Powerpoints Test 2 module 3 Flashcards
stages of labor
Stage 1:
0-10 cm dilation
Phase 1-3= latent , active, and transition dilation
Stage 2 of labor
10 cm dilated (complete) to the delivery of the infant
Stage 3 of labor
Delivery of infant to delivery of the placenta
Stage 4 of labor
First hour to four hours after placental delivery
Phase 1 of delivery
Latent phase - dilation of 0-3 cm
Phase 2 of delivery
Active dilation 4 to 7 cm
Phase 3 of delivery
Transition phase
Dilation is 8 to 10 cm
What are the Ps of labor
Woman/fetus-
Power Passageway Passenger Position Psyche
What are the Ps of labor
for providers support persons
Patients
Persistence
Practice/pain relief
Psyche
power-
The uterus is stretched to threshold point leading to what?
Synthesis and release of prostaglandin
Pressure on the cervix causes what?
The release of oxytocin
Oxytocin stimulation in blood Does what during pregnancy?
Increases
Estrogen in progesterone ratio does what during pregnancy?
The ratio changes and estrogen increases
And progesterone decreases
and excites her uterine response
Placental aging and deterioration triggers what?
Contractions
during pregnancy Fetal cortisol concentration rises and causes the placenta to do what?
Reduce progesterone
Prostaglandin is produced by fetal membrane during pregnancy and stimulates what
Contractions
Power -contractions move downward over the uterus, which portion is contracted for the longest time ?
Upper part of uterus
What is responsible for effacement and dilation of the first stage of labor ?
Myometrial Activity -The myometrium is the middle layer of the uterine wall, consisting mainly of uterine smooth muscle cells (also called uterine myocytes), but also of supporting stromal and vascular tissue.
Its main function is to induce uterine contractions.
Myometrial activity increases with what?
Good blood flow to the uterus (walking/activity and relaxation to eliminate fight or flight response)
How to assess contractions?
Duration - (length beginning to end)
Frequency- time between start of one contraction to the start of the next )
Intensity - palpate uterus
Resting tone- palpate uterus
When manually palpating the uterus, for a contraction assessment, what does
Mild
Moderate
Strong
look/feel like?
Mild- uterine wall is easily indented
Moderate-Uterine wall demonstrates resistance to pressure, some indention
Strong- uterine wall can not be indented
What is the external machine monitoring contractions called?
And what does it do?
Risks?
Tocotransducer
It measures increased intraabdominal pressure
(Not intrauterine pressure)
No known risks
Internal machine monitoring such as FSE (fetal scalp electrolode)-heart monitor or iucp Intrauterine pressure catheter does what ?
Risks
Direct measurement of intrauterine pressure
Include infection and uterine rupture
What do Montevideo units do in a contraction assessment
Measurement and quantify uterine work
Expressed by the number of contractions in 10 minutes multiplied by their intensity
**Measures Intensity of contractions
How to measure intensity of contractions in montevideo units ?
Review 10 minutes of the contractions strip
Count each contraction peek from baseline, total all contraction peak values in 10 minute period
This total peak value equals the MVU
What is a normal range of contraction/intensity Montevideo units ?
180-300 = Adequate contractions
Passageway-
Normal female pelvis
Labor progresses good
Most common
Rounded
Gynecoid
Labor progresses poor
Flat-oval side to side
Uncommon
Platypelloid
Male pelvis shape
Labor progress is poor
Higher among Caucasian women
Heart shaped
Android
Higher among non-Caucasian women
Pelvis that has increased OP delivery
Labor progresses good
Up and down oval shape
Anthropoid
Effacement -(Thinning r shortening of the cervix) how thin?
What is
Palpable with 100% effacement?
2cm- paper thin
A thin edge
Nulliparas (a woman who has never given birth) - when does effacement Of cervix begin?
Begins before the onset of labor
Multiparas (a women who has given birth to two or more babies) - when does effacement of cervix begin?
May it begin until the onset of labor
Opening of the external OS
Dilation
Dilation of the cervix is caused by what
Pressure of presenting part
Contraction and retraction of uterine muscles
Diameter of cervix increases to how many cm during labor?
When is it not palpable?
10cm
At 10cm dilated
During labor, the cervix of who remains thicker?
Multipara women remain thicker than women who have never birthed before
What to asses for in the passenger (baby)
Fetal lie - transverse, longitude Fetal altitude , neck flexion Presentation- brow, breech etc Station - out of pelvis - 0, +1 Position- loa
Longitudinal position of baby vs transverse
Longitudinal- baby’s head in down by cervix
Transverse- head and butt are side to side angling head angling down to cervix
Relationship of fetal parts to each other and degree of flexion or extension of the fetal head
Attitude
What is normal attitude?
Moderate flexion with chin flexed
Presentation determines what?
How the baby is presented to come out of the cervix first
Brow, breech , etc
Cephalic presentation
Head first - most common - 95%
Breech presentation
Pelvis first - 3% term deliveries
Shoulder presentation
Shoulder first - 2%
Relationship of presenting part to ischial spines of moms pelvis
How far the baby is out of pelvis
-3 to +4
What number is at ischial spine
Ballotable head moves when gentle pushed against
passenger station-
0
Relationship between the fetal presenting part and four quadrants of the mothers pelvis
Fetal position
Posterior fontanel,Anterior fontanel, sagittal suture, lamboid suture, coronal suture, Parietal
What is the most common and Best birth position for the fetus
LOA
False labor s/s
Regular contractions ?
Decrease in frequency and intensity
Disappear with sleep
No change in cervix
Sedation decreases or stops contractions
Show usually not present
True labor s/s
Regular contractions
Increase in frequency and intensity
Discomfort begins in back and radiates to abdomen
Activities such as walking increases contractions and continues with rest
Cervix dilate and effaces
Sedation does not stop contractions
Show is present
Labor assessment information
Labor symptoms
Pregnancy hx
Allergies
Cultural needs
Support persons
Medications
Smoking drugs alcohol
Last meal and time
Group b strep status
Vitals
Frequency and duration of uterine contractions
Well being
Urinary protein
Cervical dilation
Fetal presentation and station
Status of membranes
Date and time of arrival and notification of provider
Latent stage of labor duration
Multi gravida - 5.3 hours
Primigravida- 8.6 hours
Contraction frequency in latent stage of labor
every 3-30 minutes , may be irregular
Contraction duration in latent Stage of labor
30 to 40 seconds
Contraction intensity and latent stage of labor
Mild to palpation, 25 to 40mmhg
What do you contractions attempt to do to the cervix?
Soften, efface, dialate
What’s involved in psyche: labor support
Emotional support
Physical support
Advocacy
Support of partner
The physical presence of someone during labor as well as offering words of encouragement
Emotional support
Comfort measures in pain relief, hygiene, reassurance touch, application of heat or cold, calm environment, information and advice during labor
Physical support
Ways one can assess the fetus
Leopold’s
Auscultation
Vaginal exam
Ultrasound
FHR are incomplete without what?
The clinician should recognize and respond to both palpated and electronically obtained what?
Uterine activity assessment
Uterine activity data
Requires attention to audible characteristics of fetal heart rate
Auscultation
Methods of auscultation of FHR
Fetoscope and Doppler
Intermittent auscultation IA
Advantages of external FHM
Continuous information Noninvasive Antepartum and during labor Permanent record Assess LTV Can assess contractions Can detect some variable and periodic change
Disadvantages of FHR monitoring
Expensive equipment Subject to artifact Cannot assess STV Variability Belts can be uncomfortable Subject to double or half count Less than 70 bpm double count Greater than 180 bpm half count
Internal FHR monitoring advantages
Accurate continuous information
Information not subject to artifact
Internal FHR monitoring disadvantages
Expensive
Need to have ROM and 2-3 cm
Slight risk of infection to mom and baby
Transfer of oxygen and carbon dioxide between the maternal and fetal circulation
Utero placenta unit
Primarily mediated by the Vagus nerve innervating the SA and the AV node’s in the heart
Decreases the heart rate **
Develops around 28-30 weeks of gestation
Parasympathetic nervous system
Stimulation increases the FHR
Stimulation of nerves is responsible for long term baseline variability
Action occurs through the release of norepinephrine
May be stimulated during periods of fetal hypoxemia
Sympathetic nervous system
Stretch receptors present in the aortic arch and the carotid arch
Detect pressure changes *
Maintains homeostasis - regulate the heart rate
Baroreceptors
Located in the aortic arch and the CNS
Respond to changes in fetal O2 CO2 and ph levels
Chemoreceptors
How to determine the FHR baseline rate?
Best straight line image
Need at least 10 min monitor strip to determine baseline rate
FHR between patterns and contractions
Causes of tachycardia in pregnancy
Maternal fever Prematurity Fetal infection Fetal and maternal anemia Early fetal hypoxia Maternal dehydration Tocolytic therapy Maternal anxiety Excessive fetal activity
Management of tachycardia in pregnancy
R/o maternal fever or drug effect Hydrate Decreased maternal anxiety O2 8-10L R/O Underlying medical history Notify Dr. and team Determine if associated with late or variable decelerations and anticipate interventions
Causes of bradycardia in pregnancy
Fetal hypoxia Fetal asphyxia Fetal arrhythmia Drugs Maternal hypotension Prolong compression of cord Maternal hypothermia Mild bradycardia May be associated with post term infant
Presence of variability suggests what in a monitor strip?
good central nervous system control over FHR
An irregular FHR baseline on strip demonstrates what?
Normal healthy fetus
If baseline is flat on external monitor, how will it look on the internal monitor?
Even flatter
Defined range, fluctuations, oscillations in a fetal monitor strip
Rate change in heart rate over many seconds to minutes - 2-6 changes per minute
Amplitude up /down from baseline
Increases with fetal movement
Decreases when fetus is asleep
Variability
Amplitude greater than 25 per min
6-25 bpm
Less than 5 bpm
Amplitude range undetectable
Marked
Moderate
Minimal
Absent
Causes of decreased variability
Congenital
Tachycardia
Deep sleep
Drugs
Prematurity
Increases in FHR above baseline
Accelerations
Clauses of accelerations
Fetal movement
Stimulation
Contractions
Can be periodic or episodic
If everySingle contraction has an acceleration maybe breech presentation
Different decelerations
Veal Chop:
Veal chop :
Variable decelerations
Early decelerations
Accelerations
Late accelerations
Cord compression
Head compression
Okay
Placental insufficiency
Nadir means ?
The lowest point
Gradual vs abrupt ?
Ask what is the shape
Abrupt decreases in fetal heart rate may occur with or without What?
They may also vary in?
Contractions
shape, depth, duration, and timing with contractions
Most common cause of variable decelerations
How long does the deceleration have to last to be considered variable?
If less than 15 seconds long what is it?
Occlusion of the umbilical blood flow
These decelerations are believed to represent a vagal response to a cerebral re distribution of blood flow caused by compression of the fetal head
When contractions occur the fetal heart is subjected to pressure which stimulates the Vagus nerve
Mirror the contraction causing them
Can be present in the normal FHR pattern. Benign
Early decelerations
This deceleration reaches its lowest point (nadir) after the peak of contraction
Typically symmetrical and returns to baseline once contraction resolves
If moderate - adequately oxygenated
If they reoccur with absent or minimal variability they may represent what?
Late decelerations
Heart hypoxic depression and risk of acidemia/acidosis
Blood cord gases in the newborn
Why is it taken?
Determines their metabolic condition at birth
Recommended I’m high risk deliveries such as fever, cesarean section compromise , Growth restriction , abnormal FHR , apgar score less than 7 , multifetal gestation
Target new born cord blood gas ranges
PH
Pco2
Bicarb
Po2
BE
7.10 or greater
60 or less
22 or higher
20 Or greater
-12 or greater
Interval between full cervical dilation and delivery of the infant
Bloody show
Maternal desire to bear down with each contraction
Onset nausea and vomiting
Increased maternal shaking
Second stage of labor
Operative vaginal birth should be considered to who?
First time birth women - when there is lack of progress for 3 hours with regional anesthesia or for 2 hours with out anesthesia
Multiparous women after lack of continuous progress for 2 hours with regional anesthesia or for 1 hour without anesthesia
Stage of laceration/episiotomy:
involves the perineal skin and vagina mucus membrane
First degree
Stage of laceration/episiotomy:
Involve the skin, mucus membrane and fascia (superficial) of the perineal body
2nd degree
Stage of laceration/episiotomy:
Involve the skin, mucus membrane and muscle of the perineal body and extend to the rectal sphincter
Third degree
Stage of laceration/episiotomy:
Extends into the rectal mucosa and expose the lumen of the rectum
Fourth degree
Delivery of the baby to the separation of expulsion of the placenta
Mild uterine contractions and fullness in vagina as placenta is released -mom feels relief
Third stage of labor
Duration of third stage of labor
5-30 minutes
Physical findings in third stage of labor
Gush of blood
cord lengthens
Fundus rises
Uterine shape changes from flat to firm and globular
Nursing interventions for third stage of labor
If further assessment, stimulation, or resuscitations are needed after birth explain procedure and infant status as needed
Early infant contact
- skin to skin until first feeding is completed
- encourage touching infant
- initiate breastfeeding if possible
Fourth stage of labor
- encourage what?
- how often fundal checks and vitals?
- assess what? And where?
Close observation of maternal and newborn for 2-3 hours
Continue to encourage bonding
Maternal vs and fundal checks every
15 minutes for the first hour and then
Every 30 minutes during the 2nd hour
Newborn vs- at 30 minutes, 1 hour, 1.5 hours, 2hours of age
Assessment of bladder function, palpate above symphysis pubis
Education about pain is necessary. Educate on what?
Contractions
Vaginal exams
Labor progress
Comfort measures
Plan of Care
Help then support person feel comfortable
Your role as the nurse
Maternal response to pain
Physical factors-
Pathology-
Psychological-
Cascade of events-
Speed, OP position, fatigue
Endorphins are opioids
Fear and anxiety
Labor outcome
How to provide basic nursing psychology comfort
Apply cool wash cloths
Back rubs
Body massage
Keep patient dry and clean
Lip balm
Keep linens dry and clean
Psychology test and relaxation
Nursing interventions
provide Calming stimuli - because it affects the thalamus in the brain and controls emotional response
And increases pain tolerance and decreases anxiety
Decreases catecholamines and muscle tension
Physical movement -
Patient should be able to move around unless what?
Avoid what?
How to support joints?
Experiment with what during contractions
Change what frequently
Unless continuous electronic fetal monitoring
Avoid laying flat on back
Use pillows to support joints
Experiment with walking, rocking back and forth, or swaying during contractions.
Change positions frequently
What aids in release of endorphins
This decreases hyperventilation-
Moaning - encourage
Decreases in carbon dioxide
Psychological-
Visualization and affirmation nursing interventions
Guided imagery- Visualize creating mental images of the body letting go, the cervix thinning an opening, the baby moving down in the pelvis
Encourage the patient to talk to their body as part of the visualization and talk to the baby. Use familiar pictures of openings such as a flower or butterfly emerging from a cocoon
Imagine the baby smell, touch, noises
Effleurage
Gentle massage used during or between contractions
Use of prana (breath) the body’s energy fields
the body’s energy fields
Therapeutic touch
Healing energy
consists of steady, strong force applied to one spot on the lower back during contractions using the heel of the hand, or pressure on the side of each hip using both hands.
helps alleviate back pain during labor, especially in women experiencing “back labor.”
Counter pressure
A warm bath, Jacuzzi or shower is comforting
This does not increase chances of infection
A sponge bath maybe soothing in bed or soaking your feet
Hydrotherapy
Soothing scents of essential oils
Aromatherapy
Ice pack to lower back or heat pack on lower abdomen
- May alternate
- don’t apply heat to skin covered in what? Why?
Heat and cold packs
Lotion or ointment - it might burn
The inability to feel pain while still conscious
Analgesia
Total or partial loss of sensation, especially tactile sensibility, induced by disease, injury, acupuncture, or anesthetic, such as chloroform or nitrous oxide
Anesthesia
Parental analgesia meds?
Fenanyl
Morphine
Stadol
Nubain
Local anesthetic
Lidocaine
Regional analgesia techniques
Epidural Intra spinal narcotic Spinal Combined spinal epidural Pudendal block
Does not eliminate pain- blunting effect
Should not be given until labor is well established
Exception is made with morphine to allow an early laboring patient to sleep in preparation for active labor
Administration- peak of a contraction
Parental analgesia
Parenteral Analgesia:
Side Effects
What should be available for resp depression?
Maternal Sedation
Maternal respiratory depression
Transient decreased fetal heart rate variability or psuedosinusiodal pattern
Fetal respiratory depression
Neonatal sedation, decreased tone, altered suck reflex
Naloxone hydrochloride (Narcan) should be available to treat respiratory depression, but should not be used on infants whose mothers are addicted or suspected of being addicted to narcotics or who are in a methadone treatment program.
Regional Analgesia Techniques
Pudendal
Lumbar Epidural
Spinal
Intraspinal Narcotic (ISN)
Lidocaine can be injected into the perineum and posterior vagina before an episiotomy is performed and after delivery of the placenta for perineal repair.
Duration of action is approximately 20-40 minutes.
Pudendal nerve block
Great potential to provide pain relief in 1st and 2nd stage of labor
Test Dose: local anesthetic mixed with epinephrine may be injected to determine proper placement.
◦Vein placement causes?
◦Subarachnoid placement causes ?
Loading Dose: local anesthetic, ropivicaine
Epidural
tachycardia, palpitations, increased BP, numbness of tongue and mouth, metallic oral taste, slurred speech, tinnitus
immediate upper thoracic sensory loss, initiates severe lower extremity motor blockade, and potentially causes respiratory arrest.
Epidural advantages
Superior pain relief throughout delivery
Placement of epidural catheter means that emergency c-section delivery can occur more quickly
Entire pelvis and lower extremities are affected so that the client perceives touch but not pain
Epidural disadvantages
Increased chances of Maternal fever
Increased need for episiotomy, forceps and/or vacuum extraction
Increases need for oxytocin
Decreases bear down reflex
Increases first and second stage of labor
Increases your ability, inconsolable, uncoordinated suck and decreased responsiveness, interfering with the newborns response to breast-feed
Epidural Nursing Care
Pre-procedure:
◦Lactated Ringers Bolus ◦Patient empty bladder ◦Obtain baseline vital signs ◦Resuscitative equipment in room ◦Emergency equipment ◦Collect appropriate paper work
Epidural Nursing Care
Procedure-
◦Position patient with head and hips flexed and shoulders and hips squared to facilitate the insertion of the epidural needle
◦Provide ongoing emotional support and information.
◦Support person to take a seated position
◦Continuous pulse oximeter if needed
Epidural Nursing Care
Post Procedure:
◦Continue to monitor Vital Signs q 5 minutes x3, q 15 minutes x 4, q 1 hr x 4, q2 hrs x2, q4 hrs x duration of epidural
◦Fetal heart tones every 15 minutes for remainder of labor
◦Check Derms with every VS assessment.
◦Monitor lower extremities
◦Foley catheter insertion
◦Monitor Temperature
Fentanyl (6 hour pain relief), essential for longer duration.
Bupivicaine
Morphine
Intraspinal Narcotic (Intrathecal)
Used for Cesarean Delivery
Combination of Bupivicaine and Morphine
Local injection of lidocaine followed by needle placement with administration of medications.
Spinal
regional anesthesia side effects
Hypotension, change in FHT, nausea, vomiting, puritis with opiates added, urinary retention, poster all headache, maternal temperature elevation, epidural hematoma, intravascular injection of local anesthetic agents
Regional Anesthesia: Contraindications
Coagulation disorders
Local infection at the site of injection
Maternal hypotension and shock
Non-reassuring FHT pattern requiring immediate birth
Maternal inability to cooperate
Allergy to local anesthetics
Last dose of low-molecular-weight heparin within 12 hours.
DYSFUNCTIONAL LABOR PATTERNS
Hypertonic Labor (tachysystole) ◦Fetus malposition ◦CPD ◦BMI ◦Oxytocin Hypertonic Labor (2-3 cx/10 minutes)
Precipitous Labor and Birth
3 hours around…. Think of vital supplies Stay Calm Call for assistance Notify provider or other provider who may be in house
is a method in which isotonic fluid is instilled into the uterine cavity. It is primarily used as a treatment in order to correct fetal heart rate changes caused by umbilical cord compression, indicated by variable decelerations seen on cardiotocography.
Amniofusion
artificial rupture of membranes (AROM) and by the lay description “breaking the water,” is the intentional rupture of the amniotic sac by an obstetrical provider.
Amniotomy
Indications for Induction
Postterm pregnancy • Maternal medical conditions • Gestational hypertension • Fetal demise • Chorioamnionitis • Premature rupture of membranes • Fetal compromise • Preeclampsia, eclampsia
pre-labor scoring system to assist in predicting whether induction of labor will be required. It has also been used to assess the likelihood of spontaneous preterm delivery.
Scores dilation, length , consistency, position, head station
Bishop score
Cervical ripening refers to the softening of the cervix that typically begins prior to the onset of labor contractions and is necessary for cervical dilation and the passage of the fetus
What to use to help this occur?
MISOPROSTOL (Cytotec)
Foley Bulb ~ Mechanical
DINOPROSTOL (Cervidil)
Laminaria Tents
Pituitary hormone
Intravenous Oxytocin used for induction
Requirements for induction
Elective induction before 39 weeks
Oxytocin
Assisted operative vaginal delivery
What they use ?
Forceps
Vacuum extraction
Clinician externally or internally rotates a breach or transverse plane fetus to a vertex position
Internal/external version
Delivery in which the anterior shoulder of the baby is impacted against the maternal symphysis pubis
Shoulder dystocia
Dangers of Shoulder dystocia to child?
Risk factors In mother ?
Entrapment of cord
Inability of child’s chest to expand properly
Severe brain damage or death if not delivered in minutes
Risks :
Diabetes Prolonged gestation Prior shoulder dystocia Macrosomnia of fetus Maternal obesity Instrument assisted in delivery Precipitous delivery
Prevention of Shoulder dystocia
Maintenance of good glycemic control in diabetic patients helps decrease fetal macrosomia
C-section for any hx of it or diabetes
Shoulder dystocia tx
HELPERR
Call for help Evaluate for episiotomy Legs mcroberts maneuver- what is this? External pressure - suprapubic ?? Enter: rotational maneuvers Remove the posterior arm Roll the patient to her hands and knees
SD treatment
Internal Maneuvers
First line tx?
Last respite maneuvers ?
Internal Maneuvers
◦Rotate anterior shoulder –Rubin’s
Apply pressure to the posterior aspect of the shoulder
◦Wood’s screw maneuver
Apply pressure to the anterior aspect of the posterior shoulder while trying to rotate the anterior shoulder also
◦Reverse Wood’s screw maneuver
Delivery of posterior arm-Now being encourage as first line treatment
Gaskin maneuver
◦Moving patient to hands/knees position
Last resort measures
◦Fracture clavicle
◦Zavanelli maneuver
◦Symphysiotomy
when your baby has their umbilical cord wrapped around their neck
Nuchal cord
the umbilical cord drops (prolapses) through the open cervix into the vagina ahead of the baby. The cord can then become trapped against the baby’s body during delivery.
Causes what on fetal strip?
Tx?
Cord prolapse
Variable and prolonged decelerations
Alpha- c-section
Placental abnormalities
Battedore -normal
Succent uriate lobe - small price separates from the main disc of placenta
Vasa previa -blood vessels lie across the opening of cervix
Abnormal implantation definitions
1.Firm attachment to the myometrium
◦Found in 4% of previas
◦2.Invasion of myometrium
◦3.Invades through myometrium
◦Can invade into bladder/bowel
Placenta accreta
Placenta increta
◦Placenta percreta
Now Known as:
Anaphylactiod Syndrome of Pregnancy
Typically seen in labor or just after delivery
Difficult to determine incidence 2-6 per 100,000
Mortality rate exceeds 60%
◦If sustained cardiac arrest survival rate is less than 10%
Amniotic Fluid Embolism
Amniotic Fluid Embolism
S/s?
◦Hypotension ◦Dyspnea ◦Cyanosis ◦Frothing from mouth ◦Fetal heart rate abnormalities ◦Loss of consciousness ◦Cardiac arrest ◦Bleeding from uterus, incisions, or IV sites ◦Uterine atony ◦Seizure-like activity
If you have had a cesarean delivery (also called a C-section) before, you may be able to deliver your next baby vaginally. This is called vaginal birth after cesarean, or VBAC. Most women, whether they deliver vaginally or by C-section, don’t have serious problems from childbirth.
Risks?
VBAC
Uterine rupture
What is cord prolapse related to?
Amntiotomy
High fetal station
Polyhydramnios
