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NCB IV > third and fourth stages of labor > Flashcards

third and fourth stages of labor Flashcards

1
Q

third stage

A

from expulsion of baby to expulsion of placenta

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2
Q

average time for third stage

A

5-15 mins

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3
Q

mechanism of placental delivery

A
  1. Uterine size decreases as baby is born placental attachment site decreases.
  2. Placenta squeezed and blood forced into spongy layer of decidua and placenta begins to buckle in.
  3. Oblique fibers tighten around maternal blood vessels, which prevents draining of blood into maternal system.
  4. With contraction, vessels become turgid and burst, causing a thin layer of blood to seep between decidua and placenta
  5. Placenta begins to separate.
  6. Separation usually begins centrally so that a retroplacental clot forms, which may further aid separation. Increased weight helps strip adherent lateral borders. OR
    Placenta detaches asymmetrically at lateral border
  7. Placenta falls into lower uterine segment, fundus changes shape (more Globular)
  8. EXPULSION - Placenta expelled into vagina via uterine contraction. After: uterus should be at or below umbilicus, firm and central.
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4
Q

schultze separation

A

center separation

Usually occurs with a placenta attached high in the fundus
Associated with more complete shearing of placenta and less blood loss

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5
Q

matthews-duncan separation

A

side separation

More common for lower lying placentas.
Associated with more ragged, incomplete expulsion of placenta and more blood loss

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6
Q

types of presesntation

A

fetal surface/schultze presentation
maternal surface/matthews presentation
schultze=baby side first
duncan=maternal side first

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7
Q

most placentas separate _____ and are born _____ OR separate _____ and are born _____

A

schultze/schultze

duncan/schultze

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8
Q

signs of separation

A 
Separation gush
Cord lengthening
Change in shape - more globular
Follow cord up and feel placenta
See placenta
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9
Q

what is the modified brandt-andrews maneuver

A
  1. Take slack out of cord
  2. With suprapubic hand, press in caudally
  3. Cord remains same length means placenta has separated.
  4. If it moves with you, it is probably still in the upper uterine segment
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10
Q

When can you wait for the placenta without intervening?

A

When uterus is firm, not boggy
When there is no bleeding
Frank
Occult - can tell because fundus is rising
When mother’s vitals are stable - esp pulse, BP(pulse shouldn’t get faster postpartum)
When mother is not dizzy, she is lucid

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11
Q

what can assist with expulsion?

A

Push with a contraction
Squatting, birth stool
Nursing, nipple stimulation, or breast pump
Appropriate botanical or homeopathic
Cord traction - guard uterus, follow curve of birth canal, do with a contraction. Need to traction cord posteriorly toward sacrum in order to deliver the placenta around the suprapubic bone; guard uterus while doing this
Pitocin - 1cc (10 units) IM usually in vastus lateralis muscle
Manual extraction

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12
Q

how much blood circulates through the placenta per minute?

A

~400cc

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13
Q

what is normal blood loss?

A
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14
Q

tx of bleeding

A

Rub uterus - only until firm, do not overstimulate
Monitor vitals - pulse will rise first, then blood pressure drops
Nursing, nipple stimulation, or breast pump
Consider Pitocin
Bleeding could mean partial or total separation

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15
Q

examination of placenta

A 
Completeness of lobes and membranes 
Meconium staining 
Infarctions 
Calcifications 
Cord (should attach firmly into placenta)
Size (relative to baby; 1/5 or 1/6 of baby's weight; thick placenta could be missed diabetes)
Smell 
Color (rich dark red)
Weight
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16
Q

placenta abnormalities

A

Bipartite placenta vs. placenta duplex:
Placenta succenturiata:
Placenta membranacea: associated with more fetal demise, still birth, and hemorrhage
Circumvallate placenta:
Placenta acreta: abnormally attached into the uterine muscle and myometrium
Meconium Stained Placenta
Accessory lobe

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17
Q

fourth stage

A

from birth of placenta to 1 hour postpartum (mb up to 6 hours)

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18
Q

postpartum uterus should be

A

firm, central, at or below umbilicus

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19
Q

if uterus to the side consider

A 
mb bladder or uterus is full
Uterine prolapse
Uterine rupture
Undetected twin
Broad ligament hematoma (higher on one side with pain greater on side of the hematoma)
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20
Q

mom should urinate within _ hours of the birth

A

2

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21
Q

pp bleeding 1st hour

A

up to 100cc

> 100cc in 15 mins is abnormal

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22
Q

evaluating/managing blood loss

A

Consider where uterus is and how much total blood loss
Pulse reacts first to blood loss
Document amount of blood loss with change of kotex and chux
Give fluids, replace fluids for energy, keep pt voiding and eating

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23
Q

bonding

A

Important in first 30 minutes
Increases sucking response in baby
Chest to chest, nose to breast

24
Q

checking for tears

A

Remember to look at perineum before birth so you know what is normal for her
Visualize inside and out
Use flashlight, gloves, gauze, warm water, povidone or calendula succus
Assess whether you need to suture
Clean her up – wipe away from perineum

25
Q

hematoma (labial/vulvar) ssx

A

pain, pressure, swelling

26
Q

complications of hematomas

A

results in blood loss
site for infxn
urinary retention (hematoma can block urethra)

27
Q

management of hematomas

A

ice, pressure, arnica

may need to incise and drain as a last resort

28
Q

involution

A

1/2-1 Fingerbreadth/day after delivery

Day 1 - 1 1/2-2 FB below umbilicus or at umbilicus
By Day 14 should be normal (at pubic bone)

29
Q

reasons for subinvolution

A 
Retained membranes
Placental parts
Infection
LGA
Twins
Multip
Age-dependent
30
Q

management of infant during 3rd/4th stage

A 
Dry/Provide tactile stimulation
Suction if necessary
Evaluate HR
Check for respirations
Check color
Assign Apgar
31
Q

fontanelles

A

Not too small, not hard, not bulging
Sunken reflects dehydration
Can measure fontanelles
1-3 cm is normal for ant fontanelle

32
Q

what can you measure from cord blood?

A

Rh factor
Direct Coombs
Paternity
Cord Blood Banking

33
Q

danger signs

A

Respiration - Grunting, nasal flaring, high resps
Poor color - gray, white, blue
Lethargy (most common cause is hypoglycemia)
No urine, poop
High or low temp
Dehydration
Cord - Foul smell, bleeding indicates infection or trauma to cord

34
Q

arsenicum

A

Uterus is inflamed/infected
More a remedy for retention of a piece of the placenta after 4th stage
Woman is anxious, restless, wants company and reassurance.

35
Q

belladonna

A 
Copious, bright red hemorrhage
Blood feels hot and clots quickly
Her face is also red, flushed
She is sensitive to the least jarring, touching the cord etc.
Hour glass contractions.
36
Q

cantharis

A

Spanish fly
Indicated when there are no uc’s to expel placenta
Burning with urination or burning of pelvic area
Entire abdomen is sensitive
Swollen os
Vomiting

37
Q

carbo veg*

A

Scanty bleeding despite retention of placenta
Lack of muscle tone and weak contractions in labor
Women has prenatal hx of:
Fatigue
Anemia
Sluggishness
Weakness

38
Q

caulophyllum*

A

Retention of placenta due to weakness
Primip postpartum atony
Retention may cause flooding due to partial separation

39
Q

cimicifuga*

A

Absence of contractions but tearing pains
She reports soreness all over, even eyeballs
Seems like she is in more physical pain than practitioner can explain

40
Q

crocus

A 
Wildy alternating emotions
Exuberance and gratitude to rage
This is usually a remedy used when a piece of placenta is retained (so maybe a week postpartum)
Hemorrhage is:
dark and slimy
mb with stringy blood
large clots
41
Q

gelsemium*

A 
Exhaustion after delivery
That jasmine state
Sleepy
Dopey,
Unresponsive
Severe lower abdominal pains radiating up and back
42
Q

gossypium

A

Firmly adhered placenta
Or if os closes down after delivery
Remedy helps dislodge stuck placenta

43
Q

hydrastis

A

Used preventatively in women with history of adherent placenta
Use either low potency or mother tincture

44
Q

ipecacuanha

A

Constant nausea
Bright red blood flow
Sharp, pinching pains around umbilicus which shoots into uterus
Worse lying down

45
Q

pulsatilla*

A 
Most common state to get in during pregnancy, labor, and postpartum 
No expulsive contractions
Just spasms of uterus
Intermittent blood flow
Pulsatilla mental/emotional picture
Emotional
Irritable
Worried about baby
Needy
Restless
Weepy
Requests fresh air, cool air
46
Q

secale

A

Constant bearing down pains
No palpable uterine contractions
Or hourglass, ineffective contractions

47
Q

sepia

A

Strong bearing down sensation
With sharp, shooting or burning pains in the cervix
Irritable, snappish, controlling
Flaccid muscle tone

48
Q

viscum

A

Other major remedy for adherent placenta
Bright red blood, partially clotted
Signs of shock
Sacral pains that travel down into pelvis.

49
Q

calc carb (subinvolution)

A

Uterus remains enlarged and low down
Sense of weight and bearing down
Poor pelvic tone
Woman may report inability to stand dt bearing down sensation
Constipation with dry, knotty stools, which take much straining to pass
Woman may be unaware of constipation for long periods of time
She may need to insert vaginal finger to express stool or use perineal counterpressure.

50
Q

carbo veg (subinvolution)

A 
Uterus remains weak and enlarged due to poor tone
Etiology can be:
excessive blood loss
prenatal weakness
anemia
51
Q

lilium tig (subinvolution)

A

Enlarged, bloated feeling of lower abdomen, not specifically uterus
All of pelvis feels swollen
Intense bearing down sensation
She feels the most relief by applying counterpressure to vulva
Urgent desire to move bowels
Aching in low back and knees
All is better when resting

52
Q

natrum muriaticum (subinvolution)

A 
Etiology of prolonged congestion and afterpains
Poor recovery after childbirth
Very sensitive to:
Music
Noise
Loud talking
Unexpected noises
53
Q

pulsatilla (subinvolution)

A 
Enlarged uterus presses against bladder
Pain at end of urination
Pain worse if she delays urinating
Urinary incontinence
Stress incontinence with coughing
Prolapse with no bearing down sensation
54
Q

secale (subinvolution)

A 
Bearing down sensation in entire abdomen
Foul smelling discharge
Thin, dark lochia
General weakness following delivery
Thin, weak, emaciated women, who look older than they are
Prolonged weakness postpartum
55
Q

sepia (subinvolution)

A

Constant bearing down
Venous congestion of uterus and rest of pelvis
Grandmultiparity
Weak, worn out feeling with low back pain

56
Q

ustilago (subinvolution)

A 
Uterus remains enlarged
Flabby with constant aching
Bearing down
Worse with nursing
Os remains dilated and flabby
Pains shooting into thighs

NCB IV (7 decks)

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