Unit 1- Intrapartum Nursing Flashcards
1
Q
What are contractions?
ASK
A
- Coordinated and involuntary- Contractions become organized as women approaches term and pattern increases in frequency & intensity
- Uterine muscle-power comes from upper uterine segment
2
Q
What is effacement during the labor process?
ASK
A
Thinning and shortening of the cervix
estimated as a percentage of orignal cervical length
3
Q
What is dilation during the process of labor?
ASK
A
Opening expresed in centimeters– cervix is pulled upward as fetus is pushed down
at 10cm the cervix cannot be felt by the examiner
4
Q
Cervical effacement in a nullipara happens early or late in the process of cervial dilation?
ASK
A
Early
5
Q
True or false: A multipara’s cervix is thicker than a nulipara at any point during labor?
ASK
A
True
6
Q
What is happening to the moms cardiovascular system during each contraction?
A
- Muscle fibers of uterus constrict around spiral arteries that supply the placenta
- Temporarily shunts 300-500 ml of blood back into the maternal systemic circulation
–Supine hypotension possible if women lies on her back
- Temporarily shunts 300-500 ml of blood back into the maternal systemic circulation
7
Q
When should you take a laboring moms vitals?
ASK
A
Between contractions
8
Q
What effects do labor have on a moms resp. system?
ASK
A
- Depth and rate of respirations increase during labor
- Women may experience hyperventilation
- May feel tingling of her hands and feet and numbnesss and dizziness
- Nurse should help slow breathing thorugh relaxation techniques
- breath into paper bag or cupped hands
9
Q
What effect dose labor have on the GI system of mom?
ASK
A
- Gastric motility decreased during labor- can result in n/v
- Women need calories for the work of labor– npo is contraversy
10
Q
Labor has what effect on a moms urinary system?
ASK
A
- Reduced sensation of full bladder
- Full bladder can inhibit fetal desent
- Bladder status should be evaluated throughout labor for distention
11
Q
Labor has what effect on moms hematopoietic system?
ASK
A
- Normal blood loss for vaginal birth is 500ml; cesection is 1000ml anything over is considreded hemorrhage- usually tolerate loss well (reserves from baby)
- Clotting factors (esp. fibrinogen) are elevated in pregnancy
- Increased risk for DVT in pregnancy and PP - ambulation is important
12
Q
How does the fetus respond to placental circulation?
ASK
A
- placental exchange occurs during the interval between contractions
- Exchange of oxygen, nutrients and waste products occur in the intervillous spaces
13
Q
How does the fetus response to the cardiovascular system?
ASK
A
- Heart rate ranges from 110-160bpm
- Rate and rhythm changes may be a result from normal labor or suggest intolerance to labor stress
14
Q
How does a fetus respond to the pulmnonary system?
ASK
A
- Produce lungs fluid to allow normal airway developemnt which decreases near term
- Compression of the fetal thorax at birth clears lung fluid for normal breathing after delievery.
15
Q
What are the 4 p’s that play a major factor during childbirth?
ASK
A
- Powers- contraction and maternal pushing effort
- Passage- Pelvis and soft tissue
- Passenger- Fetus, membranes and placenta
- Psyche- Psychological response to labor and birth influenced by, anxiety, culture, expextations, life experiences, support
16
Q
Power refers to what during the labor process
ASK
A
- Uterine contractions
- Primary force that moves the fetus through the maternal pelvis
- Maternal pushing efforts
- Second stage of labor- contractions continue to properl fetus through pelvis
- Ferguson’s reflex- fetus distends vagina and pusts pressure on rectum so women feel the urge to push and bare down
- Mom starts to crown
17
Q
What is fergusion’s reflex?
ASK
A
It is when the fetus distends vagina and puts pressure on the vagina.. In return the mom feels the urge to push and bear down
18
Q
Passage refers to what during the labor process?
ASK
A
Birth passage
1. Maternal pelivs “True Pelvis”- the most important outcome of labor
2. Bones and joings doin’t readily yield to forces of labor
3. RELAXIN softens cartilage linking pelvic bones near term
4. Soft tissues (cervix and vagina make up the passage way)
19
Q
What are the parts of the “true pelvis” ask
ASK
A
- Inlet- upper pelvic opening
- Mid pelvis- pelvic cavity
- Outlet- lower pelvic opening
20
Q
What are the favorable pelvis types for birth?
ASK
A
- Gynecoid: most common; found in 50% of women; round shape
- Anthropoid: resembles pelvis of antropoid apes: found in 24% of women; oval shape
21
Q
What are the least favorable pelvises for birth?
ASK
A
- Android: resembles the male pelvis; found in 23% of women; heart shaped
- Platypelloid: flat pelvis found in 3% of weomen; flat shape
22
Q
What important to know about the fetal head?
ASK
A
- Bones, sutures adn fontanels will
- Mold and assists in determining fetal position
- Important to know fetal head diameters
23
Q
Fetal lie tells us what?
ASK
A
- Orientation of the long axis of the fetus to the long axis of the women
24
Q
Longitudinal lie indicates
ASK
A
Cephalic or breech
25
Treansverse lie indicates...
| ASK
Perpendicular
26
Oblique lie indicates....
| ASK
Slanted
27
Fetal attitude tells us....
| ask
Relationship of the fetal part to one other
Flexion- desirable- smallest part to move through the pelvis
Extension
28
What are different types of cephalic fetal presentations?
| ASK
1. Vertex- tucked
2. Military- straight forward
3. Brow- eyebrows first
4. Face- thumb sucker
29
What are different types of breech presentation?
| ASK
1. Frank breech
2. Complete breech
3. Footling breech
30
What is fetal position?
| ASK
Relationship of the point of reference (occiput, mentum, acromion, or sacrum) on the fetal presenting part (vertex, face, breech, or shoulder) to moms pelvis
1. Right or Left- presenting part pointing to moms L or R
2. Occiput (O) or sacrum (S)- what part is coming out first
3. Anterior (A), Posterior (P), or transverse (T)- presenting part pointing toward front of moms body (a), towards sacrum of moms body (P) or toward hip (T)
Fetal positions change during labor as the fetus moves downward and adapts to the pelvis contours (cardinal movements of labor)
31
What might anxiety cause during labor?
| ASK
1. May decrease a women's ability to cope with pain in labor
2. Releases catecholamines-inhibit uterine contractility and placental blood flow-slow labor
3. Enhance the perception of pain
32
What is the nurses role during labor?
| ASK
1. Advocate for laboring women and her support person
2. Increase their sense of control and mastery of labor
3. Reduces anxiety and fear
4. Achieve there disired birth
33
What causes labor?
| ASK
Exact mechanisms that initate labor remain unknown. Factors that appear to have a role
1. Changes in ratio of maternal estrogen to progesterone
2. Fetal membranes release prostaglandin
3. Prostaglandins prepare uterus for oxytoxin stimulation
4. Increased secretion of natrual oxytocin
5. Oxytocin receptors in the uterus increase markedly
6. Large quantities of cortisol released by fetal adrenal glands
7. Stretching, pressure and irritation of the uterus and cervix
34
What are premonitory/prodromal signs of labor?
| ASK
1. Braxton hicks contractions
2. Lightening
3. Increased vaginal mucosus secreation
4. Certival softening and slight effacement
5. Bloody show or loss of "mucous plug"
6. Energy spurt or "nesting instinct"
7. Weight loss (slight)
8. Diarrhea, Nasuea
35
What are true labor contractions desribed as?
| ASK
Consistent increase in frequency, duration and intensity with walking
Starts in the lower back and moves around to the lower abdomen
36
Discomfort in true labor is described as...
| ASK
May persist as back pain in some women and increasing intensity and pain
37
In true labor whats happening with the cervix?
| ASK
Progressive effacement and dilation-- most important factor in distingusing between true and false labor
38
The contractions in false labor can be desribed as?
| ASK
Inconsistent in frequency, duration and intenisty. Decrease in frequency/intenisty with walking
39
The discomfort in false labor can be desribed as....
| ASK
Localized in abdomen
More annoying than truely painful
40
What is happening to the cervix in false labor?
| ASK
No significant change in effacement or dilation
41
When should a patient go to the hospital or birth center?
| ASk
1. Contractions- patterns of increasing regulatirty, frequency, duration and intenisty
- Nulip- regular contractions, 5 mins apart last 1 min for 1 hour
- Multip- regular contractions, 10 mins apart, last1 min for 1 hour
2. Ruptured membranes- suspected or certain, contractions or not
3. Bright red vaginal bleeding or heavy bleeding should be evaluated promptly
4. Decreased or absent fetal movement
5. Concerns- severe pain, vision changes, headache, epigastric pain, feeling" something isnt right"
42
Fetal station is defined as...
| ASK
Desent of fetal presenting part in relation to ischial spines
43
Engagement is considered what "station"
| ASK
0 station
widest diameter of the fetal presenting part reaches the level of the maternal ishial spines
44
What are the cardinal movements of labor in order?
| ASK
1. Flexion (cramped)
2. Internal rotation
3. Extension
4. External rotation
5. Explusion
45
What do we need to know about the 1st stages of labor?
| ASK
1st stage of labor is the only stage with phases... 1st phase is the latent phase
1. Cervical dilation and effacement occur
2. Begins with the onset of TRUE labor and ends with complete dilation of the cervix
46
What is the 1st phase of stage 1 of labor?
| ASK
Latent phase
1. dilaton 1-3 cm historically
2. May pass unoticed
3. Sociable, excited
4. Mild contractions ~ 5 mins apart
5. Average dilation- primigrav 1.2 cm/hr ranging 3-4 hours, multip 1.5cm/hr ranging 2-3 hours
6. Prolonged latent pahse- primgrav. >20hours, multipara is >14 hours
47
What is the 2nd phase of stage one labor and what do we need to know?
| ASK
Active phase
1. Begins at 4cm historically
2. Cervical dilation accelerates, and internal rotation begins
3. Contractions 2-5 mins apart, lasting 40-60 seconds moderate intensity
4. discomfort increases
5. Maultiparas progress faster than nuliparas usually
6. Behavioral changes- increasing anxiety, sense of helplessness, becomes more inwardly focused
48
What is the 3rd phase of the 1st stage of labor and what should we know about it?
| ASK
Transition phase
1. Cervix dilates from 8cm to 10cm
2. fetus descents futher into pelvis
3. bloody show increases
4. contractions very strong 1 1/2 to 2 mins apart lasting 60-90 seconds.
5. Women may have the urge to push and bear down (fergusons reflex)
6. Leg tremors, n/v/ are common
7. Woman may be irritable and lose control
8. Actions that were helpful previous now bother her
9. Easily discouraged, oberwhelmed and panicky
10. May say they cant continue
49
What is the second stage of labor and what should we know about it?
| ASK
Second stage- stage of explusion
1. Begins with complete dilation (10cm) and 100% effacement and ends with birth of a baby
2. Length varies depednign on if a pt is a nuli or a mutip or has an epidural
- second stage avg. for prim is 1 hour and a multip is 15 mins
3. Ferguson's relfex- pressure of presenting part on pelvic floor causes involentary pushing response
- May feel need to have a bowel movement or say "the baby is coming" or " i have to push
- volunatary pushing efforts augment inoluntary contractions
- Vulva distends as fetus descents into pelvis
- Crowning of fetal head, may cause a stretching or splitting sensation
- Allow to labor down
- Women often regains a feeling of control
50
What is an episotomy?
| ASK
Incision in perineum made to provide more space for presenting part
1. Median or midline: at midline
2. Mediolateral: cut at 45 decree angle to left or right- used for a large infant
51
What are episotomy indications?
| ASK
1. Shoulder dystocia
2. Face presentation
3. Breech delivery
4. Macrosomic fetus
5. Vaccum or forcepts-assisted births
52
What are the risks of episiotomy ?
| ASK
Infection
Perineal pain
53
what is a laceration & what are the degrees?
| ASK
Tear in the perineum occuring at delivery
1st degree- perineal skin and vaginal mucous membrane
2nd degree- skin, mucous membrane and fascia of the perineal body
3rd degree- Skin, mucous membrane, muscle of the perineal body and extends to rectal sphincter
4th degree- Extends into rectal mucosa exposing the lumen of rectum
54
What is the 3rd stage of labor and what do we need to know about it?
| ASK
1. Begins with birth of baby and ends with the explusion of placenta
2. Shortest stage- average length of 5-15 mins
55
What are signs of placental seperation in the 3rd stage of labor?
| ASK
1. Uterus rises in abdomen as placenta descents into vagina and pushes fundus upwards
2. Cord descends (lenghtens) from the vagina
3. Gosh of blood appears from vagina as blood trapped behind placenta is released
56
A uterus must contract firmly to compress open vessels to prevent ....
| ASK
Hemorrhage
1. Massage the fundus
2. Administer uterotonic medications
57
What are 4 types of uterotonic medicaitons?
| ASK
1. Ocytocin
2. Methylegonovine
3. Carboprost Tromethamine
4. Misoprostol
58
How is Oxytocin given?
| ASK
IV: SLOW IV push or added to fluid (wide open)
IM
59
How is methylegonovine given? Any contraindications?
| ASK
IM: 200mcg q2-5 hours up to 5 doses
PO: 200-400mcg q4-6hours for 2-7days
IV: emergency only **contraindiated for HTN pt**
60
How is carboprost Tromethamine given? Any contraindications?
| ASK
IM: 250mcg in large muscle or directly into uterus (**massive diarrhea**)
Contraindicated: Pts w/ashtma
61
How is misoprostol given?
| ASK
PO/Rectal 200-1000mcg
62
What is the 4th stage of labor and what do we need to know about it?
| ASK
Postpartum begins with delivery of placenta
1. Inital delivery room focus is on
- Assessment and intervention to assist w/uterine involution and prevent postpartum hemorrhage
- Comfort measure- ice pack to episiotomy or lacerations, warm blanket for chills
- Newborn delivery room care
- Promotion of maternal-infant bonding, skin to skin care, breast feeding and family adaptation
63
If birth is imminent who should we obtain records from?
| ASK
Support person if possible and perform quick focused assessment
64
What should be included in our inital nursing assessment for labor admission?
| ASK/REVIEW
1. GTPAL(M)
2. Gestational age
3. FHR & Maternal vital signs
4. Contractions- frequecy, duration and intenisty
5. Sterile vaginal exam and membranes (INTACT/Ruptued)
6. Dip urine for glucose and protien
7. Comfort level
8. Labor and deliver preperation of a patient and support patient
9. notify provider
10. Obtain informed consents
11. IV access and lab tests
65
If membranes rupture should you use lubercation during SVE?
| ASK
ASK
66
How is a SVE procedure done?
| ASK
1. Sterile procedure using a sterile glove
2. Water-soluable lube (no lube if assessing ROM)
3. First and second fingers are inserted into vaginal introitus
- assess for ruptured or bludging membranes
- Assess for cervical dilation, effacement, position and consistency
- Assess for fetal station, presentation and position
67
When are SVE performed?
| ASK
1. Before analgesia or anesthsia
2. Determine labor pregression and when second stage pushing can begin
Frequency of SVE depends on parity, status of membranes and speed of labor
68
If babies head is not engaged can she ambulate?
| ask
NO
69
Spontaneous rupture of membranes (SROM) occurs when?
| ASK
1. Occur before onset of labor- but typically occurs during labor
70
What is SROM?
| ask
1. The protective barrier is lost- organisms have access to the intrauterine cavity
2. Delivery should happen within 24 hours can develope choriamnionitis after 24 hours
71
SROM calls for immediate assessment of what?
1. FHR
2. Document date, time, color, odor and amount of fluid after ROM
72
What is polyhydramnios?
| ASK
1. Excessive amniotic fluid
- Abnormaltities such as TE fistula or GI obstructions
73
What is oligohydraminos?
| ASK
Small amount of amniotic fluid
1. Placental insufficiency or urinary tract abnormatlities
74
How often should you check pts temp after SROM?
| ASK
q2hrs
75
Ambulation is allowed only if the fetus is...
| ASK
Engaged
76
Normal amniotic fluid is?
| ASK
Clear with white flecks (vernix) with mild musty odor
77
Meconium-stained amniotic fluid may indicate...
| ASK
Fetal compromise and should be reported
78
Foul smelling or yellow amniotic fluid might indicate....
| ASK
Chorioamnionitis- should be reported
79
What is PROM?
| ASK
Premature rupture of membranes- PROM- SROM before onset of labor.. Usually before 37 weeks and associated with 1/3 of preterm births
80
How can we assess for ROM?
| ASK
Nitrazine paper
1. SVE performed without lubicant- inserting piece of nitrazine tape into vagina
2. Amniotric fluid is alkaline (7.5); paper truns blue-green to deep blue if postive
3. bloody show or semen being present can kew results.
81
What is a fern test?
| ASK
Speculum exam: assess for fluid in the vaginal vault
Place fluid from vagina vault on glass slide and allowed to dry.
82
What is aminisure ROM test
| ASK
Rapid, non-invasive immunoassay lab test
83
What is artifical rupture of membranes or amniotomy (AROM)?
| ASK
1. Performed by CNM or MD using an amnihook or amnioc
2. Vital to confirm fetal head is engaged prior to AROM
3. Often used for induction or augmentation of labor
4. Allows for internal electronic fetal monitor (FSE) and internal contraction monitoring (IUPC)
84
What are the risks associated with rupture of membrane?
| ASK
Prolapse of the umbilical cord
1. Cord slips down in gush or fluid
2. Cord compressed between presenting part and pelvis creating
- Variable decelerations
- Prolonged decelerations
- bradycardiac FHR
3. Priority assessment after ROM is the FHR
- Assess FHR for at least 1 full min. after ROM
85
What is the nursing responsiblities for the 1st stage of labor?
| ASK/REVIEW
1. FHR- q30. Latent, q 15-30mins, q5-15 min transition- continous FHM if high risk
2. Vital signs
- B/p q1hr. side-lying position, between contractions more frequent if abnormal
- Temperature q.4hr until ROM, then q1hr
3. Contractions-frequency, duration, and intensity
4. Urinte status q2hr, dip glucose/protien q8hrs
5. Labor progress
6. Psychoproprhylactic coping techniques- breathing, exercises, and effleurage
- Hyperventilation- breathing into a sack
7. Comfort
- Patient- oral care, peri care- frequent pad changes
- Offer analgesia/anesthesia in active phase
- Support persons should be included in teaching and support
86
What is the nursing responsiblities for the 2nd stage of labor?
| review/ASK
1. Labor is stressful for both patient and support person
- Involuntary need to push
- Additional force of uterine contraction, rapid fetal descent, enhances cardial movement
2. Monitor FHR w/each contraction
3. Observe perinea area
- Bloody show, amniotic fluid color changes, bulging or perineum and anus
- Visibility of fetal presenting port
4. Continue comfort measures
5. Teach mother and support person
- Pushing positions- squatting, side-lying, high fowlers, lithotomy
- open glottis "gentle pushing" exhale through open mouth while pushing
6. Set up for delivery- delivery table, perineal cleansing, mirror for viewing
87
Bloody show normally indicates mom is dilated to
| ASK
7-8cm
88
Nursing responsiblities for the 3rd stage of labor?
| AKS
1. observe for signs of placenta seperation
2. Palpate fundus of uterus for firmness and location below the umbilicus
3. Administer oxytocin as order following the delivery of the placenta
4. Ovserve for blood loss- if loss is excessive, obtain quantitative blood loss assesment
5. Performed newborn care on mothers abdomen to promote thermoregulation and assist provider with supplies for episotomy/laceration repair
6. Clean perineal area, place ice pack, and apply two sterile perineal pads from front to back
7. Remove both legs simutaneously from stirups
8. Provide clean gown and warm blanket
9. Assist mother into a comfortable position for breastfeeding
10. Allow sibling and family members once mother and support person are ready
89
90
What are adverse effect of excessive pain?
| ASK
1. Increases maternal fear and anxiety resulting in an increase maternal metabolic rate and oxygen demand
2. Poorly managed pain can interfere with bonding, create unpleasent memories effecting future births
3. Creates feels of inadequacy, helplessness, and frustration for the support person
91
What is our goal for pain during labor?
| ASK?
1. Should be a positive birth experience, as absence of pain is unrealistic
92
What factors influence the perception or tolerance of pain?
| ASK
1. Labor intensity, cerivical readiness
2. Fetal position- fetal OP- position- sacral discomfort
3. Pelvic anatomy
4. Fear, anxiety, and fatigue
5. Culture
6. Caregiver instructions
93
What are some non-pharmacologic pain management for labor?
| ASK
Gate control theory of pain
1. Application of gate control
- relaxation
- Cutanous stimulation (effleurage
- Hydrotherapy
- Mental stimulation
94
What are advantages to non-pharmacological pain management?
| ASK
Do not slow labor
No side effects or risk for allergy
Only realistic option in advanced or rapid labor
Limitations- level of pain control is not achieved
95
What are different types of breathing techniques for laboring moms?
| REview
1. Cleansing breath
2. Slow paced breathing
3. modified paced breathing
4. Patterned-paced breathing
5. Breathing to prevent posting
6. Second stage- open glottis pushing
96
What are some pharmacologic pain management we can provide a mom in labor
| ASK
1. Analgesia
- Medication-pain relief, relaxation and CNS depression
- Given mid-active phase of labor (4cm)
- If given earlier can slow labor and if given late in labor can cause neonatal depression
2. Anesthsia
- Local-episiotomy or perineal site (Perineal block)
- Reginal block- epidural, spinal- intrruption of nerve impulses, cause vasodilation and hypotension
- General anesthsia
Examples: morphine, demorol, fentanyl, spinal, epidura;l
97
Prior to given pain medication what assessments should we do on a patient in labor?
| ASK
1. Acute pain level
2. Brith plan- Plan in place for medication?
3. Signs of decreasing coping or increasing anxiety
4. Assess pt
- Vital signs and FHR
- Labor/cervical progression
- Last time and amount of ingestion
- Labs, hbg, hct and clotting time
- Hydration status
- S/s of infection
98
Interventions before analgesics in a laboring mom includes?
| ASK
1. Determine patient/family desire for anagesia
2. Assess phase and stage of labor
3. Baseline vital and FHR
4. Obtain order for medication
- Butorphanol, fentanyl, meperdine, nalbuphine
- Explain purpose of medication
5. Administer IVP slowly at start of contraction-- contricted uterine blood flow so less goes to fetus
6. Opiod antagnosts- narcan
7. Adjunctive drugs-antiemtic
99
IV anagesics: onset peak and duration
| REVIEW
Onset:5mins
Peak: 30
Duration: 1 hour
100
IM anagesics: Onset,peak and duration?
| REVIEW
Onset: 30 mins
Peak: 1-3 hours
Duration: 4-6 hours
101
Intervention after administering analgesics is are
| ask
1. Assess pain level response
2. Monitor vital signs, FHR & Contractions
- q 15 mins for 1 hour
3. Monitor for bladder distention
4. Decrease environmental distractions
- Darken room, tv, reduce visitors
5. Not time of between medication and delivery
- Delivery time during peak absorption time
- Obtain order for narcan
- Be prepared to recesitate infant
102
What is local anesthia and what is its role in labor
| ASK
injection of lidocaine in perineal body
Utilized for repair of episotomy or lacerations
103
What is a pudendal block?
| ASK
1. Injection of anesthetic to numb pudedal nerve
- Anesthetizes the vagina and perineum
- Does not block the pain from contractions
104
What are complications related to a pudendal block?
| ASK
Complications include
1. TOxic reaction to the anesthetic
2. Rectal puncture
3. Hematoma
4. Sciatic nerve block
105
What is an epidural?
| ASK
It is administered by an anesthesiologigy or nurse- anesthetis
Local anesthetic agent often combined with opiod
106
Epidurals are contraindicated when...
| ASK
Coagulation defects, allergy, infection in injection space and hypovolemia
107
What are adverse affects of epidurals?
| ASK
1. Maternal hypotension is caused by vasodilation below block
2. Bladder distension- often requires cath
3. Catheter migration
4. Prolonged second stage
5. Csection births
6. Maternal fevers
7. Pruitis- esp. if narcotics are given
108
Epidural nursing assessment and interventions include?
| ASK
1. Maternal hypotension is the most common complication
- Preload with 500-100ml of warmed LR or NS
- Nurse remains at bedside continously
- Assess blood pressure every 2-5mins for 30 mins
- Monitoring fetal heart rate
- Metalic tast, ringing in the ear- possible injection into bloodstream
Correct hypotension with
1. Left lateral position
2. Fluid bolus
3. Medication- ephedrine 5-10mg IV- remain alert, hypotension can occur again at any time.
109
What is a subarachnoid (spinal) block?
| ASK
1. Simpler procedure; no catheter left in place
2. Performed just before birth primarly for csections- dense block last 2 hours
3. Local anesthetic combined with an opiod to proide about 24 hours of relative comfort
110
What are adverse effects of a spinal?
| ASK
1. Maternal hypotension(most common)
2. Bladder distension- requires cath placement
3. Post-dural puncture headache (later)
111
How can you tell the difference between a spinal headache and a posteclampsia head ache?
| ASK
If you set a patient up and their head feels like its going to explode and then lay them back down and thier is relief its likely a spinal headache.
112
What is the purpose of general anasthsia with labor?
| ASK
1. Systemic pain control- involves loss of consciousness, used in cseactions birhts
- Women who refuse spinal or epidural
- Inadequate epidural or spinal for surgical incison
- Emergency csection
113
What are the adverse effects of general anesthesia?
| ASK
1. Maternal aspiration of gastric contents- cricoid pressure
2. Respiratory depression in mom and baby- resuscitation equipement
3. Uterine relaxation- watch for hemmorhage
114
What can we have mom do to minimize the adverse affects of general anesthesia?
| ASK
1. Clear fluids or NPO if surgery is expected
2. Use cricoid pressure to block esophgus during intubation (nurse)
3. Administer drugs to speed up gastric emptying, raise gastric PH making secretions less acidic
115
How can we minimize the fetal effects of general anesthesia?
| ASK
1. Reduce time from anesthesia to clamping of umbilical cord
2. Minimal use of anesthetics and dedation until the cord is clamped
116
What is induction and augmentation of labor?
| ASJ
Artifical methods to stimulate uterine contractions
Goal being- produce acceptable, effective uterine contractions
117
What are indications of induction or augmentation of labor?
| ASK
1. SROM at or near term without labor
2. Post term pregnancy
3. Chorioamniontis
4. Gestational hypertension
5. Placental abruptions that are small
6. Maternal medical conditions
7. Fetal demise (IUFD)-- once baby dies baby starts breaking down and mom can become very sick if not delivered soon.
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What are contraindications of inducation and augmentation of labor?
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1. Known cephalopelvic disproportion (CPD)
2. Placenta previa or vasa previa
3. Abnormal fetal presentation- breech, brow, face
4. active genital herpes or diagnosis HIV
5. Overdistended uterus- multifetal pregnancy
6. Maternal conditions- heart disease, severe hypertension
7. Previous uterine surgery- classical csection incision
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What are the risks of induction and augmentation of labor?
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1. Excessive uterine activity
2. Uterine rupture
3. Maternal water intoxication
4. Chorioamnionitis
5. Csection birth
6. Postpartum hemorrhage
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What is the bishop score and what do we need to know about it?
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Performed prior to scheduled inductions
1. Assesses whether the cervix if favorable for induction of labor
2. Score of 6 or less indicates unfavorable
3. Cervical ripening a process to soften and dilate the cervix is recomended
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What is labor augmentation?
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Stimulation of ineffective UC after onset of spontaneous labor to manage labor dystocia
Lower doses oxytocin are required because cervical resistance is lower
Same precautions apply as with induction of labor
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What are some complimentary therapies for inducing or agumenting labor?
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1. Herbal preps (evening primrose)
2. Bowel stimulation
3. Nipple stimulation
4. Sexual intercourse
Remember 3Ns
nyloid
Nipple
Nookie
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What is cervical ripening
| ASK
Dinoprostone vaginal insert- placed by RN
1. 10mg time release insert is placed in the posterior fornix
2. left in place for up to 12 hours and removed by rn
3. Place patient recumbent (w/wedge under hip) or lateral for 2 hours after insertion
4. Requires continous FHM
5. Oxytocin may be started within 30-60mins of removal
6. Not recommended for women with previous uterine scar
7. Tachysystole can occur- remove insert if it does
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What should we know about inducation and augmentation of labor in regards to misoprostol?
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1. 25-50mcg vaginal or oral 25mcg can be repeated q6h
2. Higher doses associated with tachysystole
3. Oxytocin may not be started until 4 hours after last dose
4. Never use w/women with previous uterine scar
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What are mechanical methods of inducing labor and augmentation?
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1. Transcervical ballon cath
2. Membrane stripping
3. Hydroscopic inserts- laminaria
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What do we need to know about ocytocin
| review
Oxytocin is pwerful; most common drug given for induction/augmentation of labor
Oxytocin receptor sites become more desenstized to prolonged exposure
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What do we need to know about oxytocin administration?
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1.Diluted in an isotonic solution- decreased risk of water intoxication
2. always administed as a secondary piggy back by infusion pump
3. start slowly; titrate gradually based on maternal and fetal response
4. continous FHR required before start- obtain a 20min baseline strip of uterine activity, fetal heart rate baseline and variablity
5. Must decrease or stop infusion for tachysystole or abnormal FHR patterns
6. Response occus in 3-5mins, half life is 10 mins
- uterine contractions q 3-5mins lasting less than 90 seconds
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What are our nursing responsibilites for abnormal response to oxytocin?
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Nursing actions for cat II FHR pattern or tachysystole
1. Maternal repositioning
2. IV fluid bolus of at least 500ml of LR
3. Administer oxygen at 10l/min by non rebreather
4. Decrease rate of oxytocin by half
5. STOP oxytocin if no response and pattern persists
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What are some nursing actions for tachysystole with a cat II or cat III FHR
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1. Stop oxytocin
2. IUR plus consider terbutaline/brethine
3. womens response are individualized
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What is a external version?
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1. Turn the fetus from breech, oblique or transverse presentation to cephalic
- 37+ weeks, tocolytic is given to relax uterus
- RHo D immune globin given if women is rh neg
- EFM-minimum of 1 hour after version
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# W
What is an internal version?
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change the position of a second twin in a vaginal birth
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Why should we avoid oxytocin in patients who have severe cardiac issues?
It is an antidiuretic so the more oxytocin we give the more of a chance mom will retain the fluid
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What are contraindications for versions?
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1. Uterine malformations
2. Previous csection scare
3. Placental abnormatlities
4. CPD
5. Multifetal gestation
6. Oligohydraminors, ruptured membranes
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What are the risks of versions?
| ASK
1. umbilical cord entanglement
2. Placental abruption
3. Fetal compromise
- emergency cesection
4. Fetal and maternal blood mixing
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What is an amnioinfusion?
| ASK
Instillation of isotonic fluid though an IUPC into uterus to respore amniotic fluid volume-used to decrease incidence of variable decelerations
1. Infusion pump at 120-180ml per hour
2. utilize warmed solution
3. avoid uterine distension
- weigh under pads (also keep pt clean and dry)
- monitor for increased uterine resting tone or no relaxation
- Stop infusion if overdistension occurs
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What are maternal indications for the use of forceps or vacums?
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1. Cardiac or pulmonary disease
2. Exhaustion, ineffective pushing
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What are fetal indications for the use of forceps or vacumn?
| ASK
Failure of presenting part to descent in the pelvis
Partial seperation of the placenta, often with non-reassuring FHR patterns
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What are contraindications of using forceps/vaccum?
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1. acute materinal conditions
2. Severe fetal compromise
3. High fetal station/cephalopelvic disproportion
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What are the risks of using forceps or vacuums during delivery?
| ASK
1. Maternal and fetal/neonatal trauma
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What are nursing consideration to do before using a vacuum or forceps in delivery?
| ASK
1. Prior- empty bladder, adequate anesthisa, cervix is completely dilated
2. Following- assess for maternal and neonata trauma
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What are indications for csections?
| ASK
1. labor dystocia or CPD
2. Hypertension, if prompt delivery is indicated
3. Condition labor is not avised (diabetes, heart disease)
4. Active gential herpes or HIV with high viral load
5. Previous uterine incision
6. Persistent/ indeterminate/abnormal FHR pattern
7. Prolapsed umbilical cord
8. Fetal malpresentation-breech transverese
9. Placental abruption or previa
10. Maternal req.
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What are contraindications to a csection?
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1. fetus too immature to survive
2. Current fetal demise
3. maternal coagulation defects that could cause harm to mother during surgery
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What is the maternal cesection risk?
| ASK
1. Infection- endomyometritis
2. Hemorrhage
3. Urinary tract trauma or infection
4. Anesthesia complication
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What risks does a cesection pose to a newborn?
| ASK
1. Injury- laceration, bruising,fractures, or other trauma
2. inadvertent preterm birth
3. Transient tachypnea of the newborn
4. Persistent pulmonary hypertension
5. lung immaturity
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csection birth prep includes?
| ASK
1. labwork- blood available for transfusion if mother is at risk for hemorrhage
2. Informed consent- csection, anesthesia, support person attendace
3. notify- team
4. Prophalactyic SCIP anitbiotic-IV dose of ampicillin/cephalasporin giving within 30 mins of incision
5. pubic hair clipped from about 3 inches above the mons pubis along with fronts of upper thighs
6. Spinal, epidural or combined is commonly used; general anesthetic for emergencies
7. wedge under the hip for left tilt- prevent supine hypotension and promote placental blood flow
8. indewlling catheter inserted after regional block established but before surgery
- Emergency or general cath must be done before induction
- sterile abdominal prep is done just before sterlie draping
- position support person at the head of the bed by mother
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what is our nursing responsibilites for csections post care
| ask
1. observe mother for hemorrhage
2. Vital signs q 5-15mins in PCU
3. assess bladder and fundus
4. Promote comfort
5. Postoperative care
6. Care of baby
- RN for each baby- care is transistion care
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