Week 4 Labor Management Flashcards
0-3/4 cm is the ___________ phase
Latent
Onset- begins with ROM onset of contractions
Contractions are what in latent phase?
Generally short, mild , and irregular
Cervical dilation in latent phase is
0 to 3/4 cm
Effacement is 0-100%
Other signs in Latent Phase
Bloody show
Cramping
Loose stools
Emotions in latent phase of labor
Excited apprehensive, mild discomfort, good time for teaching
Nullipara dilate is
1cm per hour
Multipara dilate is
1.5 cm/ hour
LOA
Occiput is area over the occipital bone on posterior part of the fetal part of the bone
Left anterior quadrant of the woman’s pelvis
When fetus is LOA
Posterior fontanelle is in upper left quadrant of maternal pelvis
LOP
Posterior fontanelle is in the lower left quadrant of maternal pelvis
ROA
Posterior fontanelle is in upper right quadrant of the maternal pelvis
ROP
Posterior fontanelle is in lower right quadrant of female pelvis
Anterior fontanelle is
Diamond shape because of roundness of the fetal head
Only portion that can be seen and is triangular view
Fetal head progresses through the pelvis and the change the nurse will feel detect what upon palpitation?
Occiput through the cervix.
What maneuvers determines fetal positioning and presentation?
Leopold’s maneuver
First maneuver of Leopold’s Maneuver
Facing the woman palpate upper abdomen with both hands
Note shape, consistency, and mobility of the palpated part
fetal head is firm and round and moves independently of the trunk. Buttock feel softer and moves with the trunk.
Second maneuver of Leopold’s
Moving hands on the pelvis and palpate the abdomen with gentle but deep pressure
Fetal back on one side of the abdomen and feels smooth. And extremities are knobby on the other side.
Third maneuver of Leopold’s
Place one hand don the pubic symphysis
Note whether part is palpated feels like head or the breech and whether is engaged
Fourth maneuver of Leopold’s maneuver
Facing the woman’s feet, place both hands on the lower portion of the abdomen and move hands gently down the side of the uterus toward the pubis.
Note cephalic prominence or brow.
First stage assessments include
VS- if normal is low risk
BP, pulse, and respirations every 60 min
Temp every 4 hours if intact and every 2 if ROM
Use nursing judgement for regarding activity, need for continous monitoring, IV, medications, etc
FHR and uterine contraction pattern assessed every ____ min and documented assessment in 1st stage
15 min
FHR and Uterine contraction assessments include
Baseline
Baseline variability
Periodic changes
Fetal oxygenation and well being
UCs- frequency, duration, intensity
If normal findings continue this can be accomplished by
1st stage assessment FHR
handheld doppler and allowing pt ambulate in hallway or around the room
Assessment 1st stage of SVE
Least amount of SVE
If pt needs meds
If pt needs need for BM
If FHR indicates need
If SROM
change in behavior of the pt
Interventions include:
Continuous assessment of changes in PT behaviors, contractions, and FHR established
Activity
- Encourage ambulation for uncomplicated labor
- Bedrest if preterm labor, abnormal bleeding, SROM, and presenting part is not engaged, administration of narcotics for pain, Pt request
Interventions while in bed include
Frequent position changes
optimal position is lateral recumbent
Continuous monitoring of FHR and contractions
Great time for teaching and paper work if necessary
Nutrition interventions include
Slowed gastric activity
Clear fluids and light fluids during labor
Hydration is very important can affect contractility of the uterus
Side rails up at all times
Practice universal precautions at all times
Aseptic technique
Privacy
Cultural
Keep pt and family members informed
- HIPPA established early and who will be informed
Safety
Elimination interventions include
Assess bladder and encourage voiding every two hours
Periodic testing for ketones
In and out cath, only if can’t void
Active phase of labor includes
Contractions- stronger and longer
Cervical dilation- 4-7 cm
effacement- 0-100%
Other signs of active stage of labor
Increased introversion, increased blood show, ROM
Emotions- increased discomfort and decreased ability to cope
Duration- Nullipara- 1cm/hour
Multipara- 1.5 cm/ hour
What are the assessments for the active phase of labor?
Same as latent but more often
Name some nursing dx for active phase of labor
Impaired gas exchange rt
Ineffective breathing pattern
Altered patterns of elimination
Vomiting
Interventions for active phase of labor
Continuous assessment for fetal status
Assess for labor progress
- Bloody show increase, increased introversion, strength of uterine contractions
ROM
Activity
- Frequent position changes and avoid supine hypotension
Continue ambulation as long as safe and tolerable
Nutrition interventions for Active Phase
Maintain IVF, may bolus if needed
Check with provider, clear fluid diet or npo with ice chips or strict NPO
Elimination
Same as latent every 2 hours
Monitor output
Non Narcotic measures for pain management
Sacral massage
Breathing techniques - Slow chest breathing
Relaxation
Shower if safe
Birthing ball at bedside
Nursing support for pain management
Stay at bedside
Keep bed clean, dry
Feed support person
Anticipatory teaching
What is the distribution of labor pain during the later phase of first stage and early of second?
Most pain below umbilical and these contractions are intense. Pain also near the cervical area. Intense pain in the lower back area as well.
Name medication for labor management
Pitocin- IV 1mlu per minute
Stadol- IVP, 1 mg per hr
Fentanyl- 100mcg per hr, IVP
Nubain- 10 mg every 2-3 hr, IVP
Give IVP meds slowly over 2 contractions
Do not let patient ambulate alone with these medications
What is the timing of meds for pain management?
nullipara at 4-5 cm up to 8 cm
multipara at about 3-4 cm up to about 7 cm
Demerol usually dose is
25 mg IVP
50-100 mg IM every 4 hrs
How must nursing documentation must be ?
Chronological
Current, take charting with you in room
Use the strip for documenting in current time
Evaluation includes
Evidence of adequate fetal oxygen
SVE for progress of labor
Pt coping with labor
Documentation procedures, IV, meds, VS, Interventions, provider input or contacts
Transitional phase contractions are
Very strong and last 60-90 seconds
UC’s frequent abdomen board like
Cervical dilation of transitional phase is
8-10 cm
100% effacement
Other signs of transitional phase include
Increased bloody show
Leg shakes
nausea and vomiting
low back pain
increased diaphoresis
May need to push
Emotions of transitional phase is
Very irritable and uncomfortable
May panic if left alone
Duration of nullipara
Generally no longer than 3 hours
average 45-60 min
Duration for multipara is
No longer than 1 hour
average 10-30 min
Assessments for 1st stage of transitional
VS every 30 min
Temp could be elevated
100.4 ok
Continue all other assessments
Interventions for Transitional
Everything more intense
SVE only when needed but more often
Nursing care for transitional phase
Same as latent and active
Increase IVF if needed
Get ready for delivery room and supplies
Second stage of labor begins with
Complete dilatation of cervix and ends with birth of infant
Contractions are strong, frequent, and long
Maternal expulsion efforts aid the force of contractions
100% effacement
Other signs of second stage labor
Heavy bloody show
Progressive bulging of perineum
Opening of the introitus
Emotions of 2nd stage of labor
Most patients feel better and in control and need support for pushing
Efforts may complain of burning and tearing sensation of perineum when fetal head fully distends the area
2nd stage of labor duration nullipara is
no longer than 3 hours avg 1-2 hours
2nd stage of labor duration for multipara is
no longer than 2 hours and average of 15 mm - 1 hour
2nd stage assessment includes
SVE determines complete dilation tell HCP
Continuous FHR monitoring
VS every 15 min
Watch appearance for fetal head
Name interventions for 2nd stage
Assist with pushing, labor progress, pushing only with UC’s
Privacy
Fetal status assist with monitoring at all times
Discomfort is generally less than transition
May get back feeling now from epidural
May get pudendal for pain relief
Neonatal care includes
Infant placed mother’s chest for skin to skin
On warmed resuscitation bed
Towel dried, hat on head, suction mouth and nose to open airway
APGAR at 1 and 5 min
Brief overview for anomalies
Note number of vessels in cord
ID bands on bay and parents
Erythromycin to eyes and Vit k to leg
Third stage back to mom includes
birth of placenta
Contractions decrease
Other signs of placental separation include
Gush of blood from the introitus
Lengthen of cord
Globular shape of uterus
Emotion is tired and glad it is over
Duration is 30-40 min for all patients
Name two types of mechanism for placental separation
Duncan
Schultze
Third stage nursing implications include
Time placenta is delivered and document
Add 20 units of Pitocin to 1000 ml LR and open wide
Assist with suturing if needed
Monitor bleeding- crucial time for PP hemorrhage
Onset begins right after birth of placenta and ends 1-2 hours after delivery with transfer to pp floor
4th stage
Contractions are mild, cramping, afterbirth pains
In the 4th stage the uterus can become?
Boggy and need massage
Perineal repair may be needed in progress, need to be assessed for bladder distention
Emotions are tired, excited, want to hold infant, hungry, may have perineal discomfort
The assessment for 4th stage is every 15 min to 1hr
True
VS more often if not stable
Fundus- Assess firmness and position
Lochia- Type, amount, any clots
Perineum: Swelling, bleeding from repaired site, hematoma formation
Bladder: Distention, up to void
Episiotomy types include
Mid line
Medio lateral
Laceration Types
1st: Skin of perineum and vaginal mucosa
2nd: Muscles of perineum and the above
3rd: Involves depth of the fascia of the anal sphincter tissue
4th: Laceration into the rectum
4th stage interventions include
Documentation if heavy bleeding, pad count, and clots
Maintain IVF with Pitocin
Massage boggy fundus
Ice pack to perineum
Medications for pain
Assist with breastfeeding
APGAR score measures
HR
Respiratory
Muscle tone
Reflex irritability
Color
Management of Hemorrhage/Shock
Massage fundus
Increase IV Pitocin
Empty bladder
Evaluate VS and O2 saturation
- Apply o2
Call HCP
Code Crimson
- Alert and activate emergency
- Alert Lab
Establish second IV line for massive transfusion with large gauge
How to manage eclamptic seizure?
Protect pt from injury
Call for help
Prepare administration of Mag Sulfate bolus and infusion if ordered by MD
Profound allergic type reaction and possibly to amniotic fluid embolus
Causes rapid deterioration and can cause sudden maternal death
AFE
This result of massive loss of clotting factors from blood loss, sepsis, or HELLP Syndrome causing arteriolar blood clotting with concomitant hemorrhage
DIC
May be treated with blood, FFP, Platelets, and anticoagulant therapy
