Exam 2 Flashcards
(232 cards)
1
Q
What is trauma-informed care?
A
Trauma-informed care: Care that recongizes the impact of trauma on individuals and creates a safe space, supports, and heals with an emphasis on safety and trust.
2
Q
What are possible settings for childbirth?
A
1) Traitional hospital settings with L&D and PP
2) Free-standing birth centers
3) Home births
3
Q
What is labor?
A
Labor: Regular uterine contractions with cervical change in order to expell the fetus, amniotic fluid, placenta, and membranes from the uterus into the world.
4
Q
What is preterm labor?
A
Preterm labor: labor that in a gravid person w/ a gestational age prior to 37 weeks
5
Q
What does dystocia mean?
A
Dystocia: Abnormally slow or protracted labor
6
Q
What does nulliparous labor “Nullip” mean?
A
Nulliparous labor: labor in a person who has never given birth to a child
Multiparous labor: labor in a person who has given birth before
7
Q
What are the characteristics of a normal labor: between how many weeks, what risk level, what position/presentation, post-birth condition
A
1) Spontaneous labor at 37-42 weeks
2) Low risk throughout
3) Birth in vertex presentation = fetus is head down, headfirst and facing your spine with its chin tucked to its chest
4) Parent and child are in good condition post birth
8
Q
**What is the cause of labor?
A
Exact cause of labor initiation is unknown
9
Q
**What is the lightening and when does it happen?
A
Lightening: the subjective feeling by the pregnant person as the baby settles into the lower uterine segement
When: 2-3 weeks before term
10
Q
**What is engagement and when does it happen and for whom?
A
Engagement: When the widest part of the baby’s head passes through the pelivc inlet and into the pelvis
When/who: 2-3 weeks before term in first time parents
11
Q
**What are some events, aside from lightening and engagement, that occur before the onset of labor?
A
1) Vaginal secretions increase
2) Mucus plug is discharged
3) Cervix is soft and effaced
4) Persistant bachache may be present
5) Possible rupture of membranes (amniotic sac)
6) Spotting, bloody show
12
Q
**Are stages of labor typically shorter or longer for nullip parents?
A
They are typically longer for nullip parents
13
Q
**Describe the first stage of labor and it’s substages:
A
**First stage: the initiation of labor to complete dilation (10cm)
* Latent: minor contractions, pregnant person is talkative, eager, 0-3cm dilated
* Active: increased contractions that are strong, rapid dilation, fetal head engages, effacement complete, bloody show, N/V, shaking 4-7cm dilated
* Transition: strong contractions with no break, have the urge to push, most difficult, shaky, emesis common, sweaty belly and brow, 8-10cm dilated
14
Q
**Describe the second through fourth stages of labor:
A
Second stage: complete dilation to birth of baby
Third stage: birth of baby to delivery of the placenta (5-30 minutes)
Fourth stage: placental delivery to 1 hour postpartum, stabilization
15
Q
**What is the cutoff time for the third stage of labor? What is the term for failure to deliver this key product of conception during the third stage?
A
1) Cutoff time: 30 minutes
2) Retained placenta: is the term used when the placenta is stil within the uterus after 30 minutes and it is considered an urgent concern
16
Q
What the important action a nurse must take after a placenta has been delivered?
A
Inspect it for intactness to ensure none is left in the uterus
17
Q
What happens to the cervix and vagina during the first stage?
A
Cervix
* Dilation: goes from 0 to 10cm dilated, completely opened
* Effacement: is complete with cervical thinning at 100% = paper thin
Vagina:
* Stretches for distension
* Increased lubrication
18
Q
Describe the second stage of labor:
A
1) Spontaneous urge to push w/o epidural
2) Contractions increase or stay instense
3) Fetal head may develop caput (cone shape d/t swelling = normal), mold, and rotate
4) Completion of body mechanics = baby is facing down, back to front, and tucked = vertex
5) Takes longer in nullips
19
Q
What are physiologic labor changes?
A
1) Cardiac output increases at second stage
2) Heart rate increases in first and second stage
3) BP increases during contractions and normalizes between
4) Increased WBC count
5) Increased RR
6) Temperature slightly elevated
7) Gastric motility and absorption decreased w/ N/V during transitions
8) Low blood glucose
20
Q
What are the five P’s of Labor?
A
1) Passenger
2) Passageway
3) Positions
4) Powers
5) Psyche
21
Q
What does passengers mean in labor?
A
Size of fetal head and other factors allowing the fetus to navigate the birth canal
22
Q
What does “presentation” mean in labor? Which type is compatible?
A
Presentation: the part of the fetus nito the pelvic inlet first
* Head: cephalic - vertex = compatible
* Shoulder: transverse lie = not compatible
* Sacrum/feet: breech = not great
23
Q
What does “lie” mean in labor? Which type is compatible with birth?
A
Lie: relationship of maternal longitudinal axis (spine) to fetal spine
* Longitudinal: vertical (compatible)
* Transverse: horiztonal (not compatible)
24
Q
What does “attitude” mean in labor? Which type is compatible with birth?
A
Attitude: relationship of fetal body parts to one another
* Flexion: chin to chest and extremities to torso = compatible
* Extension: chin and extremities extend away = not compatible
25
**What does fetal "position" mean in labor? What is the preferred fetal position?
**Position:** relationship of the presenting part of the fetus (i.e. sacrum, mentum, occiput) in relationship to its directional position of one of four pelvic quadrants
**Preferred positon:** Left occipitalanterior (**LOA**) - right occipitalanterior is also acceptable but less preferred
26
**What does passageway mean in labor? Describe each shape and which ones are good/bad?
**Passageway:** Pelivmetry-pelic shapes
* **Gynecoid:** the most common, **best shape**, 50% of pelvic shapes
* **Android:** male-type pelvis, may be difficult, labor will likely not progress, bad
* **Platypelloid:** least common, NOT conducive to vaginal birth
* **Anthropoid:** often results in occiput posterior birth (face up), 25%
27
There are three major parts to the fetal head. Which two are fused and which one is not and why?
**1) Fetal face** = should be well fused
**2) Base of skull** = should be well fused
**3) Vault of cranium** = **not fused**, normal, allows for head to adjust to peliv shape
28
**What does fetal station mean? Which station is at ischial spine? At what station can pushing start?
**Fetal station:** relationship of presenting part to an imaginary drawn line **between the ischial spines** of the maternal pelvis
* -5, -4, -3, -2, -1 = above ischial spines
* 0 = **at ischial spine**
* +1, +2, +3, +4, +5 = below ischial spine
* You can start pushing at 0 and + stations
29
What is fetal engagement? At what station is engagement?
**Engagement:** The latgest diameter of the presenting part reaches or passes through pelvic inlet
**Station:** 0
30
What is biparietal diameter? How is it related to vertex position?
**Biparietal diameter:** is the maximum width of a fetus' head and is used to assess engagement
**Relation to vertex:** it's related to vertex beucase biparietal diameter is the smallest when in vertex position
31
What does power mean in the 5 P's? Define contractions, duration, frequency, and intensity of them:
**Power:** It means the contractions of the birthing person.
**Contractions:** rhythmic tightenings and shortening of the uterine muscle
* **Duration:** beginning of one contracting to completion
* **Frequency:** time between the beginning of one contraction to the beinning of the next
* **Intensity:** the strength of uterine contractions
32
How is the intensity of uterine contractions described in terms of palpation?
**Mild:** like pressing the tip of one's nose trying to indent it
**Moderate:** like pressing one's chin trying to indent it
**Strong:** like pressing on one's head trying to indent it
33
What does positions mean in the 5 P's and what can it optimize?
**Positions:** means frequent position changes to promote comfort, reduce fatigue, and promote circulation
**Optimize:** promotes optimization of fetal position
34
What does psyche mean in the 5 P's?
**Psyche:** the mental and emotional state of the birthing person
35
What is pain versus suffering?
**Pain:** unpleasant sensations we want to avoid
**Suffering:** distressing state that includes feeling of helplessnesss and loss of control
36
What are ways to promote physical comfort as part of the atmosphere, partner suggestions, and encouraging use of space during labor?
**Atmosphere:** relaxation techniques, calming vocalizations, rhythmic breathing
**Partner suggestions:** massage/pressure, wiping face with damp cloth, praise
**Encouraging use of space:** using the bath/shower, birth ball, lounge
37
**What physical assessment tasks should the nurse complete during labor?
**1)** Vitals: BP, HR, RR, temp
**2)** **Leopold's maneuvers:** abdominal palpation to determine fetal position
**3)** Heart assessment
**4)** Lung assessment
**5)** Ask about any headache, diziness, or vision changes
**6)** Check upper and lower pulses
**7)** Check cervical dilation and effacement
**8)** Check status of membranes
**9)** Monitor contraction pattern
**10)** Assess pain
38
**What assessments should be done during the first stage of labor?
**1)** Review prenatal hx and labs
**2)** Review cultural preferences, language, and religious preferences
**3) Labor status:** contractions, cervix, membranes
**4) Fetal status**: FHR, amniotic fluid (clear = good, red=bad, brown/green indicate meconeum = bad)
**5) Maternal status:** coping level, comfort level, desires for L&D, support for L&D
39
What are active phase labor assessments?
**1)** Support **pain relief** options
**2)** **Fetal survelliance:** FHR + contractions
40
What are second stage of labor preparations?
**1)** Position change support
**2) Delivery meds ready**
**3) Continue to monitor fetus + parent**
**4)** Meet baby
41
What are third stage of labor assessments?
**1)** Uterine contractions to deliver placenta
**2) Check fundal tone**
**3) Weigh pads for bleeding**
**4)** Set up for laceration repair as needed
**5) Parent-baby bonding**
**6) Breastfeeding if desired**
42
What are fourth stage of labor assessments?
**1) Fundal checks and vitals**
**2)** Bonding (skin-to-skin, breastfeeding)
**3) Bathroom needs**
**4)** Bring to PP
43
What is family centered care and what are its three beliefs?
**Family centered care:** recognizes physical and psychosocial needs of the family including the newborn and older children
Beliefs:
* Childbirth is noraml and healthy
* Childbirth affects the whole family
* Families can decision-make with all the information and support
44
What are three barriers to family centered care? What can help alleviate these problems?
**1)** Lack of communication, role negotiation, and relationships between providers and parents
**2)** Lack of time by providers
**3)** Lack of support from system and provider team
**Validation** of these difficulties can help alleviate them
45
What age range is the birth rate declining for? Are individuals becoming pregnant earlier or later in life?
**1)** Declining for 15-24 y/o
**2)** People are waiting to become pregnant until later in their lives
46
What does maternal death mean?
Any death while pregnant, aside from accidental/incidental causes, or within 42 days after pregnancy irrespective of duration, site, or termination or any cause d/t pregnancy
47
Which population is disproportionately affected by maternal and infant death rates?
Black individuals
48
What are the three main causes of maternal death?
**1)** Cardiovascular conditions or other related CV issues
**2)** Infections/sepsis
**3)** Cardiomyopathy
49
About how many pregnancy-related deaths have been considered to be preventable?
80%+
50
**What are methods for fetal surveillance (FHR and uterine activity)?
**FHR:**
**1)** Intermittent ascultation of FHR (handheld doppler)
**2)** Continuous electronic FHR recording (external transducer, internal fetal scalp electrode)
**Uterine activity recording:**
**1)** External tocodynanometer or pressure transducer = "Toco"
**2)** Internal intrauterine pressure catheter = balloon captures **reading and strength**
51
What is a normal fetal heart rate?
110-160 BPM
52
**What is baseline fetal heart rate? What might being below or above the normal range indicate?
**Baseline:** the average FHR during a **10 minute window** rounded to 5BPM
* Below 110 BPM = bradycardia, which may indicate **hypoxia**
* 110-160 BPM = normal
* Above 160 BPM = tachycardia, possible fetal **fever or distress**
53
What does variability mean in FHR tracing?
**Variability:** fluctuations in the baseline FHR quantified as the amplitude from peak-to-trough in BPM
54
What are the four types of FHR variability and what can they mean?
**1) Absent:** amplitude undetectable
**2) Minimal:** amplitude 0-5 BPM
**-** Absent or minimal may mean hypoxia, acidemia, fetal sleep, or medication effects
**3) Moderate:** amplitude 6-25 BPM = what we want, **good**
**4) Marked:** amplitude is >25 BPM = may mean acute hypoxia or umbilical compression
55
What are accelerations? Are accelerations good or bad? What should an acceleration be at 32 weeks or greater of gestation?
**Accelerations:** temporary increases in FHR of at least 15 BPM lasting at least 15 seconds.
They are generally a reassuring sign of **good oxygenation and movement**
**32 weeks+:** peak is equal to or greater than 15 BPM and lasts at least or longer than 15 seconds
56
Early deceleration: What is it, onset to nadir time, and cause
**Early:** a gradual decrease and return to baseline in FHR associated with a contraction where the **nadir of the decel and peak of the contraction happen at the same time**.
**Onset to nadir: is >30 seconds**
**Cause:** head compression, not very concering
57
Late decerlation: what is it, onset to nadir, cause
**Late deceleration:** a gradual decrease and return to baseline in FHR associated with a contraction where the **nadir of the decel occurs *after* the peak of the contraction**.
**Onset to nadir:** >30 seconds
**Cause:** placental insufficiency = need fetal monitoring
58
Variable deceleration: what is it, onset to nadir, cause
**Variable deceleration:** abrupt decrease below baseline by greater than or equal to 15 BPM lasting at least 15 seconds but less than 2 minutes from onset to baseline.
**Onset to nadir:** less than 30 seconds
**Cause:** cord compression or prolapse
59
Prolonged deceleration: what is it, cause
**Prolonged deceleration:** decrease in FHR below baseline greater than or equal to 15 BPM lasting longer than 2 minutes but less than 10.
**Cause:** epidural, sudden position change by mother or fetus, quick labor
60
What is a baseline change in FHR tracing?
**Baseline change:** when a prolonged deceleration or acceleration lasts **longer than 10 minutes**
61
**Describe the acronym VEAL CHOP in FHR tracing:
**V:** Variable deceleration
**E:** Early deceleration
**A:** Acceleration
**L:** Late deceleration
**C:** Cord compression/prolapse (bad)
**H:** Head compression (fine)
**O:** Okay
**P:** Placental insufficiency (not great)
| Letters go with their respective letter in each word, i.e. V+C, E+H, etc
62
**Define uterine contractions in FHR tracing, what is the normal amount, what is duration and frequency of contractions?
**Uterine contractions:** number of contractions in a 10 minute window averaged over 30 minutes
**Normal:** 5 or less contractions in 10 minutes, averaged over 30 minutes
**Duration:** start of one contraction to the end of the contraction
**Frequency:** start of one contraction to the beginning of another contraction
63
What is tachysystole in uterine contractions and how is it treated?
**Tachysystole:** >5 contractions in 10 minutes, averaged over 30 minutes
**Treatment:** maternal repositioning, fluid bolus, discontinue oxytocin
64
What factors affect intensity and fatigue during labor?
**1)** Interval of contractions and duration
**2)** Fetal size
**3)** Rapidity of fetal descent
**4)** Maternal position
**5)** Maternal mobility during labor
65
Why is childbirth pain unique?
**1)** Self-limiting and normal
**2)** Can be prepared for
**3)** Ends with birth
66
Describe the pain and characteristics of each labor stage:
**1st stage:** **dilation of the cervix is the main source of pain**, hypoxia of uterine muscles during contractions, stretch of uterus, pressure on lower back, butt, thighs
**2nd stage:** **distension of vaginal perineum**, hypoxia of uterus continues, pressure again
**3rd stage:** **perineal pain**, uterine contractions, cervical dilation w/ placental expulsion
**4th stage:** contractions, **after pains (breastfeeding), perineal/incisional pain**
67
How should you ask a laboring individual about their pain? When should you assess them for pain?
**How:** "Are you coping with your labor?"
**When:** on admission, every shift, as needed, any sign of change
68
What are signs the laboring patient is not coping with their pain?
**1)** States they are not coping or doing well
**2)** Panicked
**3)** Tense
**4)** Crying
**5)** Fear
69
What are pain management goals during labor?
**1)** Safe for birthing person
**2)** Safe for fetus
**3)** Ideally does not interfere with course of labor
70
When can each pain management method be used during labor: non-pharmacological, nitrous oxide, sedatives, opioids, epidural, nerve block
**non-pharmacological:** anytime
**nitrous oxide:** anytime
**sedatives:** early labor only
**opioids:** early to active labor and during the 3rd stage
**epidural:** early to active labor
**nerve block (local infiltration):** 2nd stage to 3rd stage
71
What are some possible comfort measures to alleviate pain during labor:
**1)** Heat/cold
**2)** Toch/massage
**3)** Psychosocial support
**4)** Hydrotherapy
**5)** Continuous labor support (doula, partner, friends, family)
**6)** Breathing techniques
**7)** Movement
**8)** Birth ball
**9)** TENS machine (electrical stimulation)
**10)** Sterile water injections for back pain
72
Nitrous oxide: what is it, how does it help pain, long or short lasting
**What is it:** also known as laughing gas, it is an inhaled anesthetic of 50:50 mix of O2 and nitrous oxide via handheld mask
**Helps:** only modulates pain, it does not remove it
**Length:** short duration
73
Sedatives: what sedative is most commonly given during labor, what does it help with
**Sedative:** Vistaril (hydroxyzine pamoate) 25-100mg
**Helps with:** N/V, anxiety and apprehension, sleep induction at higher doses
74
Opioids: which opioids are given during labor, what is pain relief dependent on, do they cross the placenta, side effects (maternal, fetal, newborn)
**Opioids:** Morphine (5-10mg IM) or Fentanyl (50-100mcg IV)
**Dependent on:** pain relief is dependent on maternal metabolism
**Placenta:** All cross the placenta
**Side effects:**
* **Maternal:** dizziness, N/V, sedation, tachycardia, hypotension
* **Fetal:** decreased variability in FHR tracing
* **Newborn:** respiratory depression at birth
75
Narcan: what is it, when is it available to use, what does it reverse, contraindications
**What is it:** opiate antagonist
**When:** available anytime, labor and birth
**Reverses:** it reverses respiratory depression, sedation, and hypotension
**Contraindications:** mother/fetus/neonate with maternal **drug abuse or methadone treatment** becuase it** may precipitate withdrawal**
76
What does regional analgesia vs. regional anesthesia block?
**Regional analgesia:** provides moderate pain relief with motor block
**Regional anesthesia:** provides complete pain relief with motor block
77
Local perineal infiltration anesthesia: when is it given, what kind of medication
**When:** prior to episiotomy or after birth for repair of lesions
**Medication:** 1% lidocaine (10-20mL to site)
78
What is a pudendal nerve block and which stages of labor is it used in?
**Pudendal nerve block:** needle guide and luer-lock syringe to inject medication for pain relief
**Stages:** 2nd and 3rd stages
79
What are the advantages and disadvantages of spinal anesthesia?
**Advantages:**
* Awake and can participate in birth experience
* Retains relaxed airway
**Disadvantages:**
* maternal hypotension
* FHR changes d/t impaired placental perfusion
* Delayed respiratory depression
* N/V
* Puritis
* Urinary retention = needs catheterization
* Spinal headache
80
Spinal block: what is it, when used, effect
**What is it:** a pain relief measure placed into the subarachnoid space (L3-L4)
**Use:** c-section
**Effect:** paralysis from xiphyoid process down
81
**Epidural block: what is it, when used, effect
**What is it:** a pain relief measure placed lower into the epidural space (between L4+L5) given via **continuous infusion** of anesthetic (marcaine) and opiate (fentanyl)
**Use:** vaginal delivery often during active labor
**Effect:** abdominal paralysis and analgesia only - **can move**
82
**What is the nursing role before spinal anesthesia admistration?
**1)** vitals (mother and fetus)
**2)** Hydration
**3)** Check labor progress
**4)** Assess pain
**5)** Help void
**6)** Guide parent during process
**7)** Have O2 and suction ready
**8)** Monitor for toxicity
**9)** IV for saline/Lactated ringers
83
**What is the nursing role during/after spinal anesthesia administration?
**1)** Vitals
**2)** Assess pain
**3)** Check if bladder distended (Cath needed)
**4)** Change positions side-to-side every hour
**5)** Bed rails up
**6)** Call light in reach
**7)** Educate patient to not get up without help
**8)** Educate patient to not place pressure on anestheized parts
**9)** Check insertion site for reactions
**10)** Keep insertion site clean and dry
**11)** Assess for sensory and motor return
**12)** Encourage pushing
84
General anesthesia: when used, risks
**When:** only in emergencies, not offered to patients
**Risks:** difficulty with intubation/extubation, aspiration of GI contents
85
How is pain managed postpartum after vaginal delivery:
* Analgesia PO (acetaminophen)
* NSAIDs PO (ibuprofen)
* Topical comfort
**Alternate acteaminophen and ibuprofen every 3 hours**
86
How is pain managed postpartum after c-section delivery:
* Opoid analgesia, patient controlled first 24 hours, and then PO (i.e. oxycodone)
* NSAID IV (i.e. toradol) first 24 hours only, then PO **(IV and PO NSAIDs cannot be used at the same time)**
87
What is induction of labor and what do you need to document when doing this?
**Induction of labor:** artificial initiation of labor before spontaneous onset, useful when deliery outweighs benefits of continued pregnancy
**Documentation:** Ensure documented risk/benefit/alternatives with rationale for induction method, method used, risks of method
88
What are maternal indications for labor induction:
* PROM
* Hypertensive disorder of pregnany
* Intrauterine fetal demise
* Maternal diabetes
* Post-term pregnancy
* Elective
89
What are fetal indications for labor induction:
* Fetal growth restriction
* Oligohydraminos
* Chorioamnionitis
* Non-reassuring FHR tracing
90
What are contraindications for induction of labor?
**1)** Complete placenta previa
**2)** Non-cephalic presentation
**3)** Active genital herpes
**Contraindicated becuase they are high risk and need C-section instead**
91
What is done as part of a vaginal exam prior to induction of labor?
**1)** Palpate cervix
**2)** Check presentation (Head first?)
**3)** Position (LOA?)
**4)** Membrane status
**5)** Pelvic asssessment -> fetopelvic relationship (station)
92
What is a bishop score? What goes into a bishop score? What score determines ready for induction versus cervical ripening?
**Bishop score:** a score of 0-15 that determines if inducement is possible or if ccervical ripening is needed
**Components:** dilation, effacement, cervix position, station, cervical consistency
**Induce:** 6 or higher
**Ripen:** less than 6
93
Mechanical cervical ripening: options, benefits risks
**Options:** Foley or Cook balloon (double) - open the cevix
**Benefits:** safe for those with prior cesarean
**Risk:** rupture of membranes on insertion, fetal head displacement
94
Pharmagcologic cervical ripening: options, contraindications, risk, and treatment of the risk
**Options:** Prostaglandins such as **misoprostol (Cytotec;** PO/Vaginal; very small dose) + **Dinoprastone (Cervidil** ; Vaginal)
**Contraindication:** cannot be used in those with previous c-section/uterine surgery as there is risk of overstimulating the uterus/scar tissue rupturing it
**Risk:** Tachysystole is possible (>5 contractions in 10 minutes)
* **Tx:** position changes, fluid bolus, discontinue pitocin, remove meds
95
What is induction compared to augmentation of labor?
**Induction:** initiating labor **before** it begins on its own
**Augmentation:** stimulating uterine contractions **after labor has begun**
96
What are the two common methods of induction/augmentation? What Bishop score do you need to induce?
**1)** IV Pitocin (most common)
**2)** Artificial Rupture of Membranes (AROM)
**3)** **bishop score of 6 or more to induce)
97
**Pitocin: what is it, route, effects, dangers
**What is it:** a synthetic version of oxytocin used via IV for induction
**Route:** IV
**Effects:** causes uterine contractions
**Dangers:** Tachysystole, uterine rupture, uterine atony to postpartum hemorrhage
98
**What are six important points when starting a Pitocin infusion?
**1)** Hang bag as a secondary line (piggyback)
**2)** Insert secondary line into primary line as **close to proximal port (near the IV site)** as possible to limit the amount of drug infused after stopping
**3)** Low dose to start and **increase every 20-30 minuntes** until uterine contractions are regular
**4)** Requires verification by two nurses in MAR d/t high risk status
**5)** Monitor patient's **BP/HR Q30 minutes**
**6)** Must continually monitor FHR and contractions
99
**What five actions should you take if you're using Pitocin and notice non-reassuring fetal heart tones?
**1)** Reduce/stop the Pitocin
**2)** Increase rate of primary IV line
**3)** Move patient to side-lying position
**4)** Assess FHR and contractions
**5)** Administer **Terbutaline:** a tocolytic that is a beta 2 agonist to relax smooth muscle and delay contractions
100
Artificial rupture of membranes (AROM): what is it, when is it used, risks
**What is it:** a procedure to artificially rupture the amniotic sac by using an amnihook to induce/augment labor
**Used:** Labor augmentation, labor induction, internal fetal monitoring needed
**Risk:** cord prolapse, chorioamnionitis
101
What is the nursing role in artificial rupture of membranes?
**1) FHR:** obtain baseline FHR **20-30 minutes prior to the precedure** and continue to monitor after
**2) Supplies:** towels, omnihook, sterile gloves, sterile lubricant
**3) Chart:** color, quantity/amount, and odor of fluid
**4) Assess:** for any infection following rupture
102
Operative vaginal delivery: types, indications
**Types:** vacuum and forceps
**Indications:** to shorten 2nd stage with reason =
* maternal exhaustion
* ineffective pushing
* cardiac/pulmonary disease
* intrapartum infection
* cord compression
* non-reassuring FHR
* premature placental separation
103
What are the maternal and fetal risks for an operative vaginal delivery?
**Maternal:**
**1)** laceration or hemtoma to vagina/perineum
**2)** Need for a large epiosiotomy
**Fetal:**
**1)** ecchymosis (bruising)
**2)** facial/scalp lacerations/abrasions
**3)** facial nerve injury
**4)** cephalohematoma
**5)** intracranial hemorrhage
104
What are nursing maternal and fetal considerations for an operative vaginal delivery
**Maternal:**
**1)** Patient's bladder should be empty
**2)** Observe for trauma
**3)** Cold application to perineum/vagina to reduce pain, bruising, and edema
**4)** Check if fundus is firm
**Fetal:**
**1)** Assess FHR
**2)** Check for any skin breaks
**3)** Check facial asymmetry
**4)** Check for any neurologic abnormalities
**5)** Assess for scalp edema and facial bruising (both will resolve w/o tx)
105
What is tiral of labor after cesarean (TOLAC) and VBAC mean?
**1) TOLAC:** means the parent is trying to labor and deliver vaginally after already having a c-section
**2) VBAC:** a successful vaginal birth after c-section
106
What considerations should be made before a trial of labor after cesarean (TOLAC)?
**1)** Small, but significant risk of uterine rupture
**2)** Avoid in setting w/o emergency services access or anesthesia
**3)** Prostaglandins like misoprostol (Cytotec) and dinaprostone (Cervidil) **cannot be used**
**4)** Pitocin **can be used**
**5)** Continuous FHR will be needed
107
What are the benefits vs. risks of trial of labor after cesarean (TOLAC)?
**Benefits:**
**1)** Achieved VBAC
**2)** Avoid surgery
**3)** Lower rates of hemorrhage, infection, and thromboembolism
**4)** Shorter recovery
**5)** Decreased risk of multiple c-sections
**6)** VBAC = fewer complicaions than c-section
**Risks:**
**1)** Unsuccessful TOLAC ending in a c-section has more complication than elective, repeat c-section or VBAC.
108
What are the indications for a cesarean birth? Which two indications make up half of all c-sections?
**1) Labor dystocia** 1+2 make up half of all c-sections
**2) Abnormal FHR tracing**
**3)** Fetal mal-presentation
**4)** Macrosomia
**5)** Genital herpes
**6)** Placenta previa
109
What are the risks of a c-section?
**1)** Major hemorrhage
**2)** Uterine rupture
**3)** Anesthetic complications
**4)** Shock
**5)** Cardiac arrest
**6)** Infection
**7)** Wound disruption
**8)** Injury to newborn
110
**What are c-section pre-op interventions?
**1)** Assess the time of last oral intake (must be NPO 8 hours before surgery)
**2)** Allergies
**3)** Current meds and last dose
**4)** Informed consent signed
**5) Lab work:** CBC, blood type and screen
**6)** Pre-op teaching
**7)** Start IV + bolus
**8)** Clip abdominal hair
**9)** Administer pre-op antibiotic = Ancef (Cefazolin)
**10)** Meds to control gastric secretions = Pepcid
**11)** Insert catheter
**12)** Help patient onto table and place a hip wedge
**13)** Get grounding pad for cautery
**14)** Sterile prep of abdomen
111
What is dystocia and dysfunctional labor?
**Dystocia:** lack of progres in labor for any reason
**Dysfunctional labor:** long, difficult, or abnormal labor
112
Name 1 reason from each of the 5 P's that may contribute to dysfunctional labor:
**1) Passenger:** fetal causes, size, HR
**2) Passageway:** bony pelvic structure
**3) Power:** inneffective contractions or pushing efforts
**4) Position:** abnormal presentation
**5) Psyche:** maternal coping fails
113
What are risk factors for labor dystocia/dysfunction?
**1)** Advanced maternal age
**2)** Obesity
**3)** Nulliparity
**4)** Short stature
**5)** Possible induction of labor
114
What is hypertonic labor dysfunction and what is the nursing care?
**Hypertonic labor dysfunction:** painful and frequent contractions, but ineffective in causing cervical change
**Nursing care:** supportive coping, rest, **manage expectantly**
115
What is hypotonic labor dysfunction and what is the nursing care?
**Hypotonic labor dysfunction:** inadequate uterine activity
**Nursing care:** position changes, labor augmentation (pitocin, AROM)
116
What care possible causes for ineffective pushing during labor and what is the nursing care?
**Causes:** exhaustion, absent urge (anesthesia), or a very dense epidural
**Nursing care:** change positions, contact anesthesia about epidural rate, assisted delivery may be needed (vacuum, forceps), c-section prep
117
What are possible problems with the passenger in continued dysfunctional labor?
**1)** Fetal size - macrosomia
**2)** Fetal presentation/position - rotational abnormalities, deflexsion abnormalities, breech
**3)** Multifetal pregnancy
**4)** Fetal anomalies like hydrocephalus
118
Problems with passage: what is pelvic dystocia?
**Pelvic dystocia:** when a contracted pelvis reduces birth canal capacity caused by abnormalities, malnutrition, trauma, or immature pelvis
119
Problems with passage: what is soft-tissue dystocia?
**Soft-tissue dystocia:** non-bony obstructions such as placenta previa, fibroids, tumors, full bladder/rectum
120
Aside from soft-tissue and pelvic dystocia, what other passge problems can cause dystocia?
**1)** Edema
**2)** STIs can weaken the cervical tissue affecting dilation and effacement
121
What are possible problems with psyche in continued dysfunctional labor?
**1)** Environment
**2)** Fear
**3)** Lack of trust
122
What is prolonged labor and what are the risks?
**Prolonged labor:** labor that falls outside the normal labor curve (duration)
**Risks:**
**1) Maternal/neonatal infection**
**2)** Maternal exhuastion
**3)** High levels of anxiety in future labors
**4) Manternal hemorrhage**
123
What is precipitate labor and what are the risks?
**Precipitate labor:** is rapid birth **within 3 hours** of labor onset
**Risks:**
**1)** Tears
**2)** Infection
**3)** Fetal/maternal harm
124
What is preterm and what are the possible consequences?
**Preterm labor:** Any birth before 37 weeks
**Consequences:**
**1)** Developmental delays
**2)** Respiratory issues
**3)** Vision/hearing impairment
**4)** Financial/personal cost
125
**What is the second leading cause of infant death and what percentage of live births is it?
* Preterm birth is the **second leading cause** of infant death
* It accounts for **10.4% of live births**
126
Which group of individuals has the highest rate of preterm births?
Black individuals
127
What are factors associated with preterm birth?
**1)** Demographics
**2)** Social/economic
**3)** Medical complication
**4)** Obstetric history
**5)** Current conditions in pregnancy
128
What are risk factors of preterm birth?
**1)** Low pre-pregnancy weight
**2)** Smoking
**3)** Substance use
**4)** Short interval pregnancy spacing (less than 18 months)
**5)** H/o preterm birth
**6)** Cervical length concerns
129
What are signs/symptoms of preterm labor?
**1)** Palpable contractions
**2) ROM**
**3)** Pelvic/vaginal pressure
**4)** Low backache
**5)** Cramps
**6)** Vulvar/thigh pain
**7)** Bleeding/spotting
**8)** Diarrhea
130
**How is preterm labor defined? How many contractions in what time frame?
**Preterm labor:** regular contractions **AND** cervical changes
**Contractions:** 4 contractions in 20 minutes or 8 in 60 minutes
131
**Are bedrest and hydration effective mangement strategies in preterm labor?
No, they are not effective and outdated
132
**What four medications can be used to manage preterm labor?
**1)** Corticosteroids: Betamethasone
**2)** Tocolytic: Terbutaline
**3)** Tocolytic: Nifedipine
**4)** Tocolytic/neuroprotectant: Magnesium sulfate
133
**Betamethasone: what is it, rationale for use, route, dose
**What is it:** a corticosteroid used in the management of preterm labor
**Rationale:** used to enhance fetal lung development/maturity
**Route:** IM in the butt
**Dose:** two doses, each 24 hours apart between 24-33 weeks if at risk of delivery within 7 days
134
Terbutaline: what is it, rationale for use, MoA, route, side effects, max number of doses
**What is it:** a tocolytic acting helping to delay preterm labor
**Rationale:** short term use to delay delivery allowing time to administer corticosteroid (betamethasone)
**MoA:** Rleaxes uterine smooth muscle by stimulating B2 receptors reducing contractions
**Route:** SubQ
**Side effects:** Tachycardia (fetal and maternal), palpitations
**Max dose:** 3 dose max d/t side effects
135
Nifedipine: what is it, rationale for use, MoA, route, side effects
**What is it:** a tocolytic helping to delay preterm labor
**Rationale:** used to delay preterm labor in order to deliver corticosteroid
**MoA:** Calcium channel blocker in smooth muscle decreasing contractions
**Route:** PO
**Side effects:** hypotension, headache, dizziness, flushing, nausea
136
Magnesium sulfate: rationale for use in labor
**Rationale:** used for fetal **neuroprotection before 32 weeks** during preterm labor (can also be used as a tocolytic)
137
What is the most important way to prevent preterm birth?
Good prenatal care
138
When preventing preterm birth what needs to be communicated to the patient?
**1)** Importance of prenatal care
**2)** Education on normal pregnancy and warning signs
**3)** Consequences of preterm labor/birth
139
Define SROM, PROM, and PPROM
**SROM:** spontaneous rupture of membranes when water breaks at term and labor follows
**PROM:** prelaobor rupture of membranes is when spontaneous rupture occurs but **without labor following**
**PPROM:** preterm prelabor rupture of membranes is preterm and prelabor rupture
140
What should the nurse ask if a patient complains of vaginal discharge or a gush of fluid while pregnant?
**1)** When, amount of fluid, color, and odor
**2)** Any bleeding present
**3)** Any contractions, pain, or pressure
**4)** Is there fetal movement
**5)** What is your gestational age
**6) Instruct them to go to the clinic/hospital to be evaluated**
141
What might mimic rupture of membranes?
**1)** Urination, leakage
**2)** Vaginal discharge
142
**PPROM has a higher risk of neonatal and maternal complications. What are they?
**1)** Infection
**2)** Preterm labor
**3)** Nonatal morbidty
143
What are risk factors of PROM/PPROM?
**1)** Amniotic infections
**2)** Low BMI
**3)** Short cervical length
**4)** Smoking
**5)** 2/3rd trimester bleeding
**6)** Ilicit drug use
**7)** Low SES
**8)** H/o PROM/PPROM
144
What are complication of PROM/PPROM?
**1)** Intrauterine infection
**2)** Premature fetus
**3)** Newborn sepsis
**4)** Respiratory distress in newborn
145
How is PROM managed?
**1)** Weighing risks vs. benefits of expectant and induction of labor
**2)** GBS status
**3)** Monitoring for s/s of infection
**4)** Fetal monitoring
146
**How is PPROM managed?
**1)** Hospitalization (possibly for weeks)
**2)** Labor induction if possible at 34-36 weeks (if less than 34 weeks, infection versus preterm birth risks are weighed)
**3)** Monitor for infection (Tachycardia, temperature, tenderness)
**4)** Fetal considerations (**Goal = prevent complications of prematurity** = betamethasone for lung development, latency antibiotics, and mag sulfate for neuroprotection)
147
**What is chorioamnionitis? What is Triple I?
**Chorioamnionitis:** bacterial infection of the amniotic cavity
**Triple I:** Intrauterine inflammation, infection, or both (indicates the origin of the chorio)
148
**What are risk factors of chorioamnionitis?
**1)** Prolonged ROM
**2)** Multiple vaginal exams
**3)** Prolonged labor duration
**4)** Low SES
**5)** Nulliparity
**6)** Young age
149
**What are the symptoms of chorioamnionitis?
**1)** Maternal temp of 100.4+ **AND one of the following:**
**2)** WBC >15,000
**3)** Maternal HR >100
**4)** FHR >160
**5)** Tender uterus
**6)** Foul smelling amniotic fluid
150
**What are neonatal complications of chorioamnionitis?
**1)** Pnueomonia
**2)** Bacteremia
**3)** Meningitis
**4)** Respiratory distress syndrome
**5)** Inflammatory response -> pulmonary + CNS damage
151
**What is the nursing role in chorioamnionitis?
**1) Antibiotics:** ampicillin/gentamycin, penecillin
**2)** Expedite delivery
**3)** Intrauterine resuscitation
**4) Intrapartum:** maternal and fetal vitals, antibiotics, education
**5) Postpartum:** endometritis, UTI, and spesis monitoring, S/S education on infection
152
What is cord prolapse? What is the main problem?
**Cord prolapse:** It is when the umbilical cord prolapses out of the uterus in front of the presenting fetus cuasing compression of the cord between the fetus and pelvis
**Problem:** Cord compression decreases O2 delievery to fetus possibly resulting in death
153
What are risk factors for cord prolapse?
**1)** PROM
**2)** Polyhydramnios
**3)** Long umbilical cord
**4)** Fetal malpresentation
**5)** Multiparity
**6)** Multiple gestation
**7)** High fetal station
**8)** Growth restricted fetus (small)
154
**What is the nurse role in cord prolapse?
**1)** **support the fetal head** - put on a sterile glove and lift the head to relieve compression. You must stay in this position until c-section.
**2)** Get help and position **maternal hips higher than head**
155
What is shoulder dystocia and turtle sign?
**Shoulder dystocia:** The descent of the anterior or posterior shoulder is obstructed by the pubis symphysis
**Turtle sign:** infant's head come out of the vagina and then gets sucked back in slightly and wont move
156
What are risk factors for shoulder dystocia?
**1)** Large birth weight/size (large for gestational age/macrosomia)
**2)** Diabetes melitus
**3)** Prolonged labor
**4)** Excessive weight gain in pregnancy
**5)** H/o of prior shoulder dystocia
157
How is shoulder dystocia diagnosed?
Diagnosed when there is failure to deliver the shoulder and slight downward traction does not move the infant
158
What are maternal and neonatal complications of shoulder dystocia?
**Maternal:**
**1)** Higher risk of PP hemorrhage and lacerations
**2)** Obstetric anal sphincter injuries
**3)** Symphaseal separation and lateral femoral cutaenous neuropathy
**Neonatal:**
**1)** Brachial plexus injuries
**2)** Clavical/humerus fractures
**3)** Encephalopathy d/t asphyxiation
**4)** Death
159
**What is the nursing role in shoulder dystocia?
**1) COMMUNICATE**
2) Do your assigned role
**3) Document:** time of head delivery, time of shoulder dystocia diagnosis, and time of delivery
4) Request help -NICU/RNs
5) Communicate to the **pregnant person to not push**
6) Assist with first maneuvers (McRobert's, suprapubic pressure
**7) NEVER GIVE FUNDAL PRESSURE**
160
What two maneuver's can help in shoulder dystocia and how are they done?
**1) McRobert's:** place the pregnant person supine with legs pulled up toward the chest (helps shift the pelvis)
**2) Suprapubic pressure:** place downward pressure just above the pubic bone (helps push the shoulder down)
161
What is the incidence of baby blues and postpartum depresision
**1) Baby blues:** 80-85% of pregnant people will experience this
**2) PP Depression:** 8-20% of PP individuals will experience this, about 1in 7
162
What are the baby blues, when do they peak, and when does it resolve?
**Baby blues:** a **transient period** of "depression" that is common PP and may be d/t hormonal fluctuations, sleep deprevation, and role change
**Peak:** 3-5 days after delivery
**Resolves:** 10-12 days PP, self-resolving
163
What are the symptoms of the baby blues?
**1)** Mood lability
**2)** Anxiety
**3)** Sleeplessness
**4)** Crying
**5)** Loss of appetite
164
**What is the nursing role in baby blues?
**1) Education**
* S/S of depression
* Provide resources
* Discuss sleep hygiene
* Discuss infant behavior regulation
165
What is perinatal or pospartum depression and what is the diagnosis?
**PP Depression:** major of minor depressive episodes that occur during pregnancy or the first 12 months after birth
**Dx:**
**1)** depressed mood and/or anhedonia must be present for most of the day for two weeks with at least 5 of the following
**2)** changes in weight or appetite (loss/gain)
**3)** Insomnia or hypersomnia
**4)** Psychomotor agitation or slowness (apparent to others)
**5)** Fatigue
**6)** Feelings of worthlessness/guilt (often with helplessness/hopelessness)
**7)** Thoughts of death or suicide
**8)** Functional impairment must be present
166
How is postpartum depression different than the baby blues?
**1)** PP depression often accompanied by a previous history of mood disorders/episodes
**2)** PP depression is longer than baby blues, it lasts at least two weeks and is more severe with **functioning impaired**
**3)** PP depression is not self resolving while baby blues is
167
What mental health disorder is most common is those who experience postpartum psychosis?
**1)** bipolar disorder 1 (up to 30%)
168
What non mental health factor contributes significantly to postpartum psychosis development?
Sleep deprivation for >48 hours
169
What is bereavement and mourning?
**Bereavement:** entire process precipitated by the loss of a loved one through death
**Mourning:** the cultural/public display of grief through one's behavior; a process through which grief may be resolved
170
What are the 5 stages of grief by Kubler-Ross? Do these stages follow a linear path?
**1) Denial** - shock, numbness, disbelief
**2) Anger** - guilt, frustration, anxiety
**3) Bargaining** - difficulty finding meaning, reaching out to others
**4) Depression** - searching, disorientation, overwhelmed, hostility
**5) Acceptance** - resolution, moving forward, integration
* These stages do not follow a linear path and individuals may go through all of them, some of them, in any order, and may reexperience them
171
Define early and late pregnancy loss, and concurrent death on survival multi-fetal pregnancy:
**1) Early pregnancy loss:** loss in the first or second trimester, less than 20 weeks
**2) Late pregnancy loss:** intrauterine fetal death (IUFD) and still birth >20 weeks
**3) Concurrent death:** Loss of one twin
172
What is nursing care for grief and loss in childbirth?
**1)** Being sensitive and emotionally present, responsive to grief
**2)** Comprehensive plan of grief care
**3)** Clinic and hospital guidelines use and social service use
**4)** Offer written material
**5)** F/u with the parents by phone, card, or at a clinic visit
173
What is the postpartum period considered? What are some challenges during this time?
**PP period:** The first 6 weeks after birth
**Challenges:** sleep, fatigue, pain, breastfeeding, stress, exacerbation or onset of mental health issues, lack of sexual desire, substance abuse, intimate partner violence
174
What is involution and what can it be ehanced by?
**Involution:** the rapid reduction in size of the uterus and return to prepregnancy state
**Enhanced by:** uncomplicated labor and birth, complete placental expulsion, breastfeeding, and early ambulation
175
What is subinvolution and what does it increase the risk of?
**Subinvolution:** when the process of involution does not happen properly
**Risk for:** PP hemorrhage
176
What is exfoliation?
It allows for the healing of the placental site and is an important part of involution
177
Where should you expect the uterus to be after birth? How far should it drop each day after birth?
**After birth:** At umbilicus
**Drop:** It should drop one fingerbreadth each day after birth (i.e. 2 days = 2 fingerbreadths below umbilicus)
178
Who is after pain/involution more acutely uncomfortable for?
**1)** Multiparas
**2)** Distended uterus (multifetal gestation, polyhydramnios, LGA, retained blood clots)
**3)** Breastfeeding person - more cramping d/t oxytoxin
179
What are nursing consideration for involution/after pains?
**1)** Administer analgesics short term (Tylenol/motrin)
**2)** Change positions
**3)** Apply heat
180
What should lochia look like postpartum?
**1)** After birth - bright red
**2)** First 3 days: dark red - "rubra"
**3)** 4-10 days: pink-brown-tinged - "serosa"
**4)** Days 11-14 (up to 6 weeks): cream, yellow - "Alba"
**5)** Onward: clear
181
**How much blood loss is expected postpartum?
Up to 500 mL of blood loss is expected
182
What happens to the cervix and uterus postpartum?
**Cervix:**
**1)** Internal os closes and cervix returns to almost normal
**2)** External os may remain slightly open (1cm) and is slit-like by 1 week
**Vagina:**
**1)** Rugae regained by 3-4 weeks
**2)** Edematous tissue resolves by 6-10 weeks
**3)** Mucpsa becomes atrophic and does not regain its thickness until estrogen production by ovaries is reestablished
**4)** Breastfeeding people are likely to experience vaginal dryness and dyspareunia (painful intercourse)
183
How does the body tolerate substantial bloodloss during childbirth?
By undergoing hypervolemia
184
How is cardiac output affected postpartum?
**1)** Immediately after delivery it increase
**2)** Returns to normal pre-labor values within an hour
**3)** 6-12 weeks it returns to pre-pregnancy levels
185
How does plasma volume return to pre-pregnancy levels postpartum?
**1)** Diuresis
**2)** Diaphoresis
186
What two factors clotting risk increased postpartum and when do they resolve?
**1)** Leukocytosis occurs increasing WBC to >30,000 during labor and immediately following - Resolves in 6 days
**2)** Increased plasma fibrinogen; resolves within 4-6 weeks PP
187
How is elimination affected postpartum?
**1)** Intestines are sluggish b/c of progesterone and decreased muscle tone
**2)** BM may not occur for 2-3 days
**3)** Temporary constipation is common
**4)** Normal elimination is achieved by days 8-14
188
**How is the urinary tract affected postpartum?
**1)** Diminished sensitivity to fluid pressure = lack of urge to void
**2)** Bladder fills rapidly d/t diuresis increasing the risk of distension adn retention of risidual urine increasing the risk of UTIs
**3)** Stretched uterine ligaments can allow a full bladder may push fundus from midline
**4) Stress incontinence** may occur, but improves within 3 months and with pelvic floor exercises
189
**If the fundus is not midline, what should you first suspect?
You should suspect bladder distension
190
**What is the problem with bladder distension pushing the fundus from midline?
Decreases uterine contraction leading to atony and increased risk of postpartum hemorrhage
191
How is the musculosketeal system affected postpartum?
**1)** Relaxin gradually decreases and the ligaments and cartilage of the pelvis return to pre-pregnancy conditions; may cause hip/join pain
**2)** May have overall muscle ache/fatigue for 1-2 days d/t labor effort (arms, neck, shoulder back)
192
Diastesis recti: what is it, when does it resolve, how can you help reduce it
**What is it:** when the longitudinal abdominal wall muscles are separated
**Resolves:** within 6 weeks
**Reduce:** can help reduce it with gentle abdominal exercises to strengthen muscles
193
Postpartum neurologic difficulties: bilateral/frontal and spinal headache - what causes them and how do you treat spinal headaches
**1) Bilateral and frontal headaches:** within the first week d/t changes in fluid and electrolyte balances
**2) Spinal headache:** headache caused by **CSF leak** after epidural, may be more **severe when upright** and relieved when supine
* **Tx:** blood patch
194
What are endocrine changes to ovulation during the postpartum period?
**1)** The first few cycels, lactating and non-lactating are often anovulatory
**2)** Ovulation may occur before menses return
**3)** Ovulation resumes as early as 3 weesk PP
**4) Non-breastfeeding:** 6-8 weeks start ovulating, almost all by 6 months
**5) Breastfeding:** resume as early as 8 weeks or 18 months
195
Describe postpartum weight loss immediately after, in the following weeks, and adipose tissue:
**1)** Immediately post partum: 10-12 pounds are lost from the fetus, amniotic fluid, blood loss, and placenta.
**2)** 2 weeks postpartum: 9 pounds are lost as fluid
**3)** Adipose tissue: gained during pregnancy is hard to remove and **takes about 6-12 months to reach prepregnancy weight**
196
How long are hospital stays for vaginal deliveries and for c-sections?
**Vaginal:** 1-2 day stay
**C-section:** 2-4 day stay
197
What is the postpartum assessment schedule?
**1)** Immediately following birth: every 15 minutes for 1 hour, then every 30 minutes for 1 hour, then every hour for 2 hours
**2)** Then Q4H for 24 hours
**3)** Then Q8H until dischage
198
What are the 7B's + E
**1)** Brain
**2)** Breasts
**3)** Belly
**4)** Bladder
**5)** Bottom
**6)** Bloods
**7)** Bowels
**8)** Extremities
199
What is the brain assessment as part of the 7 B's
**Brain:** emotional status, feelings toward birth experience, having a new child, bonding
200
What is the breasts assessment as part of the 7 B's
**Breasts:**
* Breast vs. formula feeding
* Tenderness
* Soft vs firm
* Color
* Nipples everted, flat, inverted
* Signs of nipple trauma = air dry them, apply cream to soothe
* May feel lump as lobes begin to produce milk
201
What is the belly assessment as part of the 7 B's
**Belly:**
* Incision and dressing if c-section
* Uterus consistency and location (up and right = bladder distension?; soft/boggy = fundal massage pressing down to lower segment)
202
What is the bladder assessment as part of the 7 B's and what are signs of a distended bladder?
**Bladder:**
* Monitor first 2-3 voids post birth or removal of catheter
* 300-400 mL voids indicates empty bladder
**Signs of distended bladder:**
**1)** fundus displaced from midline
**2)** excessive lochia
**3)** bladder discomfort
**4)** base of bladder above pubic symphysis
203
What is the bottom assessment as part of the 7 B's
1) Inspect the perineum for healing of any lacerations and episiotomy
2) Inspect for edema and hematoma
3) Use a peri bottle after using the bathroom, **pat dry instead of wiping**
4) Change pads
5) Use ice and topical agents for comfort
204
What is REEDA when in specting the perineum/bottom area?
**R:** redness
**E:** Edema
**E:** Ecchymosis (bruising)
**D:** Discharge (from leison/incision)
**A:** Approximation (are any sutures well-approximated = together, or are they coming apart?)
205
What is the blood assessment as part of the 7 B's
**1) Check:** amount, type, odor (foul may indicate endometrial infection)
* **Scant:** < 2.5cm
* **Light:** 2.5-10cm
* **Moderate:** 10-15cm
* **Heavy:** pad fully saturated within < 1 hour **(concerning)**
206
What is the bowels assessment as part of the 7 B's
**1)** Gas is common especially in c-section with anesthesia causing sluggishness = increase fiber and fluids, use stool softener
**2)** BM usually occurs in 2-3 days following birth
**3)** Constipation may cause hemorrhoids
207
208
What is the extremities assessment as part of the 7 B's + E
Extremities: inspect legs for variosities and signs of thrombophlebitis
Edema and DTR: pedal or peritibial edema may be present, often goes away days 2-5
Abmulation: assess level of feeling and ability to move if anasthesia is used
209
**What comfort measures can be taken postpartum?
**1) Ice packs:** to cause vasoconstriction, prevent edema, best in **first 12-24 hours**
**2) Sitz bath:** first 12 hours cool water to reduce pain; 24+ hours use warm water to promote circulation and healing
**3) Pericare:** squit warm water over perineum after each void + and bowel movement to cleanse area, provide comfort, and prevent infection
**4) Aromatherapy:** for anxiety, nausea, and pain
**5) Acetaminophen:** pain relief
**6) Ibuprofen:** antiinflammatory and pain relief
**7)** Alternate ibuprofen and acetaminophen
**8) Narcotics:** surgical or severe pain as needed
**9) Topical:** witch hazel for comfort
210
How does breast care differ for bottle vs breast feeding:
**Bottle:** wear sports bra, use ice, ibuprofen for pain relief, body will absorb milk
**Breast:** educate on s/s of mastitis, proper latching to avoid trauma, air dry after feeding
211
**What postpartum warning signs indicate you should call your provider?
**1)** Severe mood changes, thoughts of harming onself
**2)** Concerns for infection (tender uterus, painful breasts, fever, chills)
**3)** Heavy bleeding
**4)** High BP
**5)** Increase in swelling
**6)** Shortness of breath
212
What are important sexual education points postpartum?
**1) Nothing in the vagina for 6 weeks postpartum**
**2)** Vaginal dryness is common (use lubricants and vaginal moisturizers)
**3)** Milk letdown with orgasms is common
**4)** Decreased sexual interest in initial postpartum period is common
213
Which contraceptive method can you not use while breastfeeding?
You cannot use combined birthcontrol methods (combined pill, patch, ring)
214
Describe each stage of perineal laceration:
**Stage 1:** tear is limited to fourchette, **superficial** skin, or vaginal mucosa
**Stage 2:** laceration includes the above and extends to **perineal muscles**
**Stage 3:** Tear includes the above and **anal** sphincter
**Stage 4:** Tear includes the above and **rectal mucosa**
215
What is the most preventable cause of maternal mortality?
PP hemorrhage
216
How is PP hemorrhage diagnosed?
Cumulative **blood loss of >1,000 mL** **OR** blood loss accompanied by s/s of **hypovolemia within first 24 hours** pp
217
What is early PP hemorrhage and what is late PP hemorrhage?
**Early:** hemorrhage within first 24 hours PP
**Late:** hemorrhage after first 24 hours up to 12 weeks PP
218
What are causes of PP hemorrhage:
**1) Uterine atony**
**2)** Lacerations
**3)** Retained placenta
**4)** Abnormally adhered placenta (accreta)
**5)** Defects in coagulation (DIC)
**6)** Uterine inversion
219
**What are risk factors for PP hemorrhage?
**1)** Prolonged use of oxytocin
**2)** High parity
**3)** Chorioamnionitis
**4)** General anesthesia
**5)** Twins or multiple gestation
**6)** Fundal implantation of cord
**7)** Operative vaginal delivery
**8)** Precipitous delivery
**9)** Placental abruption or previa
**10)** Fetal death
**11)** Fever, sepsis
**12)** Anticoagulation
220
What might a high risk PP hemorrhage look like?
* Low hematocrit (< 30)
* Placenta previa, accreta, increta, or percreta
* Bleeding
* Coagulation defect
* H/x of PP hemorrhage
* Abnormal vitals (high HR, low BP)
221
What is the main cause of early PP hemorrhage? What can cause uterine atony?
**Uterine atony** causes 70-80% of cases where the uterus fails to contract effectively
**1)** Overdistension of uterus (multiple gestation, movement, polyhydraminos)
**2)** prolonged labor
**3)** long use of labor augments
**4)** obesity
**5)** infection
222
What are the symptoms of PP hemorrhage?
**1)** uterine atony
**2)** blood clots
**3)** perineal pad saturation in < 15minutes
**4)** constant oozing, trickling, or frank flow with bright red blood from vagina
**5)** Increased HR, low BP
**6)** Pallor or skin, cold, clammy, poor turgor
**7)** Oliguria
223
**How is PP hemorrhage managed?
**1) FUNDAL MASSAGE TO CREATE CONTRACTIONS (primary action)**
**2) Quantify blood loss (QBL):** weight saturated pads, measure fluids, subtract irrigation
**3) Assess and manage uterus:** fundal massage, check height, firmness, position, check lochia
**4) Check for bleeding source:** check lacerations, episiotomy, hemtomas
**5) Vital signs and circulation:** BP, HR, O2 sat, **elevate legs 20-30 degrees**
**6) Bladder management:** assess for distension, catheter if needed
**7) Fluids + 02:** maintain IV fluids and O2 support at 10-12L/min via nonrebreather
224
What medications can be used to manage PP hemorrhage?
**1)** Pitocin
**2)** Methylergonovine (Methergine)
**3)** Misoprostol (Cytotec)
**4)** Hemabate (Carboprost tromethamine)
**5)** Transexamic acid (TXA):
225
Pitocin: what does it do, use, route
**What:** contracts uterus
**Use:** pp as postpartum hemorrhage prevention
**Route:** IM, IV dilution, IV during c-section
226
Methylergonovine (Methergine): what does it do, use, route, contraindication
**What:** contracts vascular smooth muscle
**Route:** IM (acute), PO
**Contraindication:** Hypertension or cardiac disease
227
Misoprostol (Cytotec): what does it do, route, onset
**What:** contracts uterus
**Route:** buccal, PR (rectally)
**Onset:** 15-20 minutes (slow)
228
Hemabate (Carboprost tromethamine): what does it do, route, contraindications, side effect
**What does it do:** contracts uterus
**Route:** IM
**Contraindications:** **asthma**, renal/liver/cardiovascular damage
229
Transexamic acid (TXA): what does it do, route, when
**What:** antifibrinolytic, aids in blood clotting
**Route:** IV
**When:** 20-30 minutes prior to or PRN for postpartum hemorrhage
230
Hematoma: what is it, symptoms, causes, location, treatment
**What is it:** when blood enters loose connective tissue while overlying skin is intact
**Sx:** deep, severe, **unilateral pain,** pressure, hypovolemia (tachycardia, hypotension)
**Causes:** bleeding lacerations r/t episiotomies or operative deliveries, injury to vessel in asbesence of laceration/incision
**Location:** vulva, vaginal/paravaginal, retroperitoneum
**Tx:** **conservative tx firt (elevation),** surgical intervention, arterial embolization
231
232
