Unit 3 Flashcards

Question

What to include in Physical Exam during First Stage of Labor What affects the speed of dilation?

Answer 1

Fetal Heart Rate - put mom on monitors first Contractions - Primary Powers Vaginal examination (what tells us if she is in true labor) - Dilation, Effacement, Station: 3/100/-2 - What affects cervical dilation? - Movement: the more a woman moves, the faster dilation occurs - Multips dilate faster than nullips - Stress: slows down dilation - The weight of the baby and amniotic fluid can affect dilation - Force of the presenting part - Scarring of the cervix (biopsy of cervix, or part of cervix remove) slows down dilation - Multips tend to dilate and efface together - In nullips, effacement usually happens faster than dilation

Answer 2

Analysis of urine specimen Blood tests: CBC, H&H, type and screen IV access: 18 gauge needed (for blood), green. 20 gauge = pink

Answer 3

General hygiene - Use pads or towels and change them on a regular basis; this also prevents infection Nutrient and fluid intake - Oral intake: usually NPO, limited to ice chips only - Intravenous intake (b/c they are NPO) Elimination - Voiding: want the bladder to be empty on a regular basis - Usually when the water has broken, the woman can not get up to go to the bathroom because the cord could come out. Use bedpan or catheter. - Catheterization - usually placed if mom has anesthesia (depending on hospital and HCP, you use foley cath or straight cath every 2-4 hours) - Bowel elimination: normal to happen during labor Ambulation - Positioning: Semirecumbent, Lateral, Upright, Hands-and-knees (really good for moms experiencing back labor (baby is OP)), Peanut Ball (can help open up hips) Support: - Partner, Doula, Others

Answer 4

Visceral Pain Pain that is caused by... Uterine ischemia; usually occurs in the lower portion of the abdomen Distention of the lower uterine segment; Stretching of the cervical tissue and the pressure on the pelvic floor muscles and pressure exerted on the nerves The woman is free from pain when contraction is done

Answer 5

- Perception of pain: affected by stress, multip or nulip, culture, age, previous personal experience with pain, support available, preparation, the desire or no desire to have a natural birth - Expression of pain: BP and HR increase, RR increase or may have hyperventilation, diaphoresis, N/V, crying - Influencing factors: Affected by how tired mom is, how long she has been in labor, how big the baby is, how fast the whole process is occurring, anxiety, culture, previous experience - Management

Answer 6

The more support a woman has, the better the experience an the less pain they have during labor • Provide companionship and reassurance. • Offer positive reinforcement and praise for her efforts. • Encourage participation in distracting activities and nonpharmacologic measures for comfort. • Give nourishment (if allowed by obstetric health care provider). • Assist with personal hygiene. • Offer information and advice. • Involve the woman in decision making regarding her care. • Interpret the woman’s wishes to other health care providers and to her support group. • Create a relaxing environment. • Use a calm and confident approach. • Support and encourage the woman’s support people by role-modeling labor support measures and providing time for breaks.

Answer 7

- Individuals present: how they communicate; their philosophy of care, including a belief in the value of nonpharmacologic pain relief measures and in the woman’s specific birth plan; practice policies; and quality of support - Physical space: Should be safe and private, allowing the woman to feel free to be herself as she tries out different comfort measures. Stimuli such as light, noise, and temperature should be adjusted according to her preferences. The environment should have space for movement and equipment. The familiarity of the environment can be enhanced by bringing items from home

Answer 8

- When starting a contraction, it is helpful for the woman to take a “cleansing breath” in through the nose, out through the mouth; She can do this at the beginning and end of the contraction - Slow-Paced Breathing: IN-2-3-4/OUT-2-3-4/IN-2-3-4/OUT-2-3-4… - Modified-Paced Breathing: IN-OUT/IN-OUT/IN-OUT/IN-OUT… (avoid hyperventilation) - Patterned-Paced or Pant-Blow Breathing: 3:1 Patterned breathing IN-OUT/IN-OUT/IN-OUT/IN-BLOW (repeat through contraction) or 4:1 Patterned breathing IN-OUT/IN-OUT/IN-OUT/IN-OUT/IN-BLOW (repeat through contraction)

Answer 9

Effleurage - light stroking of the abdomen used in conjunction with breathing during contractions Counterpressure - steady pressure applied by a support person to the sacral area with a firm object (e.g., tennis ball) or the fist or heel of the hand. Heat: Warmed blankets, warm compresses, heated rice bags, a warm bath or shower, or a moist heating pad can enhance relaxation and reduce pain during labor. Cold: Cold cloths, frozen gel packs, or ice packs applied to the back, the chest, and/or the face **Don’t use heat or cold for too long, 15-20 min maximum

Answer 10

Promotes sleep, relieves anxiety Could also lead to a longer latent phase Most common used sedative: Phenergan (can also help with N/V)

Answer 11

Only want to use these once labor is well-established (usually 4 cm) Remember these readily cross the placenta and can lead to decreased RR, decreased LOC in both mom and baby. We do not want this to happen to baby, there is a cut-off point where we don’t give this medication. We want to give these meds IV NOT IM; to lower the amount the baby gets, give the medication during a contraction. Opioid agonists: Demerol, fentanyl are commonly used - Demerol can cause N/V - Fentanyl works faster but doesn't last as long Opioid agonist - antagonists: - Usually provide pain relief - Don't cause as much respiratory depression and N/V - Can make you real tired - Nubain, Stadol

Answer 12

- Typically used for C-section - Feel relief within 5-10 min - Works on T6 or nipple line down to the feet - Only last 1-3 hours - Only One dose (a shot) - Mom is Completely numb - Need a foley cath

Answer 13

- Works on T10 down to the feet (if used for a c-section, it starts at T8) - Given continuously through catheter - You are still able to move and the pressure is not able to go away (baby’s head). “Feeling like you are about to have a bowel movement” = baby about to come out - Foley or straight cath

Answer 14

Low BP Itching Limited movement Prolong the second stage of labor (pushing of the baby)

Answer 15

Maternal hypotension with decreased placental perfusion Interventions: - Turn left lateral - left tilt (lay mom back 15-45 degrees and place a pillow or wedge under one hip) - IV fluid bolus - O2 by nonrebreather at 10-12L/min - Elevate legs - Notify MDA, CRNA, OB - Medications (don’t need to know) - Monitor maternal VS and FHR Decreased BP, fetal bradycardia, absent/minimal variability Impaired placental perfusion Ineffective breathing pattern - issue with where the spinal or epidural got placed, if it goes too far up, it can affect mom’s respiratory system

Answer 16

Advantages - Ease of administration - Absence of fetal hypoxia - Mother is awake - Muscular relaxation - Non-excessive blood loss Disadvantages - Medication reaction - Hypotension - Ineffective breathing pattern - After birth: Bladder/uterine atony Postdural puncture headaches (Spinal HA): caused by leakage of CSF from the site of puncture of the dura mater (membranous covering of the spinal cord) - Prevention/Tx of Spinal HA: hydration, bedrest, medications can be given - Tx of severe spinal HA: Epidural blood patch (taking the mom's blood out and injecting it into the leakage to clot it)

Answer 17

Advantages - Alert - Comfortable - Participative - Relaxed - Intact airway - Partial motor paralysis - Small effect on fetus Disadvantages - Biggest one: Mom can’t move her legs well during labor - Takes a while to wear off - CNS effects - Loss of control of labor - ‘High spinal’ (epidural accidentally injected into subarachnoid space -> resp arrest) - Severe hypotension - Urinary retention (hard for mom to “feel” like she needs to go)

Answer 18

Assess maternal VS, hydration, labor progress, FHR (20 min) - Know mom’s baseline VS Make sure mom is hydrated - IV fluid bolus Lab results (Hct) - H&H and platelets (for clotting) Assess pain level Assess need to void

Answer 19

Assist with positioning - Hold hands on mom’s shoulders - the shoulders need to be relaxed - Chin needs to be to chest - Lower back need to pushed out Verbally guide through procedure Monitor VS and FHR Have O2 and Suction available

Answer 20

Check pain level Make sure bladder is empty Help with position changes Left tilt for hypotension Fluid bolus available for hypotension

Answer 21

Maternal hypotension Anticoagulant therapy/Bleeding disorder Infection at site Allergy - “-caines” are used, it is rare for anyone to be allergic to it Some cardiac conditions Thrombocytopenia

Answer 22

Begins with mom must be fully dilated (10 cm) and fully effaced (100%) and ends with birth of the baby Two Phases Latent: Not actively pushing; not every patient has a latent phase - Sometimes the station isn’t good enough to start pushing, mom may need to be sat up Active: Actively pushing

Answer 23

Want mom to have her hands behind her knees, chin to chest when pushing If mom has epidural, she will need help with leg movements Secondary Powers - pushing during second stage of labor - What can help mom push a baby out? If she feels pressure in her bottom, like she’s about to have a bowel movement - Want to push with contractions - Relax in between contractions and pushing - Nullips tend to have to push longer - Epidural can make pushing take longer - Pushing affected by size of baby - smaller baby is easier to push out - Position of the baby - OA is easier to push out than OP

Answer 24

Pain felt in second stage of labor Localized pain concentrated in a certain area - “ring of fire” Intense, sharp, burning pain Vaginal tissues are opening Ring of fire is felt in perineum area Some women say pushing made the pain better Not as much relief between contractions at this point

Answer 25

Fetal heart rate and pattern - The nurse must check the FHR regularly Baby warmer: need oxygen, suction, etc before baby’s delivery Support of father or partner -> may get queasy Once the woman is positioned for birth either in a birthing room or delivery room, the vulva and perineum are cleansed The nurse helps stretch perineal tissue while pushing (helps with lacerations)

Answer 26

- Need to note the exact time the head is fully delivered - After that, you need to note the exact time when the rest of the body comes out - Immediately assess the newborn Suction the mouth before the nose What happens next depends on how the baby is doing Next, the HCP clamps the cord

Answer 27

1. Engagement: biparietal diameter of head passes the pelvic inlet - Nullips experience engagement before labor - Multips experience engagement during labor 2. Descent: progress of presenting part through pelvis - Measured by station of presenting part 3. Flexion: fetal chin brought closer to the chest 4. Internal rotation: fetal head rotation begins at ischial spines and complete when presenting part reaches lower pelvis - We want the baby to be OA 5. Extension: head emerges by extension – first occiput, then face and finally chin 6. External Rotation: fetal head rotates further as shoulders engage and descend similarly to the head - Anterior shoulder then posterior shoulder 7. Expulsion: head and shoulders lifted up; rest of body delivered by flexing laterally in direction of symphysis pubis

Answer 28

1st degree: External tear occurs in the skin and initial mucus membranes; some do not need to be repaired 2nd degree: External tear in muscle and fascia of the perineal tissues; need to be repaired 3rd degree: Continuous to external anal sphincter muscle 4th degree: Extends completely through the anal sphincter and the rectal mucosa; involves external and internal sphincter muscles Vaginal and urethral Cervical

Answer 29

Risk factors that lead to cervical tears - Fast labor (precipitous labor), labor from onset to delivery is 3 hours - Not pushing well - Big baby - Previous lacerations - Younger and older mom - Small mom - Nutritional status of mom - Cervical scarring Dangerous because there is a lot of bleeding that is hard to stop How to avoid a cervical tear - Do not let mom push until she is fully dilated and effaced - Cervical scarring can cause a tear; mom may need a C-section

Answer 30

HCP makes an Incision in the perineum to enlarge the vaginal outlet These sometimes have to be done to get the baby out More likely to lead to severe lacerations

Answer 31

Birth of the baby until the placenta is expelled - Usually about 30 min - After 30 min, HCP intervenes - The longer the placenta stays in, there is risk for infection and hemorrhage Make sure the fundus is firmly contracting - Uterus needs to keep contracting after labor -> “cramping” - Helps get placenta out - Contracted = less bleeding Administration of Oxytocin - If the placenta is not coming out, oxytocin can be given Placental examination and disposal Examination of perineum and need for repair

Answer 32

The fourth stage of labor begins with the expulsion of the placenta and lasts until the woman is stable in the immediate postpartum period - Risk factors for postpartum hemorrhage: Precipitous labor, a large baby, grand multiparity, or induced labor - Postanesthesia recovery: Activity, respirations, blood pressure, level of consciousness, and color assessed every 15 min - VS: Assess pulse and bp every 15 min the first 2 hours. Assess temp every 4 hrs for the first 8 hrs after birth and then at least every 8 hrs - Fundus: Assess fundal height. Assess if it's firm or boggy (if boggy, massage) - Lochia: Assess lochia on perineal pads and on the linen under the mother’s buttocks. Determine its amount and color; note the size and number of clots; note the odor. - Bladder: Assess distension, assist woman to void, catheterize if necessary - Perineum: Assess the episiotomy or laceration repair for redness (erythema), edema, ecchymosis (bruising), drainage, and approximation (REEDA). Assess for the presence of hemorrhoids.

Answer 33

Preterm birth: the baby was physically delivered before 37 weeks Preterm labor: contractions causing cervical dilation before 37 weeks

Answer 34

• Young or old maternal age • Limited education and low socioeconomic status • African-American race • Late entry into prenatal care • Prepregnancy underweight (BMI < 19.6) and prepregnancy obesity (BMI > 30) • Poor nutritional status -> infection • High levels of personal stress in one or more domains of life • Cigarette smoking, substance abuse • Incompetent Cervix • Uterine anomaly • History of genital tract colonization, infection, or instrumentation • Bleeding of uncertain origin in pregnancy • History of a previous spontaneous preterm birth between 16 and 36 weeks of gestation • Use of assisted reproductive technology • Indicated Preterm Birth in moms with: Preexisting or gestational diabetes, Chronic hypertension, Preeclampsia; Seizures, thromboembolism, asthma, HIV, smoking; fetal disorders; advanced maternal age

Answer 35

Rhythmic lower abdominal cramping (with or without diarrhea) Backache (constant, dull, aching) Increased vaginal discharge (change in type of discharge: mucus, bloody, watery) Leaking amniotic fluid (ruptured membranes) Vaginal spotting Cervical effacement and dilation

Answer 36

Recognize it early Education!!! - Empty bladder on a regular basis, hydration, rest - If having symptoms of PTL -> try these things at home (hydration, rest, empty bladder, take tylenol) - Call HCP for: not feeling fetal movement, rupture of membranes

Answer 37

In the hospital - Calculate gestational age (LMP, ultrasound) - Fetal monitoring: are there decelerations? - Palpation of contractions - Mom can go home - Medications At home - Bed rest/ Activity Restriction - Sexual Activity -> “pelvic rest” - Home Care and “modified bed rest”

Answer 38

1. Terbutaline - Can give if mom is having too many contractions in labor - SubQ, usually given in arm - Onset: 30 sec- 1 min - Smooth muscle relaxant -> can lead to dyspnea, tachycardia (like using an inhaler) 2. Nifedipine - Calcium channel blocker - Inhibits smooth muscle contractions - Side effects: low BP, flushing - Mom can go home on this med, take it by mouth 3. Magnesium Sulfate - Relaxes the CNS - Side effects: altered LOC, respiratory depression, bradycardia, diminished reflexes, urinary retention (should be 30 mL/hr) - If breaths <12/min, stop the mag - Give mag with regular fluid (LR); sometimes must have catheter with urometer - Have O2 ready at all times - Assess cardiac, respiratory, neurological systems - Antidote: calcium gluconate 4. Betamethasone - IM injection - Promotes fetal lung maturity -> start producing surfactant

Answer 39

PROM: Spontaneous rupture of membranes at any gestational age Preterm PROM: Spontaneous rupture of membranes before 37 weeks Big risk factor: poor nutritional status -> infection Chorioamnionitis: Bacterial infection of the amniotic cavity Look for infection: - Fever - "COAT" of amniotic fluid -> malodorous fluid, cloudiness in fluid, - Maternal and fetal tachycardia - Fundal tenderness Treatment - Fluids, IV antibiotics, Tylenol for fever

Answer 40

More than 5 contractions in 10 minutes or occurring less than 2 minutes apart The contractions are painful and not doing anything to the cervix (not causing cervical dilation) Weak, inefficient causing no cervical dilation Interventions: Stop pitocin, fluids, eating a small snack or meal, therapeutic rest

Answer 41

Less than 2 or 3 contractions in 10 minutes Very weak contractions that are not doing much (not causing cervical dilation) HCP may need to do artificial rupture of membranes Give pitocin Can be due to malposition of baby or CPD

Answer 42

CPD: The head of the baby and mom’s pelvis is not proportionate to each other (Big head, small pelvis or normal head, abnormal pelvis) - Can be a result of diabetes, obesity - Can be diagnosed prenatally Malposition: Fetus changes position (OP aka sunny side up) Malpresentation: Fetal presentation is something other than head first (breech) Precipitous Labor: From onset of contractions to time of birth, labor is less than 3 hours

Answer 43

Risk factors for dysfunctional labor patterns - Obesity - Diabetes - Poor nutrition Things that can occur during dysfunctional labor pattern - Abnormal FHR patterns associated with hypoxia - Lacerations

Answer 44

Version: turning the fetus from one presentation to another The baby can be rotated externally or internally External: membranes still intact Risks: nuchal cord, abnormal FHR patterns -> hypoxemia, placental separation from uterus Monitoring is important*** Mom usually has IV in place

Answer 45

The chemical or mechanical initiation of uterine contractions before their spontaneous onset for the purpose of delivering the baby The only way you can have a baby by choice before 39 weeks is if you have a medical condition (preeclampsia, gestational hypertension, chronic hypertension, any type of diabetes, IUGR) Procedures and medication - Cervadil, primrose oil, castor oil - Foley balloon - mechanical (pulls on cervix) - Intercourse - Stripping the membranes - stripping a layer induces contractions (not breaking water) - Helps soften cervix and start dilations (maybe to 3 cm)

Answer 46

“Oxytocin” used to induce or augment labor - Augmentation: Labor has started naturally, but it needs a little push - Gets contractions stronger and closer together - Hospital policies on titration Complications - Decelerations - Placental separation from uterus - Uterine rupture - Hemorrhage

Answer 47

Indications - Mom keeps pushing, but baby won’t come out (slow) - Baby stuck in awkward position - Mom doesn’t need to push a lot because she has a cardiac issue - The baby rotated the wrong way - Fetal heart rate affected by mom pushing Postpartum Care - forceps -> Mom: Look for bleeding and lacerations (internal vaginal wall) - Forceps -> Baby: bruising on the face, could have lacerations Vacuum Assisted Delivery - More common and safer - Performed by physician - Placing the vacuum on the hard part of the baby’s head - Baby could have hematoma or swelling of the head

Answer 48

Family centered care = THE GOAL Consented by OB MD and anesthesia NPO 8 hours prior to surgery Labs and IV start Foley Medications Shave the incision site SCDs applied Removal of jewelry, nail polish, contacts Keep support person at bedside Education: what to expect before, during, after

Answer 49

OR is normally in the L&D unit Support person continues to be at bedside (if mom is awake, but not if mom is under general anesthesia) Anesthesia performed -> most of the time a spinal is done Position on OR table Keeping mom informed Nursery and pediatrician present for infant

Answer 50

Incisions - Lower uterine transverse cesarean (LTCS) most common - Vertical skin incision - if placenta is implanted in the lower uterine area - Uterine incisions: transverse, vertical Indications - Baby is breech - Had a previous C-section (elective) - Emergency

Answer 51

Maternal - Aspiration (anesthesia) - Hemorrhage - Injury to surrounding organs (bowel or bladder) - Wound dehiscence or infection - Complications from anesthesia - Scheduled vs. unplanned c section: usually less complications with scheduled c/s Fetal - Hypoxia if poor perfusion from hypotension r/t anesthesia - Injuries by scalpel - Respiratory complications -

Answer 52

Transferred to PACU Pain control, vital signs, bleeding, Is & Os - Pain control: some hospitals give PCA pump, some give pain meds PRN Uterus, lochia, fundus, bladder Postpartum Oxytocin - Everyone gets this To prevent complications: walk around - Early ambulation -> less complications Rest and relaxation

Answer 53

Trial of Labor (TOL) - Observation mother and fetus for 4-6 hours during spontaneous active labor to assess for safety of vaginal delivery - Seeing if mom is going to put herself into spontaneous labor - The most common reason for a TOL is if the woman wishes to have a vaginal birth after a previous cesarean birth - Risk: Uterine rupture Vaginal Birth after Cesarean (VBAC) - 70-80% success rate - Indications for primary cesarean birth, such as breech presentation or abnormal FHR or pattern, often are nonrecurring. Therefore a woman who has had a cesarean birth with a low transverse uterine incision may can do VBAC - Should not be attempted by women with a previous classical or T-shaped uterine incision or extensive transfundal uterine surgery, a previous uterine rupture. or medical or obstetric complications that prevent vaginal birth

Answer 54

Pregnancy extends after 42 weeks Maternal and fetal risks - The placenta stops working - starts getting calcium deposits, the “medium chunks” shrink, not good blood flow -> FHR problems - Fetus passes first meconium in utero - Increased morbidity and mortality for mom and baby Treatment - Mom may need induction

Answer 55

Fetus has passed meconium (first stool) before birth Major risk: Meconium Aspiration Syndrome (MAS) - Can lead to pneumonia in the baby Pediatricians and nursery RN will be in the room at delivery - Suction with meconium aspirator

Answer 56

Anterior shoulder can’t pass under the pubic arch -> the shoulder is stuck Risk Factors - CPD - Abnormal fetal positioning - Big baby (result of diabetes) - Previous shoulder dystocia Signs - “Turtling”: retraction of the fetal head against the perineum immediately following its emergence Interventions - Call for help - Suprapubic pressure - McRobert’s maneuver - pulling the legs as open as you can Potential maternal and fetal complications - Baby’s blood supply is cut off (asphyxia) - Fracture **Why we time when the head comes out and when the rest of the body comes out**

Answer 57

Umbilical cord lies below the presenting part Signs: - Variable decel - Prolonged decel - Heart rate stays down Contributing factors: - Long cord (longer than 100 cm) - Malpresentation (breech or transverse lie) - Unengaged presenting part Emergency Interventions - Examiner puts gloved hand into the vagina and holds the presenting part off the umbilical cord - Someone can put the bed in Trendelenburg - Get mom in hands and knees position

Answer 58

Complete nonsurgical disruption of all uterine layers Risk Factors - VBAC - Pitocin leading to too many contractions - Hx of uterine surgery (fibroid removal) Signs and Symptoms - Fetal heart rate drops - Mom stops contracting and has a lot of uterine pain and tenderness - No external blood loss, but bleeding internally Tx - HCP can repair it, may have to have a hysterectomy depending on severity and blood loss (may need fluid and blood replacement) - Hysterectomy: removing just the uterus Nursing Care - Fluids, blood replacement

Answer 59

TOP: Fetal Heart Rate Pattern - Horizontal lines = 10 bpm - Vertical lines/small square = 10 seconds - Larger box of six squares = 1 minute BOTTOM: Contraction Pattern - Horizontal lines = 5 mmHg - Vertical lines = 10 seconds - Remember, only internal monitors can tell the strength of the contractions. With external monitors, you need to palpate the strength

Answer 60

Frequency - Beginning of one contraction to the beginning of the next - Always expressed in minutes Duration - Beginning of a contraction to the end of the contraction - Always expressed in seconds Intensity: Palpating - The strength of the contraction at its peak Resting Tone: Palpating - Want it to be soft or relaxed, palpate in between contractions Goal: - Have 5 contractions in a 10 minute window - Contractions 2 minutes apart

Answer 61

Average rate during a 10 minute segment (where is the line mostly?) Rounded to closest 5 beats/min Cannot give a range, but a number. It is okay if someone says the baseline is 120 bpm and the other says 125 bpm

Answer 62

Irregular waves or fluctuations in the baseline FHR of two cycles per minute or greater Normal irregularity of the cardiac rhythm 4 categories: absent, minimal, moderate, msrked

Answer 63

Absent: undetectable from baseline - no change in the baseline Not good Can occur due to... - Fetal hypoxemia (->hypoxia -> acidosis) - Genital anomalies - CNS issues - Medications given to mom (CNS depressant) - General anesthesia

Answer 64

Minimal: change in baseline above or below 5 bpm Isn’t always bad, isn’t always good Could be due to - Fetal hypoxemia (-> hypoxia -> acidosis) - Genital anomalies - CNS issue - Medications given to mom (CNS depressant) - General anesthesia - Fetal tachycardia, which occurs due to something else (mom has a fever/infection) - Preterm fetus - Baby is in a temporary sleep state (doesn’t last longer than 30 min)

Answer 65

Change in baseline anywhere from 6-25 bpm above or below baseline Normal!! Predictive of normal fetal acid base balance Intact CNS, well-oxygenated, baby is able to compensate for everything being done to mom in labor

Answer 66

Marked: change in baseline above or below 25 bpm The line looks very jagged Can be okay if it’s just for a short period of time, does not need to continue Can occur due to some medications given to mom

Answer 67

A visually apparent abrupt increase in the FHR above the baseline rate Has to be > 32 weeks: at least 15 bpm (box and a half) above the baseline and lasts at least 15 seconds (box and a half) - It can be bigger than that, but not smaller than that - Returns to baseline within 2 minutes SIGNIFICANCE: Normal pattern INTERVENTIONS: None required Telling us the baby is well-oxygenated, normal fluid-base balance, baby is able to compensate for everything being done to mom in labor.

Answer 68

Mirror image = the lowest point of baby’s heartbeat occurs at peak of mom’s contraction - Lowest point of baby’s heartbeat = nadir The time it starts to the lowest point is almost 30 seconds The baby’s head is coming down and pushing on the pelvic tissues (getting close to delivery, occurs end of 1st stage of labor, can happen in 2nd stage) HEAD COMPRESSION - Uterine contractions - Vaginal exam - Fundal pressure - Placement of internal monitors SIGNIFICANCE - Normal pattern INTERVENTIONS - None required

Answer 69

Nadir of baby’s heartbeat occurs after peak of mom’s contraction Tells us that fetal hypoxemia is occurring is because the baby is not getting enough blood flow (because the placenta has insufficient blood flow) UTEROPLACENTAL INSUFFICIENCY SIGNIFICANCE: Fetal hypoxemia could lead to acidosis INTERVENTIONS (Box 18.5)** Change maternal position - no matter what position she was in (2nd in book) - First thing you should do! Next, change what is causing decels - Sit her up straight, change to laying on right side Correct hypotension IV fluid bolus Palpate uterus for tachysystole Discontinue Pitocin (1st thing in book) O2 at 10 L/min via facemask In laboring moms, we automatically put them on facemask at 10 L (because O2 is going to mom and baby) Notify MD if interventions are not working Perform SVE/ place FSE for more accurate reading Assist with imminent birth if decels continue May have to deliver in a different way

Answer 70

- Uterine tachysystole: more than 5 contractions in 10 minutes, contractions occurring more than often than every 2 minutes (causes cervical dilation) - Maternal hypotension: low BP causes vasodilation -> no good blood flow to placenta - Placental abruption: the placenta has started to detach from the uterus (no blood flow from uterus to placenta) - Hypertensive disorders: high BP causes vasoconstriction -> no good blood to the placenta - Intrauterine growth restriction (IUGR): hypertension causes this; with no good blood flow to placenta while the baby is growing, then the baby can’t grow in the way it needs to - Infection: when we are sick, we don’t get as good oxygenation to where it’s needed; not good blood flow to placenta

Answer 71

Does not have to occur with contractions Abrupt, nadir occurs right after start of decel Onset to lowest point is less than 30 seconds** Can look like a “V”, “U”, or “w” The time it starts and the time it starts coming back up has to be less than 2 min CORD COMPRESSION - Baby moved, contractions, can cause cord compression - When the cord is compressed, blood flow is stopped. SIGNIFICANCE - can occur in up to 50% of all labor patterns; a lot of times they are correctable, and a lot of times they are benign. But when they continuously occur, they cause disruption to the baby’s oxygen supply -> hypoxemia -> acidosis Categorized as… - Mild: down to the 90s - Moderate: between 70s-80s - Severe: 60s or below Seen at the end of the 1st stage and especially in the 2nd stage of pushing INTERVENTIONS Change maternal position from side to side (up, 30-40 degrees) Discontinue Pitocin Administer O2 at 10 L via facemask Notify MD Perform a vaginal exam Assist with amnioinfusion per MD order Assist with delivery if continues

Answer 72

From the time it goes down to the time it ends is greater than 2 min but less than 10 min Significant issue with oxygen supply INTERVENTIONS - Change maternal position - IV fluid bolus Discontinue Pitocin O2 at 10 L/min via facemask Notify MD Perform vaginal exam Assist with birth

Answer 73

FHR baseline > 160 bpm for 10 min or longer CAUSES - Early hypoxemia - Maternal or fetal infection (give tylenol) - Medications - Fetal anemia SIGNIFICANCE: abnormal when associated with late/variable decels or absent variability INTERVENTIONS: dependent on cause - Reduce maternal temperature - O2 at 8-10 L/min via facemask

Answer 74

FHR baseline < 110 bpm for 10 minutes or longer Not usually related to oxygenation CAUSES - Cardiac defect - Viral infections - Hypoglycemia - Hypothermia SIGNIFICANCE: Depends on the underlying cause and accompanying FHR patterns INTERVENTIONS: Dependent on cause

Answer 75

*Interpret EFM every 15 mins when mom in labor, every 5 mins when mom is pushing* Monitoring for accuracy Responsibilities of the RN - Assessing FHR and UA patterns - Implementing nursing interventions - Documenting observations and actions according to the standard of care - Reporting abnormal patterns to the primary care provider

Answer 76

1. Uterine activity: frequency, duration, “soft” or “relaxed” uterus 2. Fetal baseline 3. Variability 4. Accelerations 5. Decelerations Intrauterine resuscitation - Changing positions, increasing fluids, ect. things we do when we see an abnormal pattern in order to improve oxygenation and blood flow to baby Interventions for specific problems: - Maternal hypotension: increase fluids, changing positions, notify anesthesia - Uterine tachysystole: Stop Pitocin, increase IV fluids, give a medication per MD order - During pushing (2nd stage of labor): push fewer times during each contraction, push every other contraction, push when pt feels the urge to

Answer 77

Fetal scalp stimulation: touch baby’s head during cervical exam Vibroacoustic stimulation : muscle relaxer put on mom’s belly above the uterus (vibrates on belly) Do not perform if FHR decels or brady is present

Answer 78

Room temperature isotonic fluid infusion into uterine cavity - IUPC (intrauterine pressure catheter) in place - When we think there is not enough amniotic fluid to cushion cord - Set at rate HCP indicates Relieve intermittent cord compression Risks - The uterus can become distended -> hemorrhage, uterine rupture Monitor how much fluid is coming back out - Weighing peripads

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