[15] MIDTERM | INTRAPARTUM PART 3A (STAGES OF LABOR)

Question 1

• regular progression of uterine contractions
• effacement and progressive dilatation of the cervix
• progress in descent of the presenting part

Answer 1

NORMAL LABOR

Question 2

1ST STAGE OF LABOR

• stage of ____
• begins with the onset of regular ____ and ends with complete ____
• Factors affecting the length of labor: ____, maternal & fetal position, ____, and level of ____

Answer 2

• stage of dilatation
• begins with the onset of regular uterine contractions and ends with complete dilation of the cervix
• Factors affecting the length of labor: analgesia, maternal & fetal position, woman’s body size, and level of physical fitness

Question 3

1ST STAGE OF LABOR

LATENT PHASE
* Contractions are mild to moderate intensity and short, lasting ____ seconds.

• may start as mild contractions lasting ____ seconds with a frequency of ____ minutes and progress to moderate lasting ____ seconds with a frequency of ____ minutes
• w/ effacement & cervix dilates ____ cm
• Duration: Nullipara: ____ hrs. ; Multipara: ____ hours
• ____ contractions an hour is considered a meaningful signal that spontaneous birth is beginning or imminent.
• Prolonged latent phase: exceeding ____ hours in nullipara & ____ hours in multipara

Answer 3

LATENT PHASE
* Contractions are mild to moderate intensity and short, lasting 20 to 40 seconds.

• may start as mild contractions lasting 20 to 30 seconds with a frequency of 10 to 30 minutes and progress to moderate lasting 30 to 40 seconds with a frequency of 5 to 7 minutes
• w/ effacement & cervix dilates 0-3 cm
• Duration: Nullipara: 6 hours ; Multipara: 4.5 hours
• Twelve contractions an hour is considered a meaningful signal that spontaneous birth is beginning or imminent.
• Prolonged latent phase: exceeding 20 hours in nullipara & 14 hours in multipara

Question 4

ACTIVE PHASE
* Cervical dilatation occurs more rapidly, increasing from ____ cm ( ____ cm/hr in nulliparas and ____ cm/hr in multiparas)

• Fetal descent is ____
• Contractions become more frequent (every ____ minutes) and longer in duration lasting ____ seconds, and are ____ intensity

Answer 4

ACTIVE PHASE
* Cervical dilatation occurs more rapidly, increasing from 4 to 7 cm (1.2 cm/hr in nulliparas and 1.5 cm/hr in multiparas)

• Fetal descent is progressive
• Contractions become more frequent (every 3-5 minutes) and longer in duration lasting 40 to 60 seconds, and are moderate to strong intensity

Question 5

ACTIVE PHASE: WHO, 2018
* The duration of active first stage (from ____ cm until full cervical dilatation) usually does not extend beyond ____ hours in first labors, and usually does not extend beyond ____ hours in subsequent labors.

• A minimum cervical dilatation rate of ____ cm/hour throughout active first stage is unrealistically fast for some women and is therefore not recommended for identification of normal labor progression.
• A slower than ____ cm/hour cervical dilatation rate alone should not be a routine indication for obstetric intervention.

Answer 5

ACTIVE PHASE: WHO, 2018
* The duration of active first stage (from 5 cm until full cervical dilatation) usually does not extend beyond 12 hours in first labors, and usually does not extend beyond 10 hours in subsequent labors.

• A minimum cervical dilatation rate of 1 cm/hour throughout active first stage is unrealistically fast for some women and is therefore not recommended for identification of normal labor progression.
• A slower than 1-cm/hour cervical dilatation rate alone should not be a routine indication for obstetric intervention.

Question 6

ACTIVE PHASE
* Duration: nulliparas ____ hrs and ____ hrs in multiparas

• Show and perhaps spontaneous ____ may occur
• By the end of the active phase, contractions have a frequency of ____ min, duration of ____ seconds, and ____ intensity

Answer 6

ACTIVE PHASE
* Duration: nulliparas 3 hrs and 2 hrs in multiparas

• Show and perhaps spontaneous rupture of the membranes may occur
• By the end of the active phase, contractions have a frequency of 2 -3 min, duration of 60 seconds, and strong intensity

Question 7

TRANSITION PHASE
* contractions reach their peak of intensity which is ____, occurring every ____ min with duration of ____ seconds and causing maximum dilatation of ____ cm.

• By the end of this phase, both ____ and complete ____ have occurred

Answer 7

TRANSITION PHASE
* contractions reach their peak of intensity which is strong, occurring every 2-3 min with duration of 60-70 seconds and causing maximum dilatation of 8-10 cm.

• By the end of this phase, both full dilatation (10 cm) and complete cervical effacement (obliteration of the cervix) have occurred

Question 8

TRANSITION PHASE
* Does not usually last longer than ____ for nulliparas or____; increased by approx. ____ if epidural anesthesia is used

Answer 8

• Does not usually last longer than 3 hours for nulliparas or longer than 1 hour for multiparas; increased by approx. 1 hour if epidural anesthesia is used

Question 9

TRANSITION PHASE - Characteristics
* Increasing ____
* Hyperventilation
* Generalized discomfort, including ____
* Increased need for partner’s and/or nurse’s presence and support
* Restlessness
* Increased ____
* An inner focusing on her contractions
* A sense of bewilderment, frustration, and anger at the contractions
* Requests for ____
* Hiccupping, belching, nausea, or vomiting
* Beads of perspiration on the upper lip of brow
* Increasing ____

Answer 9

• Increasing bloody show
• Hyperventilation
• Generalized discomfort, including low backache, shaking and crampin in legs, and increased sensitivity to touch
• Increased need for partner’s and/or nurse’s presence and support
• Restlessness
• Increased apprehension and irritability
• An inner focusing on her contractions
• A sense of bewilderment, frustration, and anger at the contractions
• Requests for medications
• Hiccupping, belching, nausea, or vomiting
• Beads of perspiration on the upper lip of brow
• Increasing rectal pressure and feeling the urge to bear down

Question 10

MATERNAL ASSESSMENT

INITIAL INTERVIEW AND PHYSICAL EXAMINATION
Obtain information about the following:
* Woman’s name and age
* ____
* Frequency, duration, and intensity of contractions
* Amount and character of show
* Whether ____ has occurred
* Vital signs (assessed between contractions)
* Time the woman last ate
* Any known drug allergies
* Past pregnancy and previous pregnancy history
* Her ____ or what ____

Answer 10

• Woman’s name and age
• LMP and expected date of birth
• Frequency, duration, and intensity of contractions
• Amount and character of show
• Whether rupture of membranes has occurred
• Vital signs (assessed between contractions)
• Time the woman last ate
• Any known drug allergies
• Past pregnancy and previous pregnancy history
• Her birth plan or what individualized measures she has planned

Question 11

MATERNAL ASSESSMENT

HISTORY
* Physical and psychological events
* ____
* General health
* ____
* Note that all date are necessary to plan nursing care

Answer 11

• Physical and psychological events
• Review of past pregnancies
• General health
• Family medical information
• Note that all date are necessary to plan nursing care

Question 12

MATERNAL ASSESSMENT

CURRENT PREGNANCY HISTORY
* ____
* A description of this pregnancy
* ____
* Future child care

Answer 12

• OB score
• A description of this pregnancy
• Plans for labor
• Future child care

Question 13

MATERNAL ASSESSMENT

PAST PREGNANCY HISTORY
Document the following: (6)

Answer 13

• Number
• Dates
• Types of birth
• Any complications and outcomes
• Sex and birth weights of children
• Current health status of the children

Question 14

MATERNAL ASSESSMENT

PAST HEALTH HISTORY
* Previous surgeries
* ____
* ____
* TB
* Kidney disease or hypertension
* ____
* Woman’s lifestyle

Answer 14

• Previous surgeries
• Heart disease or diabetes
• Anemia
• TB
• Kidney disease or hypertension
• STI such as Herpes
• Woman’s lifestyle

Question 15

MATERNAL ASSESSMENT

FAMILY MEDICAL HISTORY
Ask if any family member is/has: (9)

Answer 15

• Cognitively challeneged
• Heart disease
• Blood dyscrasia
• DM
• Kidney disease
• Cancer
• Allergies
• Seizures
• Congenital disorder

Question 16

MATERNAL ASSESSMENT

PHYSICAL EXAMINATION
* Thorough PE, including a pelvic examination, to confirm ____ and ____
* Include inspection, palpation, and auscultation

Answer 16

• Thorough PE, including a pelvic examination, to confirm the presentation and position of the fetus and the stage of cervical dilatation
• Include inspection, palpation, and auscultation

Question 17

MATERNAL ASSESSMENT

VITAL SIGNS - Temperature
* Obtained ____
* ____ → infection on NPO, ____ → ____
* After rupture of the membranes, temperature should be taken ____

Answer 17

• Obtained q4h
• >37.2 C (99 F) → infection on NPO, ↑ temp → dehydration
• After rupture of the membranes, temperature should be taken q2h

Question 18

MATERNAL ASSESSMENT

VITAL SIGNS - Pulse and Respiration
* ____
* PR: ____
* PR >100 bpm → tachycardia (dehydration/ hemorrhage)
* RR: 18-20 cpm
* Contractions = ____

Answer 18

• Q4h
• PR: 70-80bpm
• PR >100 bpm → tachycardia (dehydration/ hemorrhage)
• RR: 18-20 cpm
• Contractions = ↑RR

Question 19

MATERNAL ASSESSMENT

VITAL SIGNS - Blood Pressure
* ____
* During contraction: BP rise ____
* ↑ BP = PIH
* ↓ BP/Pulse Pressure = ____

Answer 19

• Q4h
• During contraction: BP rise 5-15 mmHg
• ↑ BP = PIH
• ↓ BP/Pulse Pressure = hemorrhage

Question 20

MATERNAL ASSESSMENT

ABDOMINAL ASSESSMENT
* Estimate ____
* Presentation and position
* Palpate and percuss ____
* Assess for ____

Answer 20

• Estimate fetal size (fundic height)
• Presentation and position
• Palpate and percuss the bladder area
• Assess for abdominal scars

Question 21

MATERNAL ASSESSMENT

VAGINAL ASSESSMENT
* Determine the ____; confirm the ____, position, and ____
* Do not do vaginal exam in the presence of fresh → bleeding may indicate ____

Answer 21

• Determine the extent of cervical effacement and dilatation; confirm the fetal presentation, position, and degree of descent
• Do not do vaginal exam in the presence of fresh → bleeding may indicate placenta previa

Question 22

MATERNAL ASSESSMENT

ASSESSING RUPTURE OF MEMBRANES
Sterile Vaginal Examination
* After vaginal secretions are obtained, test them with a strip of ____
* ____ - Acidic
* ____ - Alkaline

____ (Examination of Vaginal Secretions under a Microscope)
* Amniotic fluid will show a ____ when dried and examined in this way; urine will not

BOW Ruptured at Home - ask mother to describe the color of amniotic fluid
* Should be ____
* ____ - blood incompatibility between mother and fetus
* ____ - meconium staining (in vertex presentation, may indicate fetal anoxia; meconium aspiration)

Answer 22

Sterile Vaginal Examination
* After vaginal secretions are obtained, test them with a strip of Nitrazine paper
* Vaginal secretions - Acidic
* Amniotic fluid - Alkaline

Fern Test (Examination of Vaginal Secretions under a Microscope)
* Amniotic fluid will show a fern pattern when dried and examined in this way; urine will not

BOW Ruptured at Home - ask mother to describe the color of amniotic fluid
* Should be as clear as water
* Yellow-stained - blood incompatibility between mother and fetus
* Green Fluid - meconium staining (in vertex presentation, may indicate fetal anoxia; meconium aspiration)

Question 23

MATERNAL ASSESSMENT

ASSESSMENT OF PELVIC ADEQUACY
* ____ - not to attempt a home birth
* ____ - to determine how readily the fetal head will born
* ____ to measure the pelvic outlet

Answer 23

• Cephalopelvic disproportion - not to attempt a home birth
• Estimate suprapubic angle - to determine how readily the fetal head will born
• Closed fist to measure the pelvic outlet

Question 24

MATERNAL ASSESSMENT

ASSESSMENT OF UTERINE CONTRACTIONS (3)

Answer 24

• Length/duration
• Intensity
• Frequency

Question 25

# FETAL ASSESSMENT **FETAL POSITION** Determined thru: * ____ - size and shape, lie: projects up and down (longitudinal lie) or left to right (transverse lie) * Palpation - ____ * ____ - presenting part * ____ - used when the fetal position cannot be determined by abdominal palpation

Answer 25

Determined thru: * **Inspection** - size and shape, lie: projects up and down (longitudinal lie) or left to right (transverse lie) * Palpation - **Leopold's manuever** * **Vaginal Examination** - presenting part * **Ultrasound** - used when the fetal position cannot be determined by abdominal palpation

Question 26

# FETAL ASSESSMENT **FHR - Auscultation of Fetal Heart Sounds** * Transmitted best through the ____ * Use stethoscope or a ____ * ____ – best heard through the fetal back * ____ – heard most clearly at the woman’s umbilicus or above * ____ – heard loudest in lower abdomen - ROA – RLQ; LOA - LLQ

Answer 26

* Transmitted best through the **convex portion of a fetus** * Use stethoscope or a **fetoscope, doppler unit** * **Vertex or Breech** – best heard through the fetal back * **Breech** – heard most clearly at the woman’s umbilicus or above * **Cephalic** – heard loudest in lower abdomen - ROA – RLQ; LOA - LLQ

Question 27

# FETAL ASSESSMENT **FHR - Auscultation of Fetal Heart Sounds** *____* * Latent Phase - q1h * Active Phase - q30 minutes * Second Stage - q15 minutes

Answer 27

*Low Risk Women* * Latent Phase - q1h * Active Phase - q30 minutes * Second Stage - q15 minutes

Question 28

# FETAL ASSESSMENT **FHR - Auscultation of Fetal Heart Sounds** *____* * Latent Phase - q30 minutes * Active Phase - q15 minutes * Second Stage - q5 minutes

Answer 28

***High Risk Women*** * Latent Phase - q30 minutes * Active Phase - q15 minutes * Second Stage - q5 minutes

Question 29

# FETAL ASSESSMENT **FHR** - ____ The monitor is left in place for continuous monitoring on women who are categorized as high risk for any reason or who have oxytocin stimulation.

Answer 29

**FHR - Electronic Monitoring** The monitor is left in place for continuous monitoring on women who are categorized as high risk for any reason or who have oxytocin stimulation.

Question 30

**NURSING DIAGNOSES (3)**

Answer 30

* Fear/Anxiety r/t discomfort of labor and unknown labor outcome * Acute Pain r/t uterine contractions, cervical dilatation, and fetal descent * Deficient Knowledge r/t lack of information about normal labor process and comfort measures

Question 31

# PAIN MANAGEMENT **FACTORS THAT INFLUENCE LABOR PAIN** * ____ - pain perception, is the least amount of sensation that a person perceives as painful * ____ - amount of pain one is willing to endure * ____ - Occurs in the spinal cord; Pain sensations are transmitted from the periphery of the body along nerve pathways to the brain; Only limited number of sensations can travel these pathways at one time. * ____ - neurmodulators; also called endorphins or endogenous opiates

Answer 31

* **Pain Threshold** - pain perception, is the least amount of sensation that a person perceives as painful * **Pain Tolerance** - amount of pain one is willing to endure * **Gate Control Theory** - Occurs in the spinal cord; Pain sensations are transmitted from the periphery of the body along nerve pathways to the brain; Only limited number of sensations can travel these pathways at one time. * **Chemical Factors** - neurmodulators; also called endorphins or endogenous opiates

Question 32

# MANAGEMENT OF PAIN **NONPHARMACOLOGICAL PAIN MANAGEMENT (12)**

Answer 32

* Cognitive Stimulation Methods * Cutaneous Stimulation * Thermal Stimulation * Breathing Techniques * Relaxation * Hypnosis * Therapeutic Touch * Music * Aromatherapy * Acupressure * Acupuncture * Prayer

Question 33

# MANAGEMENT OF PAIN **NONPHARMACOLOGICAL PAIN MANAGEMENT** *Cognitive Stimulation Methods* * Mental Stimulation: ____ * Using ____ or focusing on ____ or a ____ may help the woman block out painful sensations

Answer 33

* Mental Stimulation: **Imagery** * Using **focal point** or focusing on **breathing patterns** or a **spot on the wall** may help the woman block out painful sensations

Question 34

# MANAGEMENT OF PAIN **NONPHARMACOLOGICAL PAIN MANAGEMENT** *Cutaneous Stimulation* * Touching, rubbing or massaging (____) * Counter pressure at the point of back pain (____)

Answer 34

* Touching, rubbing or massaging (**rhythmic stroking/effleurage**) * Counter pressure at the point of back pain (**sacral pressure**)

Question 35

# MANAGEMENT OF PAIN **NONPHARMACOLOGICAL PAIN MANAGEMENT** *Thermal Stimulation* * ____ - warm bath or shower * ____ - cool, damp cloth applied to the forehead * Hot or cold towels applied to the back to relieve mild back presure

Answer 35

* **Early Labor** - warm bath or shower * **Later Phases** - cool, damp cloth applied to the forehead * Hot or cold towels applied to the back to relieve mild back presure

Question 36

# MANAGEMENT OF PAIN **NONPHARMALOGICAL PAIN MANAGEMENT** * ____ - relaxation of voluntary muscles between contractions * ____ - safe, without known side effects, and has positive physical and psychologic outcomes

Answer 36

* **Relaxation** - relaxation of voluntary muscles between contractions * **Hypnosis** - safe, without known side effects, and has positive physical and psychologic outcomes

Question 37

# MANAGEMENT OF PAIN **NONPHARMACOLOGIC PAIN MANAGEMENT** *Therapeutic Touch* * Use of touch to comfort and relieve pain (____) * Distraction effleurage, the technique of gentle abdominal massage often taught with ____

Answer 37

* Use of touch to comfort and relieve pain (**energy fields**) * Distraction effleurage, the technique of gentle abdominal massage often taught with **Lamaze preparation**

Question 38

# MANAGEMENT OF PAIN **NONPHARMACOLOGICAL PAIN MANAGEMENT** *Music* * Decreased ____ * Comforting music promotes ____ (increasing oxygen intake)

Answer 38

* Decreased **maternal anxiety** * Comforting music promotes **maternal relaxation** (increasing oxygen intake)

Question 39

# MANAGEMENT OF PAIN **NONPHARMALOGICAL PAIN MANAGEMENT** * ____ - fragrances of rose, lavender, frankincense, and bergamot oils are believed to promote comfort and relaxation and decrease pain * ____ - Pressure Point (between the first and second metacarpal bones on the back of the hand) * ____ - activation of the insertion points - release of endorphins

Answer 39

* **Aromatherapy** - fragrances of rose, lavender, frankincense, and bergamot oils are believed to promote comfort and relaxation and decrease pain * **Acupressure** - Pressure Point (between the first and second metacarpal bones on the back of the hand) * **Acupuncture** - activation of the insertion points - release of endorphins

Question 40

# MANAGEMENT OF PAIN **PHARMACOLOGICAL - Systemic Medications** *Opioid Analgesics* * Analgesic effect; induces sedation * Drugs: (4)

Answer 40

* Analgesic effect; induces sedation * Drugs: **Butorphanol tartrate (Stadol), Nalbuphine hydrochloride (Nubain), Meperidine (Demerol), and Fentanyl (sublimaze)**

Question 41

**PHARMACOLOGICAL - Systemic Medications** *Analgesic Potentiators* * Tranquilizer; decreases anxiety * Potentiate the effects of opioid analgesics * Side Effect: sedation * Drugs: (3)

Answer 41

* Tranquilizer; decreases anxiety * Potentiate the effects of opioid analgesics * Side Effect: sedation * Drugs: **Promethazine (Phenergan), Hydroxyzine (Vistaril), and Promazine (Sparine)**

Question 42

# MANAGEMENT OF PAIN **PHARMACOLOGICAL - Regional Anesthesia and Analgesia** * ____ - temporary loss of sensation of a body part * ____: epidural, spinal, and combined epidural-spinal blocks * ____ – used during labor and vaginal birth and CS * ____ – alter the transmission of impulses to the bladder, ↓ UO; interfere with BP stability and leg movement; slowed descent of fetus; ↑risk of perineal lacerations

Answer 42

* **Regional anesthesia** - temporary loss of sensation of a body part * **Regional anesthetic blocks**: epidural, spinal, and combined epidural-spinal blocks * **Epidural blocks** – used during labor and vaginal birth and CS * **Anesthetic agents** – alter the transmission of impulses to the bladder, ↓ UO; interfere with BP stability and leg movement; slowed descent of fetus; ↑risk of perineal lacerations

Question 43

# MANAGEMENT OF PAIN **PHARMACOLOGICAL - Regional Anesthesia and Analgesia** *Nursing Care during Administration of Regional Anesthesia:* * ____ before administration * Assisting her with positioning during and after the procedure * Monitoring and assessing VS and respiratory status * Monitoring ____ * Determine ____

Answer 43

* **Helping the woman void** before administration * Assisting her with positioning during and after the procedure * Monitoring and assessing VS and respiratory status * Monitoring **analgesic effect** * Determine **fetal being**

Question 44

# MANAGEMENT OF PAIN **PHARMACOLOGICAL - Regional Anesthesia and Analgesia** *Types of Local Anesthetic Agents:* * ____ - procaine hydrochloride ( ____ ), chloroprocaine hydrochloride ( ____ ) * ____ – lidocaine hydrochloride ( ____ ), mepivacaine hydrochloride ( ____ )

Answer 44

* **Ester** - procaine hydrochloride (**novocaine**), chloroprocaine hydrochloride (**nesacaine**) * **Amide** – lidocaine hydrochloride (**xylocaine**), mepivacaine hydrochloride (**carbocaine**)

Question 45

# MANAGEMENT OF PAIN **PHARMACOLOGICAL - Regional Anesthesia and Analgesia** *Adverse Maternal Reactions to Anesthetic Agents:* * ____: palpitations, tinnitus, apprehension, confusion, and metallic taste in mouth. * ____: more severe degrees of mild symptoms plus nausea and vomiting, hypotension, and muscle twitching, which may progress to convulsion. * ____: sudden loss of consciousness, coma, severe hypotension, bradycardia, respiratory depression, and cardiac arrest.

Answer 45

* **Mild reactions**: palpitations, tinnitus, apprehension, confusion, and metallic taste in mouth. * **Moderate reactions**: more severe degrees of mild symptoms plus nausea and vomiting, hypotension, and muscle twitching, which may progress to convulsion. * **Severe reactions**: sudden loss of consciousness, coma, severe hypotension, bradycardia, respiratory depression, and cardiac arrest.

Question 46

# MANAGEMENT OF PAIN **PHARMACOLOGICAL - Regional Anesthesia and Analgesia** * ____ - injection of an anesthetic agent into the epidural space (between L4 and L5) provides pain relief from uterine contractions and vaginal or cesarean birth.

Answer 46

* **Epidural Block** - injection of an anesthetic agent into the epidural space (between L4 and L5) provides pain relief from uterine contractions and vaginal or cesarean birth.

Question 47

# MANAGEMENT OF PAIN **PHARMACOLOGICAL - Regional Anesthesia and Analgesia** *Pudendal Block* * Administered by ____, intercepts signals to the pudendal nerve * Provides ____ for the first stage of labor, second stage, birth, and episiotomy repair * Relieves the pain of ____ and relieves pain in ____ but not for discomfort of uterine contractions

Answer 47

* Administered by **transvaginal method**, intercepts signals to the pudendal nerve * Provides **perineal anesthesia** for the first stage of labor, second stage, birth, and episiotomy repair * Relieves the pain of **perineal distention** and relieves pain in **lower vagina, vulva, and perineum** but not for discomfort of uterine contractions

Question 48

# MANAGEMENT OF PAIN **PHARMACOLOGICAL - Local Infiltration Anesthesia** * Injecting an anesthetic agent into the ____ areas of the perineum * Use at the time of birth, both in preparation for an ____ * Local anesthetic agents: chloroprocaine hydrochloride ( ____ ), lidocaine hydrochloride ( ____ ), and tetracaine hydrochloride ( ____ )

Answer 48

* Injecting an anesthetic agent into the **intracutaneous, subcutaneous, and intramuscular** areas of the perineum * Use at the time of birth, both in preparation for an **episiotomy and for episiotomy repair** * Local anesthetic agents: chloroprocaine hydrochloride (**nesacaine**), lidocaine hydrochloride (**xylocaine**), and tetracaine hydrochloride (**pontocaine**)