As the fetus's head settles deep into your pelvis, you may feel that the fetus has dropped lower - you can breath again! - but now u may be peeing more

- speculum exam - ferning - amnisure testing (detects PAMG-1, an amniotic fluid) - nitrazine paper (turns blue w amniotic fluid)

when chin of bb moves towards chest - happens when head meets resistance fr tissue - early in labor

head pivots underneath the pubic symphysis - caused by resistance of pelvic floor - during 2nd stage, when head is delivered

- emo stupport - comfort measures (ice chips, fluids, food) - hygiene (pericare, mouth careO - position changes - touch/massage - calm environment - advocacy - reinforce relaxation/breathing

assess position of bb - determines what part of fetus is in fundus - location of fetal back - presenting part - location of cephalic prominence

Chapter 8 - Intrapartum Assessment + Interventions Flashcards by jessica quintos

Premonitory Signs of Labor

backache
rupture of membrane
wt loss (1-3.5 lb)
lightening
regular contractions
incr discharge/bloody show
energy burst

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lightening

As the fetus’s head settles deep into your pelvis, you may feel that the fetus has dropped lower

you can breath again!
but now u may be peeing more

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ways to confirm ROM

speculum exam
ferning
amnisure testing (detects PAMG-1, an amniotic fluid)
nitrazine paper (turns blue w amniotic fluid)

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nursing actions if ROM is suspected

assess FHR
assess amniotic fluid for color, amt, odor
document date + time SROM + assessments

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amniotic fluid characteristics

clear or cloudy w normal odor like ocean water

-if meconium stained, then contact HCP bc it may indicate fetal compromise in utero

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Mechanisms of Labor are the…

positional changes in the presenting part required to navigate the birth canal
-aka cardinal mvmt

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Mechanisms of Labor is composed of…

engagement
descent
flexion
internal rotation
extension
external rotation/Restitution
expulsion

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engagement

when the greatest diameter of the head passes thru the PELVIC INLET
-late pregnancy, early labor

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descent

mvmt of bb thru birth canal during 1st + 2nd stages of labor

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flexion

when chin of bb moves towards chest

happens when head meets resistance fr tissue
early in labor

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internal rotation

when long axis of the head lies along axis of the pelvis

-2nd stage of labor

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extension

head pivots underneath the pubic symphysis

caused by resistance of pelvic floor
during 2nd stage, when head is delivered

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external rotation/Restitution

head + shoulders rotate to move under symphysis pubis

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expulsion

anterior shoulder comes first followed by the rest of the body

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6 best practices that promote normal physiological birth

1 labor starts on its own
2 freedom of mvmt 
3 continuous support
4 minimize interventions
5 spontaneous pushing in non-supine
6 no separation bw bb + mom

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4 stages of Labor

1 start: onset of labor, end: complete dilation
2 start: complete dilation, end: bb delivery
3 start: after deliver of bb, end: delivery of placenta
4 start: after delivery of placenta, end: 4 hrs later. aka postpartum period

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characteristics of 1st stage of labor

longest stage
bag of waters or fetal membrane usually ruptures
incr in CO + pulse
decr in GI motility
pain assoc w UC
3 phases

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nursing actions of 1st stage of labor

limit oral intake to clear liquids
woman dictates carb intake to decr ketosis
frequent position changes + upright
frequent emptying of bowel/bladder
comfort measures
emo + phys support

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phases in first stage of labor

latent: <5cm
active: >6cm
transition: 8-10 cm

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nonpharm actions

emo stupport
comfort measures (ice chips, fluids, food)
hygiene (pericare, mouth careO
position changes
touch/massage
calm environment
advocacy
reinforce relaxation/breathing

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latent phase of stage 1

dilatn 0-4cm
effacement 0-40%
mild contractions Q 5-10 min (like strong menstrual cramps)

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nursing actions in latent phase

start IV or insert saline lock
double check Rh, GBS, urine for protein/gluc
assess (VS, FHR, UC, membrane status, amniotic fluid, edema, hrt lung sounds,
sterile vaginal exam: dilatn + effcmt, presentation, position, station
leopold maneuver

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leopold maneuver

assess position of bb

determines what part of fetus is in fundus
location of fetal back
presenting part
location of cephalic prominence

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if GBS is pos…

give IV of penicillin

-ampicillin is alt

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sterile vaginal exam directions

- labia is separated w sterile glove hand - fingers are lubed - locate cervix

sterile vaginal exam assesses....

- dilation - effacement - position - station - presentation - fetal position

dilation in SVE

sweep finger fr side to side on margin of cervical opening

effacement in SVE

estimates shortening of cervix fr 2cm to paper-thin

position in SVE

relationship of cervix to head | -posterior, midposition, or inferior

station Iin SVE

level of presenting part in birth canal - 0 when presenting part reaches ISCHIAL SPINE - (-) still inside, (+) when outside

presentation in SVE

cephalic, breech, shoulder

ferguson's reflex

urge/readiness to bear down - phys response of women - activated when presenting part is at least 1+ station

when is intrapartum GBS prophylaxis indicated?

- previous bb w invasive GBS disease - GBS bacteria during current pregnancy - pos GBS vaginal-rectal culture in late gestation - unknown GBS status at onset of labor w <37 nwks - ROM> 18hrs - temp >100.4

s/s of active phase of 1st stage of labor

- >6cm - decr energy, fatigue - contractions more intense, Q 2-5min, lasts 45-60 sec

nursing actions for active phase of 1st stage of labor

- FHR + contractions Q 15-30 min - VS Q2 hr - --Q1 hr if rom

transition phase of 1st stage of labor

- complete dilation - easily discouraged, irritable - intense contractions Q 1-2 min, lasts 60-90 sec - incr bloody show - backache - strong urge to bear down or push

if pt has backache...

hand goes over hip, rubbing + pressing on area

nursing actions for transition phase of 1st stage of labor

- FHR + UC Q 15 min | - breathe during contractions + rest bw contractions

2nd stage of labor phases

latent/resting: urge to bear down is usually absent, fetus is passively descensding descent/active phase: incr intensity of UC + strong activation of ferguson's reflex

bearing down in the __ stage is less tiring + more effective + when started after the ___ rather than before

2nd stage> ferguson reflex (stron gurge to bear down)

2nd stage of labor characteristics

intense UC Q2min lasting60-90 sec - bloody show incr - perineum flattens

pushing education

- push for 6-8 seconds, followed by slight exhale - repeat for 3-4 pushes per contraction - discourage traditional practice of breath holding for 10 secs w each contraction

perineal stretching care for 2nd stage of labor

- warm compress | - gentle massage w warm oil

Episiotomy

incision in perineum to provide more space

Types of Episiotomy

1 median/midline | 2 medilateral

median/midline episiotomy

heals more quickly w less discomfort

medilateral episiotomy

45 degree angle incision - heals more slowly - greater blood loss - more painful

Lacerations

tears in the perineum | -can occur in cervix, vagina, perineum

1st degree Lacerations

perineal skin + vaginal mucous membrane

2nd degree Lacerations

skin, mucous membrane, FASCIA of perineal

3rd degree Lacerations

skin, mucous membrane, MUSCLE of perineal, EXTENDS TO SPHINCTER

4th degree Lacerations

extends to RECTAL MUCOSA + exposes LUMEN of rectum

3rd Stage of Labor

separation + expulsionof placenta - sudden decr in uterus size - UC continues until placenta is expelled

Active Management of Third stage of Labor + goals

- uterotonic drug (OXYTOCIN) - controlled cord traction - fundal massage goal is to decr PPH + incr UC + placenta expulsion

normal blood loss

500 mL w/in 24 hr

3rd stage of labor nursing actions

- at delivery, bb is placed on mom for skin-to-skin - if 3rd stage lasts more than 30 min, IV/IM of oxytocin 10IU - if placenta is still retained, then manual removal - if manual removal is being performed, then prophylactic abx is admin

primary mechanism to return to hemostasis

vasoconstrictions fr well contracted myometrium

when is apgar score obtained?

1 min, 5 min | -if apgar score is less than 7, then Q5min for 20 min

3 meds routinely administered to newborn

1 erythromycin 2 vitamin K 3 hepatitis B

erythromycin

ointment admin to eyes as prophylaxis ointment | -prevents gonococcal + chlamydia infections

vitamin K

via IM injection | -prevents hemorrhagic disease caused by vit K deficiency

Hep B vaccine

recommended for all newborns

initial assessment of newborn

airway, breathing, circulation, drug

Chapter 8 - Intrapartum Assessment + Interventions Flashcards

(63 cards)