Week 2 Material Flashcards
Stage 1 of labor: Latent (Early)
-Longest stage
-Cervix dilates 0-3 cm
-Intensity: mild
-contractions:15-30 minutes
Stage 1: Active Phase
-Cervix Dilates 4-7 cm
-Intensity: Moderate
-Contractions: 3-5 Minutes (30-60 sec)
Stage 1: Transition
-Cervix Dilates: 8-10 cm
-Intensity: Strong
-Contractions: 2-3 minutes (60-90 sec)
Acronym “LAT”
Labor Actively Transitioning
Stage 1 Interventions
-Comfort-warm shower, massage, epidural
-fluids/ ice chips
-quiet environment
-voiding every 1-2 hours
-Encourage participations in care/ keep informed
-Instruct partner in effleurage (light stroking of abd.)
-Enc. effective breathing pattern/ rest between contractions
Stage 2:The baby is delivered
-Starts when the cervix is fully dilated/ effaced
-ends when the baby is delivered
-pushing
Stage 2-nurse interventions
Ice chips/ointment for dry lips
-Praise/ encouragement to mom
-Monitor uterine contractions/ moms V.S.
-Maintain Privacy/encourage rest between contractions
-Enc. effective breathing
-Monitor for signs of birth (perineal bulging/ visualization of head)
Stage 3- The Placenta is Delivered
-5-30 minute=delivered placenta
-Signs of delivery=
+lengthening umbilical cord
+gush of blood
+uterus changes from oval to globular shape
Stage 3-Interventions
-Assess mom’s V.S.
-Uterine Status (fundal rubs)
-Provide warmth to mother
-Promote parental-neonatal attachment
-Examine placenta &verify it is intact, should have 2 arteries and 1 vein
Stage 4:Recovery
-First 1-4 hours after delivery of placenta
Stage 4-Interventions
-Assess fundus
-Continue to monitor temps/ V.S. for infection
-Administer IV fluids
-Monitor lochia discharge (moderate/red)
-Monitor RR depression, vomiting, aspiration if general anesthesia was used
-Watch for postpartum complication (postpartum hemorrhage)
Stage 4: Expected VS. Unexpected
Expected: firm/ at midline
Unexpected: soft, boggy, displaced
Medication: Terbutaline (Brethine)
*beta-2 adrenergic agent
*stop/prevent preterm labor by relaxing uterus, slowing down contractions
*IV, SQ
*AE=tachycardia, palpations, SOB pulmonary edema
*given during stressful time, therefore, AE can increase mom’s anxiety
*Education: what to expect, changes in vital signs
Why are antepartal test done?
-Assess baby in wound
-women that high risk
Biophysical risk factors (high risk)
*genetic, nutritional,medical, obstetrical
Psychosocial Risk factors (high risk)
*Psychosocialfactors—maternal behaviors orlifestyle that have a negative effect on mom orfetus(smoking, caffeine use, alcohol/drug use,psychological status).
Sociodemographic risk factors (high risk)
*Sociodemographicfactors—(access to care,age, parity, marital status, income, ethnicity).
Environmental Risk Factors (High Risk)
*Environmentalfactors-(chemicals radiation,pollutants).
Nurse’s Role in Antepartal Tests
Many women having antenatal tests are at high risk forfetal and maternal complications and are anxious andvulnerable.
-inform, comfort, reassure, psychosocial support, document, establish trust
Antepartal Diagnostic Tests
-Amniocentesis
-Chorionic Villi Sampling
-Magnetic Resonance Imaging (MRI)
-Percutaneous Umbilical Blood Sampling
-Ultrasonography
Ultrasound-How/ Nurse Action
-High frequency waves produce an internal image.
-Interpretation of results
Normal findings include: fetus appropriate gestational age size, viability, position and functional capabilities.
Standard US
fetal presentation and number, amniotic fluid volume, cardiac activity, placental position, fetal biometry (gestational age measurements).
Limited Examination
performed when a specific question needs to be investigated.Ex. in labor, baby is head down
Special Examination
more intense than a standard US, performed when there is an increased risk of an anomaly based on the history, lab results, or the results are limited from standard US.(not routine)
US Procedure
-transvaginal-first trimester, more accurate, uterus in pelvis, obese clients
-abdominal-full bladder to elevate uterus for better visualization
Why ultrasound first trimester?
-confirm intrauterine pregnancy, fetal cardiac activity, multiple gestations, gestational age, uterine structures, missed abortion, tubal, ectopic, aneuploidy (nuchal translucency)
Why US in 2nd trimester
Confirm gestational age, due date, fetal position/ size, placental location, fetal weight, fetal anomalies, vaginal bleeding
Why US in 3rd trimester?
Confirm gestational age, fetal viability, fetal #, position, size, anomalies, condition, growth, vaginal bleeding, visualize for diagnostics. external version
MRI-not routine
*done is suspected fetal anomaly (brain, GI, organ structures)
Procedure - the woman’s abdominal area is scanned.
Interpretation - radiologist will interpret the results.
Nursing Actions - educate, address any concerns,provide information and support
Neural Tube Defects
Caused by location
-anencephaly-up
-spina bifida-down
Anencephaly
top of neural tube fails to close during first month of conception, absence of brain, skull, scalp during embryonic development
Iniencephaly
Uncommon NTD, retroflexion of head w/out neck and severe distorted spine
Umbilical Artery Doppler Flow
-Helpful with diagnosing IUGR, poor placentalperfusion, and in High-risk (HTN, DM, Multiples,PTL).
-Ultrasound while supine - blood flow in color is seen
-Assess placental perfusion - Fetal LIFELINE
Chronic Villi Sampling, when is it done
-performed at 10-13 weeks, aspiration of small amount of placental tissue for chromosomal, metabolic, DNA testing through vagina with speculum.
-Nurse Actions: Assess fetal maternal well-being with Doppler(twice in 30 minutes) after procedure
Amniocentesis
-Needle aspiration through abdominal wall into the uterine cavity to obtain amniotic fluid.
-Genetic testing - 15-20 weeks; ideal is 16-18 weeks
-(Risks) Trauma to fetus or placenta, bleeding, preterm labor, maternal infection, Rh sensitization.
-Nursing Actions:
Administer RhoGAM if indicated, assess maternaland fetal well-being post procedure (with monitoring FHT)
Percutaneous Umbilical Blood Sampling (PUBS)
-Sample offetal blood from umbilical veinto test formetabolic and hematological disorders, fetal infectionand fetal karyotyping
-Performed after a US has detected ananomaly in the fetus (usually 18weeks)
-Have Terbutaline ready as orders in case of uterinecontractions during procedure
Maternal Serum Alpha-Fetoprotein (MSAFP) Screeing
-done at 16-18 weeks, blood draw
-Blood test for AFP - a glycoprotein produced by fetal liver, GI tract and yolk sac in early gestation.
-No risks, increased levels indicate neural tube defects, decreased levels indicate Downs by trisomy 21
QUAD MARKERSCREENING-at 16-18 weeks ideal time for detecting NTD
*Maternal blood screening test that looks for four substances:
-AFP- alpha-fetoproteinis a protein that is produced by the fetus
-hCG - human chorionic gonadotropinis a hormone produced within theplacenta
-Estriol - an estrogen produced by both the fetus and theplacenta
-inhibin-A - a protein produced by the placenta and ovaries
Quad Marker Advantages
60-80% of Downs can be detected, 85-90% of open NTDs aredetected, no risk, and Trisomy 18
DAILY FETALMOVEMENT COUNT
Maternal record of fetal movement
After 28weeksgestation
2-hour approach=10 movements in 2hours
NONSTRESSTEST (NST)
Indications
External monitoring for fetal well-being
Indications
Decreased FM
HTN
DM
Multiple gestation
Trauma
Procedure NST
20-40 minutes monitoring foraccelerationsin the fetal HR.
NST Interpretation
Interpretation
Reactive (reassuring)
15 beats x 15 sec (32 weeks or greater)
10 beats x 10 sec (less than 32 weeks)
Nonreactive
Insufficient accels in 40 min
Follow up with further testing (US or BPP)
VIBROACOUSTICSTIMULATION (VAS)
Screening tool using auditory stimulation to assess fetal well-being with EFM when NST is nonreactive
VAS Procedure/ Interpretation
-Artificial larynx cause vibration on maternal Abd near fetal head at 1 seconds
-Reactive NST
15 beats x 15 sec (32 weeks or greater)
10 beats x 10 sec (less than 32 weeks)
CONTRACTIONSTRESS TEST (CST)
Screening tool to assess the ability of thefull-term fetus to maintain normal FHR inresponse tolabor
Interpretation
NegativeCST (Good)
Nodecelswith UCs
Positive CST (Bad)
Latedecelswith 50% of UCs
AMNIOTIC FLUIDINDEX (AFI)
Screening tool that measures the volume of amniotic fluid with ultrasound to assess fetal well-being and placental function
Normal
8 cm to 24 cm
Abnormal
Polyhydramnios - > 24 cm
Oligohydramnios - < 5 cm
BIOPHYSICALPROFILE (BPP)
An ultrasound measurement of fetal status along with an NST
Interpretation
Reassuring - 8/10
Equivocal - 6/10
Nonreassuring - 4/10
Almost certain fetal asphyxia - 2/10
Triggers of Labor
Stretching uterine muscle, estrogen/ progesterone/ oxytocin changes, fetal cortisol of placenta as it ages
5 P’s
Powers (UC), Passage (Pelvis), Passenger (Fetus), Position (Maternal physical position), Psyche (women response)
Powers
Contractions; duration, range (shortest to longest), frequency (not more frequent than every 2 minute, 5 contraction in 10 minutes), intensity (strength at strongest point), resting tone (soft in between contractions)
Passage
Whole birth canal, lower uterine segment, cervix, pelvic floor, vagina, introitus
-most common gynecoid
Passenger (fetus)
-skull (fontanels override/ mobile), molding, fetal presentation (cephalic), fetal attitude (flexed? extended)
-transverse not compatible with vaginal birth
Presentation
The position of the fetus OA best
Station
High-very far up, where the babies head is compared to ischial spine (0-engaement), up is negative, positive out, -3-+3
Onset of Labor
True Labor = Uterine contractions (UCs)
Cervical dilation and effacement
Regular intervals with increased intensity
Cardinal Movements
-Engagement-pass pelvic inlet, Decent, Flexion
-Internal rotation-push
-Extension-presenting part pivots under pubic symphysis, rotation complete
-External Restitution-head showing
-Expulsion-head exposed
Apgar
-at 1 minute and 5 minute
-Activity (1 flexed arms/ legs, 2 active)
-Pulse (>100 2)
-Grimace (2, prompt response, cry)
-Appearance (full pink 2)
-RR (2 vigorous cry)
Baseline FHR
Round to increments of 5bpm during a 10-minute window.
Must include 2-minute patterns.
Baseline Variability
Fluctuations in FHR that are irregular in amplitude and frequency.
Absent (undetectable)
Minimal ( 5bpm or less)
Moderate (6bpm-25bpm)
Marked (>25bpm).
Indeterminant FHR
FHR that does not meet criteria of baseline FHR.
Accelerations-Good
Increase of FHR above baseline.
Peak is 15bpm or greater for 15 seconds and less than 2 minutes (>32), (>32) 10X10
Decelerations
Early (head compression), Variable (cord compression, abrupt less than 30 seconds from baseline nadir), Late or Prolonged (uteroplacental insufficiency, not good, nadir after peak contraction)
Tachycardia
FHR greater that 160bpm lasting 10 minutes or longer.
Bradycardia
FHR less than 110bpm for 10 minutes or longer
FHR pattern interpretation
1-determine FHR baseline
2-Determine Variability
3- Determine if accelerations are present
Baseline
-10 minute window,
Category I - Normal (ALL Present)
Baseline rate 110–160 bpm
Baseline variability moderate
Late or variable deceleration absent
Category III - Abnormal
Absent variability with any of the following:
-Recurrent late decelerations
-Recurrent variable decelerations
-Bradycardia
-Sinusoidal pattern
Uterine Activity and contraction pattern-normal
5 or fewer contractions in 10 minutes averaged over a 30-minute window.
Uterine Activity and contraction pattern- tachysystole
more than 5 contractions in 10 minutes over a 30-minute window.
Resting tone greater than 20 to 25 mm Hg, peak pressure greater than 80 mm Hg.
Most common cause is labor medications.
Intrauterine Resuscitation
Maximize intravascular volume, uterine perfusion, placental exchange, and oxygen delivery to the fetus.
Intrauterine Resuscitation
Change maternal position
IVF bolus (500 mls of LR)
Correct hypotension
O2 at 10 L/min via nonrebreather face mask
No longer recommended by ACOG, 2020 (American College of Obstetricians and Gynecologists).
Reduce uterine activity with medication
Stop oxytocin or remove medication
VEAL CHOP MINe
VEAL-Variable, Early, Acceleration, Late
CHOP-cord compression, head compression, O2-OK, Placental insufficiency
MINE-Move, Identify labor progression, no action, execute actions now
tachycardic fetal heart rate causes
-fever in mom
-infection in amniotic fluid
-fetal hypoxia
purpose of a vaginal exam at various stages of the labor process?
determine fetal position & presentation check for umbilical cord prolapse check dilation & effacement of cervix check for fetal station
Place the Leopold Maneuvers in order from #1 (top) to #4 (bottom)
Palpate the fundus of uterus to determine presentation of fetus
gently palpate the abdomen to determine location of the fetal back.
place one hand above symphysis to determine engagement in birth canal.
palpate down sides of uterus to determine whether fetus is facing L or R
