OB exam 2 Flashcards
labor. birth, fetal assessment
What decelerations are indicative of cord compression?
variable
What is the nursing intervention for variable decelerations?
Move the client to a knee chest position OR lift the baby’s head with 2 fingers through the cervical opening
What is happening when early decelerations are present on the monitor?
fetal head compression
What is the nursing intervention with early decelerations?
prepare for labor, caused be head descending into the pelvis
What decelerations are present with placental insufficiency?
late decelerations
What is the nursing priority with late decelerations?
execute immediate actions- reposition, administer oxygen, decrease or discontinue oxytocin, tocolytic may be used to decrease contractions
What is fetal station?
how far the fetus has descended into the pelvis
What does fetal station 0 mean?
the presenting part of the fetus is even with the ischial spine
What does engagement mean?
the largest part of the presenting part of the fetus has passed through the pelvis = 0 station
False labor contractions are normally
irregular in timing and stregnth, a strong one may be followed by a weaker one at irregular intervals
What do we teach the patient to know the difference between false labor and true labor?
teach the patient to drink some water, walk around, or change positions, if the contractions subside, it may be false labor
A patient presents with bloody show and cervical change, what does this signify?
true labor
True labor contractions are…
regular, consistent strength, and grow faster, longer and stronger
pain usually starts at the back and radiates to the front of the abdomen
what does NOT determine labor
bloody show
severe pain
water bag broke
having contractions
what are the 5 Ps of labor
Passenger
Passageway
Position
Powers
Physiological response
What is the preferred presentation
cephalic
What is the preferred position?
longitudinal, we want the spines of the baby and mom parallel
if they are oblique or transverse, they cannot be born vaginally
When do the fontanels closed and how do you differentiate between them?
anterior is diamond shaped 1-4 cm wide, and closes around 12-18 mnths
posterior is triangular 1-2 cm and closes around 6-8 weeks (usually comes out first)
What cervical dilation classifies as latent stage of labor?
0-3 cm
What are contractions like during the latent stage?
mom can usually talk and walk through them, last about 30-45 seconds and are around 5-10 minutes apart
What should be monitored during the latent stage and how often
VS every 30-60 minutes
temp every 2 hours if water is broken and every 4 hours if it is not
contractions measured every 30-60 minutes
FHR measured 30-60 minutes
What dilation classifies the mother during the active stage?
4-7 cm
What are the nursing interventions during the active phase of the first stage?
assist mom into different positions, encourage voiding every 2 hours, teach deep breathing, pain management, NO PUSHING
What should be monitored during the active phase and how often?
VS should be monitored every 15-30 minutes
temp 2-4 hours
contraction/FHR: 15-30 minutes
The transition phase usually lasts how long
20-60 minutes
How are the contractions during the transition phase?
last 60-90 seconds and are only 1-2 minutes apart
What phase is the cervix dilated from 8-10 cm?
transitional phase of the first stage
What should the nurse tell the patient during the transition phase?
do not push until the cervix is fully dilated
The patient states she has a strong urge to poop. What should the nurse do?
Check progress, often a sign of complete dilation
What is the second stage of labor?
from the time the cervix is fully dilated until birth
What are the nursing interventions during the second stage of labor?
help the mother practice breathing, coach through pushing, clense the perineum of fecal matter during pushing, NEVER LEAVE THEM, notify provider and prepare sterile equipment
What marks the end of the second stage of labor
expulsion
What happens during the third stage of labor?
the placenta is delivered
What are the signs that the placenta has separated from the uterine wall?
gush of dark red blood from the vag
firm fundus/round uterus
longer umbilical cord
patient reports feeling vaginal fullness
How long does the third stage of labor usually take?
usually lasts around 5-30 minutes
What is the nurses role during the third stage of labor?
check fundal height and monitor bleeding
VS q 15
keep pt talking to watch LOC
cleanse perineal area and apply pad or ice pack
What marks the fourth stage of labor
after the delivery of the placenta until at least 2 hours after
What is important for the nurse to monitor during the fourth stage of labor?
monitor lochia, fundus, maternal vital signs, and urine output
during the first 2 hours, assess vital signs every 15 minutes
assess fundus every 15 minutes during the first hour
What actions should the nurse perform during the fourth stage of labor
massage the fundus, encourage voiding,
promote parental and newborn bonding
1st degree perineal laceration
skin only : BURNSSS
2nd degree perineal laceration
through the skin and muscle of the perineum
3rd degree perineal laceration
extends through the skin, muscle, perineum, and external anal sphincter muscle
4th degree perineal laceration
extends through skin, muscle, anal sphincter, and the anterior rectal wall
What are the 5 OB emergencies?
meconium stained amniotic fluid
shoulder dystocia
prolapsed umbilical cord
rupture of uterus
amniotic fluid embolism
The nurse would assist the laboring mom into a knee chest position when?
the occiput of the fetus is in a posterior
position
Fergueson reflex
stretch receptors in the posterior vagina cause release of oxytocin that triggers more contractions & urge to bear down
What does the emergency treatment and active labor act say?
we may not turn a patient away until they are stable and transport is arranged to an appropriate facility
What 3 things would make a contraction ABNORMAL?
lasts longer than 90 seconds
less than 30 second rest periods
more than 5 contractions in 10 minutes
What is gait control theory?
nerve pathways that carry pain perception are limited, so sending alternate signals may block the pain
What are some examples of pain management that use the gait control method?
hot and cold therapy
aromatherapy
TENS unit
frequent position change
effleurage
counterpressure
What is effleurage?
light circular motions on the abdomen rhythmically with breathing
What is counterpressure?
using a heal or palm and putting pressure on the sacrum to relieve lower abdominal pain
What is the MAIN COMPLICATION of epidural anesthesia?
hypotension
What effect does the epidural have on the fetus?
none
What should the nurse do to prevent the main complication with the epidural?
give an IV fluid bolus prior to epidural placement
What are complications from the hypotension caused by epidural?
poor placental perfusion
longer second stage: risk for assisted birth
itching
urinary retention
spinal headache
cardiac arrythmia (if gets into bloodstream)
What opioid meds do you avoid for opioid dependent clients?
opioid agonist antagonists
can cause withdrawal symptoms by blocking receptors
When are sedatives administered during birth and when should they not be administered?
sedatives can be administered for sleep or anxiety during the latent stage but should not be administered if birth is anticipated in 12-24 hours
What are the nursing implications for a precipitous birth?
Do not leave the patient
grab a precip back
put the patient on side or hands and knees
check for cord around neck
clear the airway
What is visceral pain
cannot pinpoint where the pain is, intense, dull, aching
What is referred pain in labor
can radiate to the lower back, butt, and thighs
notice these signs if a patient comes in
could signify preterm labor
somatic pain
intense sharp, stretching of the perineum and pelvic floor
Why do we want to reduce pain in labor?
catecholamines that the body releases from the stress of severe pain can actually prolong labor
What are the risks in the mom of having a preterm birth
PREVIOUS PRETERM BIRTH
multiple gestations
second trimester bleed
low prepregnancy weight
What are the 2 different kinds of preterm birth
spontaneous is when it happens on its own
indicated is when there is a danger to the fetus or mother so labor is induced
What are ways to tell if a woman may go into preterm labor
fibrnectin test: glue that holds baby in
length of cervix: shorter than 3 cm can increase the risk
What can cause a spontaneous preterm birth
infection, bleeding, over distention, maternal or fetal stress, lack of progesterone
What is given to the woman between 23 and 34 weeks to promote lung maturity in the fetus
betamethasone- corticosteroid that stimulates fetal lung maturity in 24 hours
What are some things to monitor in mom who got betamethasone
blood sugar and signs of infection (can supress immunity)
What are the benefits of betamethasone
can decrease the risk of:
necrotizing enterocolitis
intraventricular hemorrhage
RDS decrease
What meds are used to stop contractions
tocolytics
what are some examples of tocolytics
indomethacin
magnesium sulfate
terbutaline
nifedipine
How does mag sulfate work to reduce contractions
reduces smooth muscle contraction
MONITOR toxicity
also decreases the risk of brain bleed
How does indomethacin work
blocks prostaglandins
can cause oligohydamnios
do not use less than 2 weeks
What is nefedipine
calcium channel blocker that works by blocking calcium channels in the smooth muscle to stop contractions
What is a risk with nefidipine
can increase hypotension
(it is a bp med)
What is terbutaline
used as a tocolytic to relax the smooth muscle in mom and stop contractions
Why do we want to monitor for preterm labor so closely
once dilation starts, we can’t stop it even if we stop contractions
Premature rupture of membranes is what
rupture of amniotic sac at any point in pregnancy at least 1 hour before labor starts
Infection is a major risk when what ruptures
amnitotic sac- it serves as the barrier
If the baby is full term with PROM, what is the most likely action
induction of labor
interventions with PPROM include
buy some time if there is no infection: administer betamethasone, broad spectrum abx sometimes
Hallmark symptoms of chorio amnion itis
maternal fever which causes fetal tachycardia
UTERINE TENDERNESS
What are the complications of a precipitous labor
trauma to mom or baby
postpartum hemorrhage
premature infant
neonatal resusitation
What can lead to dystocia
ineffective pushing, blocked birth passage, fetal size, fetal position (breech), fear and pain
What are risk factors for dystocia
overweight
advanced maternal age
infertility
head too big for pelvis
uterine overstimulation with oxytocin
What is version
turning a breech baby with skin lubricant and pushing with hands
induction of labor
want a bishop score of over 8 (signifies that moms ready)
cervical ripening
prostaglandins
mechanical- foley bulb, laminara (seeweed that expands the cervix)
amniotomy
what are the risks of an amniotomy
infection, pinching of the umbilical cord
what should the nurse monitor after an amniotomy
fetal heart rate
why is fetal heart rate so important after an amniotomy
spike could indicate a prolapsed umbilical cord which is an OB emergency
What are the precautions with pitocin use
uterine tachysystole (more than 5 contractions in 10 min)
postpartum hemorrhage (muscle is worn out)
water intoxication (related to ADH)
Describe what circumstances allow for a VBAC and possible complications?
vaginal birth after c
indications for the first c section can no longer be present
LOW TRANSVERSE INCISION previously
What is a trial of labor and when is it used
observation of a woman and her fetus in labor to assess safety of vaginal birth (4-6 hours)
must have c section available if conditions change
Meconium stained amniotic fluid is associated with
meconium aspiration pneumonia (airways are blocked) which is caused from a fetal hypoxic event or a mature bowel
what is the nursing action with meconium stained amniotic fluid
no not induce crying, suction first, may use endotracheal suctioning because the small suction catheter may get clogged with meconium
what is it called when a babys head is born but their shoulder gets stuck
shoulder dystocia
what are injuries that can occur to the baby with shoulder dystocia
hypoxia and brachial plexus injury (nerves in the arm of the affected shoulder) or fractured clavicle
What is the most likely injury to mom that experiences shoulder dystocia during labor
3rd degree or worse lacerations
hemorrhage
what does the nurse do first with shoulder dystocia
FIRST: McRoberts maneuver
What is the McRoberts maneuver
one hand on foot and one hand under knee and pushing the leg up to the chest, which bends the spine, and pelvic bones which may help the shoulder dislodge from the pelvic bone
What is the second thing the nurse tries with shoulder dystocia
suprapubic pressure: CPR position of the hands and push on the suprapubic area
What is the Wood’s screw method associated with shoulder dystocia
the physician will physically turn the baby
the nurse will support mom because this could be very uncomfortable with 2 hands inside of her
What is the nurses action with a prolapsed umbilical cord
elevate the babys head with RN fingers
then place the mom into a knee chest position with fingers still holding the baby up on the way to a STAT C section
What are signs of uterine rupture?
sudden drop in FHR
loss of fetal station (head goes back up into abdomen)
sudden constant abdominal pain
maternal shock
what does the nurse do with a ruptured uterus
oxygen administration, IV fluids, prepare immediate surgery and MASS transfusion (notify the blood bank)
What is an amniotic fluid embolism
amniotic fluid bubble enters maternal circulation through the uterine artery, which either causes an anaphylactic reaction if it is amniotic fluid or a pulmonary embolism
what does a nurse do with an amniotic fluid embolism
call a code
replace clotting factors to prevent DIC
perform CPR
what are the guidelines for intermittent monitoring
must get initial 20 minute continuous electronic FHR strip on admission
asses for any risks
first stage: 15-30 minutes
second stage: 5-15 minutes
criteria for internal monitoring
water must be broken
dilation of 2 cm
head must be engaged
skilled practitioner places the spiral electrode
how is strength of a contraction measured
palpation or internal catheter
what is a normal fetal heart rate
110-160 bpm
Decreased variability means
uteroplacental insufficiency, cord compression, maternal hypotension
uterine hyperstimulation
Decreased variability requires immediate intervention of the nurse, what does that include
1 reposition mom lateral or on hands and knees
2 IV fluid bolus
3 oxygen administration of 10-15 L/min through NONREBREATHER
What kind of o2 administration is used on mom with decreased variability in fetus
NONREBREATER (nasal cannula will not do the job)
With late decels, what should the nurse do
1 reposition
2 IV fluid bolus
3 admin high flow O2
4 stop oxytocin (even without physician but notify them after)
what is the 60x60 rule
if FHR is less than 60 bpm for greater than 60 seconds then we worry
prolonged decelerations last how long
more than 2 minutes
what are a normal FHR classification
110-160 baseline
no ominous decels
moderate baseline variability
what are some additional fetal assessment techniques
finger scalp stimulation
vibroacoustic stimulation
(a well oxygenated will respond to these)
what is the most common cause of fetal tachycardia
maternal fever
