates severe fetal anemia or severe fetal hypoxia
Cardinal Movements
Engagement: head at station 0
Descent: head moving into pelvis
Flexion: chin to chest
Internal Rotation: Head rotation to midline
Extension: chin up as head passes symphysis pubis
External Rotation: Head transverse to allow shoulders to pass
Expulsion: Head out
Stage 4 of labor
The period from 1-4 hours after delivery.
Data collection: fundus remains contracted, in midline, midway between the umbilicus and symphysis pubis.
Implementation: monitor maternal vital signs frequently. Check lochia and fundus
Evaluation of Episiotomy Healing
R. Redness E. Edema E. Ecchymosis D. Discharge/Drainage A. Approximation
LATCH Scoring
LATCH- 0= no latch achieved 1=hold nipple in mouth/stimulate to suck. 2= grasps breast, tongue down, lips flanges, rythmatic sucking
AUDIBLE SWALLOWING. 0= none. 1= with stimulation. 2= spontaneous and intermittent
TYPE OF NIPPLE: 0=inverted, 1=flat, 2=everted
COMFORT. 0=engorged, 1=filing, mild discomfort. 2=soft, nontender
HOLD. 0=full assist, staff holing baby. 1. minimal assist. 2. no assist from staff
What should the difference between infant head and chest size be
OFC and chest circumference should be 1-2 cm apart or the same.
