WH Labor and Delivery

Question 1

Ultrasound to evaluate fetal anatomy and placental location

Answer 1

18 week fetal survery

Question 2

CBC, ABS (indirect Coombs) for Rh negative mothers. Glucose screening (glucola), 3h GTT (glucose tolerance test) for those who fail the glucola

Answer 2

28 week screening

Question 3

After 32 weeks. Scored out of 8 points. Fetal movement, practice breathing efforts, flexion or tone, amniotic fluid index or pocket

Answer 3

Biophysical profile (BPP)

Question 4

Fetal heart rate monitoring and scored out of 2 points. 20 minutes of continuous monitoring or more. Fetal heart rate must show accelerations appropriate for gestational age. “Reassuring” = 2 points, “Non-reassuring” warrants further evaluation. These are performed twice weekly on many high-risk pregnancies

Answer 4

Non stress Test (NST)

Question 5

Measures blood flow in fetus, placenta and uterus

Answer 5

Doppler ultrasound

Question 6

Fetal heart rate monitoring while under the “stress” of uterine contractions- sometimes Pitocin is administered IV to the mother to create contractions and then evaluate fetal tolerance to labor (3 contractions in 10 mins). Negative result is good (no stress). Positive result indicates fetal compromise (uteroplacental insuffiency) and likely will result in cesarean section delivery.

Answer 6

Contraction stress test

Question 7

Used in low-risk scenarios without the active use of epidural anesthesia or Pitoin administration. Handheld doppler is used for FHR assessment for 30-60 seconds between contractions.
latent labor 30-60 mins
active labor 15-30 mins
pushing 5-15 mins
Uterine contractions are palpated and timed

Answer 7

FHR monitoring: intermittent

Question 8

Directed towards improving oxygen delivery to the placenta- often referred to as intrauterine resuscitation - and can include:
changing maternal position, IV hydration, oxygen supplementation, correction of maternal hypotension, turning off IV pitocin, administering tocolytics to reduce contraction intensity and frequency, calling for provider to expedite delivery (forceps, vacuum, cesarean section)

Answer 8

Nursing interventions for Category 2 and 3 FHR

Question 9

Internal monitors can be placed for more accurate FHR assessment or to evaluate strength of uterine contractions. FHR directly from a lead attached to the fetal scalp. IUPC (intrauterine pressure catheter) reads internal pressure from contractions to determine true intensity (measured in Montevideo units/ MVU’s). Internal monitors require ROMs in order to be placed.

Answer 9

Internal FHR and contraction monitoring

Question 10

At any delivery there should be 3 medical team members: a delivering provider, a nurse for the mother and a nurse for the infant. At a high-risk delivery, there may be many more personnel. Prior to delivery the infant warmer should be turned on and set up for full resuscitation if needed. Once the head delivers, the provider will feel for a nuchal cord (umbilical cord around the neck) and evaluate for shoulder dystocia. The anterior shoulder usually delivers first, followed by the posterior shoulder. The rest of the baby delivers easily. Infant is usually passed directly onto the mother’s abdomen for warmth, bonding and skin-to-skin contact. The cord may be left intact to pulsate for several minutes while baby adapts. An infant who has poor tone or lacks respiratory effort will be swiftly taken to the preheated warmer for evaluation and resuscitation if needed.

Answer 10

Delivery

Question 11

Delivery of the placenta. Following birth, the uterus continues to contract and shears of the placenta, this can take 5-30 min. After the placenta detaches, the continued uterine contraction will constrict the blood vessels which fed the placenta. Failure of this continued contracting is termed uterine atony- the primary cause of postpartum hemorrhage. Active mangement of the third stage has become widely practiced. It involves early cord clamping, Pitocin admin (at delivery of the head, the baby or the placenta), uterine massage, umbilical cord traction. It is thought to reduce blood loos but does increase maternal discomfort and intervention. An apparent lengthening of the umbilical cord or notable gush of blood may signal that the placenta has separated and is ready to deliver. Close assessment of uterine tone and ongoing bleeding is essential, at least every 15 minutes. Normal blood loss at a vaginal delivery is 500 ml.

Answer 11

Third stage of labor

Question 12

Uterine involution: the uterus is about at the height of the umbilicus just after delivery and slowly shrinks down 1 fingerbreadth below this height each day. The location of the uterus will be distended from a full bladder. The perineum may require suturing. There may also be significant edema or bruising in this area. Ice packs for the first 24h are soothing and diminish edema. Urinary retention can increase uterine atony and bleeding, therefore it is important to monitor return of bladder function and encourage voids. The first attempt to stand or ambulate to the bathroom should be attempted when sensation has returned and vitals are stable. two nurses preferable should be available as women are often syncopal from this transition. Standard practice is to closely monitor after a vaginal delivery for 2 hours before moving a woman onto the postpartum unit if stable.

Answer 12

Fourth Stage

Question 13

Patient assessment vitals, pain management, coaching, family involvement, decision making, movement, FHR monitoring, vaginal exams, evaluation for rupture of membranes, intake and elimination, fluid balance, medication, provider notification, provide comfort, teaching breastfeeding, newborn care, managing emergencies

Answer 13

Nursing care in labor and delivery

Question 14

air flow into/out of alveoli

Answer 14

Ventilation

Question 15

blood flow into alveolar capillaries

Answer 15

perfusion

Question 16

Tachypnea, nasal flaring, tachycardia, restlessness, diaphoresis, retractions, head bobbing, tracheal tugging, wheezing, grunting, stridor

Answer 16

S/s of respiratory distress

Question 17

Hypoventilation due to: Pulmonary (impaired lung tissue), acute lung injury (sepsis, pneumonia, aspiration, near drowning), other; neuromuscular disease, airway disorders, central apnea. Leading to respiratory failure; 02 demand more than supply, hypoxia, Co2 increases causing apnea leading to respiratory arrest

Answer 17

Respiratory Failure

Question 18

Device chosen based on age, situation, required flow.
1.) Nasal cannula (24-35% oxygen; 0.25 - 6L/min) less than 4 mo nose breathing only
2.) Simple mask (35-50% oxygen; 5-10 L/min)
3.) Non-rebreather (70-100% oxygen; 10-15 L/min)
4) CPAP/BiPAP
5.) Ventilator
Positioning, monitor O2 sats if on supplemental O2. Ensure proper placements

Answer 18

Nursing Interventions for Oxygenation

Question 19

Most common chronic diease in childhood. Bronchoconstriction AND airway inflammation, increased mucous secretion - airway remodeling. Airway hyper-responsiveness. Inflammatory cells: mast cells, eosinophils, neutrophils, lymphocytes, macrophages.
Reversible in some cases, severity and compliance.
Can they talk? Exhausted? Air movement? History of hospitalization?
Bronchodilators, O2, early corticosteroids, know triggers, proper use of meds/inhalers/nebs, MDI/spacer

Answer 19

Asthma