Final Flashcards
(273 cards)
1
Q
What does specialty nursing require?
A
commitment to praxis: knowing, being, doing
2
Q
What processes are required for specialty nursing care?
A
grounded in relationship centered praxis:
professionalism
creative leadership
partnership
communication
systemic inquiry
collaboration
critical thinking
involves integrating nursing ethics!
3
Q
Where does relationship centered praxis come from?
A
from our values/beliefs attained via personal experiences
4
Q
Can you think of a situation from your own nursing practice where your relationship with your client/patient made a difference in providing care and/or enhanced health promotion?
A
From caring for the same patient over a span of three days straight I was able to build a therapeutic relationship with the patient and gain a better understanding of their hospitalization experience. From building this relationship with my patient, my patient really valued what I taught and took action. E.G. Educated the patient on mobilizing, patient motivated and instantly got up to mobilize.
5
Q
What is perinatal nursing?
4
A
specialty
timeline: pregnant, L&D, up to d/c
family-centered: women, newborn, family as a whole within the context of their lives/environment
*more specifically women-focused care (because at center of each child-bearing relationship is a woman)
6
Q
How do families/communities impact the women that we care for?
A
it is the social context in which women live in
alters attitude/accessibility to HC/relationships with HCP
7
Q
What is neonatal nursing?
A
specialty
involves care for: neonate/infant (preterm/ill) up to 1 year, family
timeline: birth, hospitalization, d/c & follow up
8
Q
Hx of maternity nursing
A
Early 20th century: birth transitioning from midwifery to hospital d/t high mortality rates of mom/baby
analgesics & separate rooms for L&D/nursery/decreased BF
were hospitalized up to 14 days
treated women as if they were sick
1960-1970’s: ICEA lobbied for changes
women’s movement also more powerful at this time
Family centered care model evolved & integrated into practice
9
Q
When was positive pressure mechanical ventilation created
A
1970s
forever changed practice of the NICU
10
Q
Two important aspect of neonatal nursing
A
1) characteristics of infants are considered (how they interpret/interact with environment)
2) physical/psychological growth & development is appreciated, influences of context on the infants vulnerability is considered
11
Q
disadvantages of maternity care in Canada
A
Unequal in accessibility (rural areas, aboriginals)
Shortage of HCPs
Limited provinces offer midwifery care
12
Q
How to fix these disadvantages?
A
2005: “Multidisciplinary Collaborative Maternity Care Project”
- addresses shortage of HCPs
2006: SOGC initiated “A National Birthing Strategy for Canada”
- goal is to improve maternity care in rural areas
Perinatal Services BC
- to develop regionalization of perinatal care in BC
13
Q
4 aspects of nursing care central to relationship centered praxis
A
Communication and collaboration
Education, information and informed consent
Support and advocacy
Nursing ethics: relationships and care
C-ESN
14
Q
What is communication
3
A
written, verbal and non-verbal
meanings exchanged among individuals to come to mutual understanding
basis for forming partnerships
15
Q
What does collaboration involve
A
respecting choices
informed decision making (capacity/comprehension)
16
Q
what should informed consent include
A
Explain situation
Description of recommendations (care, test, procedure)
Common risks/benefits
Alternative options
17
Q
Support/Advocacy
A
To not just care for a women, but to be there with her in our caring.
Presence
Should provide: physical/emotional/informational support, adovacy (interpret wishes to others)
18
Q
Can you think of a situation where the focus of care may not be clear and even present a moral dilemma for the caregiver?
A
If parents chose to have the baby terminated after finding out the baby has a disability. It would be difficult to set aside own beliefs/values.
19
Q
Example of ethical practice
A
Nurse who is working in the intrapartum setting with a woman who has requested no analgesics for her labor. Morally, good nursing care respects this decision and works with the woman using non‑pharmacological methods to help her with her labor, and supports her in trying to realize her wishes.
20
Q
8 CNA code of ethics
A
safe, competent, ethical care health & well being choice dignity confidentiality/privacy justice accountability quality practice environments
21
Q
Why was family/women-centered care created
A
To get away from the medical model (sedative, partner absent for birth, neonates separated from parents)
22
Q
What is family centered care?
A
Process of providing safe, skilled, and individualized care that responds to the psycho social needs of the woman and her family
pregnancy/L&D normal health events
23
Q
factors impacting family centered care
A
Environment: e.g. separate birthing units/pp units
Collaboration between HCP e.g. anesthetist, doulas, lactation consultant
24
Q
What definition of family best fits your family?
A
The family is a group of two + who are joined together by bonds of sharing and emotional closeness and who identify themselves as being part of the family (Friedman, 1992).
25
Can you think of families who may disagree with this definition?
Individuals who believe that anyone who is "blood" is family... no matter how close you are or the bond that you share.
26
common themes in family definitions
Concern for the well-being of family members is common to all of the definitions. (Use different words)
Beutler et al. (generational ties) and Stewart (future obligation) both refer to a time factor.
Friedman, Hanson et al., and Stewart all suggest that there is an element of family membership which is self-defined.
27
How does Davies view family?
Davies seems to view families as including children and their parents. This is commonly referred to as a “nuclear” family form. We could refer to these families as “childbearing.”
28
Developmental theories
families/individuals go through series of predictable stages of change over time
e.g. Erikson- childs emotional development
Piaget- childs cognitive development
29
Duvall
Focuses on the changes that families go through over time
30
Duvalls 8 stages:
```
I Married couples
II Childbearing families
III Families with pre-school children
IV Families with school children
V Families with teenagers
VI Families launching young adults
VII Middle-aged parents
VIII Aging family members
```
For each stage there is a developmental task that needs to be completed!
31
Duvalls 2 developmental tasks for childbearing families
1) realizing the child really exists
- accepting new/added responsibility
- orienting to parent role
- begin bonding with child
2)adjusting family life to incorporate new baby
32
Duvalls developmental task for preschool/school-aged children
pre-school: to socialize/nurture children
School-aged: to promote success in school
33
5 tasks for ALL stages
physical maintenance
division of labor
allocation of resources
socialization
reproduction, recruitment, and release of family members.
34
How might families today relate to Duvalls 8 stages
Alot of families will not clearly fit into one of the 8 stages.
(single parent families, blended families, younger/older parents)
Depending on family you could say that they are working on a variety of stages at the moment.
35
How might families today relate to the 5 tasks Duval states is relevant to EACH stage
Most families relate to the 5 tasks relevant for each stage
However, they may implement them differently
36
How might Betty Davies describe families today
(believes families are subject to change over time!)
Believes families are resilient
Believes that when families are given challenges, if they have the appropriate support/resources they will work through it
37
6 factors influencing parental behaviour
| Merenstein/Gardner
personality
personal experience
previous parenting
cultural background
the degree of attachment to the infant
the expectations the parents have of themselves/infant
38
7 Factors associated with stress/role strain (Kenner)
role ambiguity (i.e. single parents, unsure of who father is)
conflict (i.e. being torn between being a teenager/mom)
incongruity
overload (i.e. returning to work, supportive partner?, birth of twins)
underload
```
over qualification
under qualification (i.e. young mothers, not enough life experience)
```
39
benefits of support during labour
research states it is associated with:
shorter labors
decreased use of oxytocin
fewer operative births/cesarean sections
and a higher rate of satisfaction for the mother
40
5 aspects of supportive care
emotional support
advocacy
comfort measures
supporting the husband/partner
offer information/advice
41
How long should BF be implemented for
exlusively for 6m
| then continued for 2 years while introducing other foods
42
3 fetal periods
pre-embryonic (0-2)
embryonic (2-8)
fetal (9-term)
43
pre-embryonic period
| 0-2weeks
conception to implantation
fertilized egg differentiates into specialized cells, travels down fallopian tubes & implants in uterus
44
embryonic period
| 2-8weeks
```
rapid G&D occurs
organogenesis
heart starts beating
rapid brain G&D
arms/legs develop joints
```
45
fetal period
| 9weeks-Term
By week 14 placenta formed & functioning
organogenesis continues
major increase in size/weight in last 10-12 weeks
46
When does the placenta begin to develop
| when is it structurally complete?
first week after conception
| complete after 12 weeks
47
normal amount of amniotic fluid at term
800-1200
2000 HIGH- d/t GI/fetal anomalies
48
When does the embryos heart start beating?
day 17 after conception
49
What are the 4 hormones that the placenta produces?
Estrogen
Progesterone
Human chorionic gonadotrophin
Human placental lactogen
50
What does Estrogen do?
| 3
increases uterine growth
increases placental blood flow
increases glandular tissue in breast
51
What does progesterone do?
| 4
maintains endometrium
decreases contractility of the uterus
increases production of breast alveoli
increases maternal metabolism
52
What does human chorionic gonadotrophin do?
aids function of the corpus luteum (making sure continued supply of hormones to maintain pregnancy.
53
What does human placental lactogen do?
| 3
stimulates the maternal metabolism to supply nutrients for fetal growth
increases maternal resistance to insulin, and facilitates glucose transport across the placental membrane
stimulates breast development in preparation for lactation
54
4 metabolic functions of the placenta
excretion
nutrition
storage
respiration
55
fetal vs. maternal side of placenta
Fetal side:
smooth/shiny/bluishpurple, with veins branching out from the umbilical cord (like tree roots).
Maternal side:
rough/gritty/red, looks like a liver, contains 15-20 cotyledons, sometimes has grey/white calcium deposits
56
5 key features of fetal circulation
fetal oxygen needs are relatively low
the placenta is the organ of gas exchange
the fetal lungs are collapsed and fluid filled
the fetal brain and heart have the highest oxygen needs.
right-to-left shunting occurs through the ductus arteriosus and foramen ovale.
57
explain what is meant by the fetus exists in a state of relative hypoxemia
the PO2 of the fetus is only 30, which would cause hypoxia in the extra-uterine life.
PO2 of 30 sufficient inutero- zero hypoxia
O2 needs low because maternal system conducts many O2 using functions such as metabolism/digestion/thermoregulation, and zero ventilation is occurring.
58
effect of low PO2 on the ductus arteriousus/pulmonary arteries
Results in pulmonary vasoconstriction and causes dilation of the ductus arteriousus.
This pulmonary vasoconstriction leads to increased pulmonary vascular resistance, high pulmonary artery pressure, righttoleft shunting, and pulmonary hypoperfusion.
59
Does the R or L ventricle have more pressure?
The right ventricle — because it is pumping blood to collapsed, fluid-filled, vasoconstricted lungs — is experiencing higher pressure than the left ventricle which is pumping blood to the low pressure placenta.
*blood always flows in a path of least resistance
60
How does an increased PO2 impact adaptation
leads to pulmonary vasodilation
ductus arteriousus closes
L to R shunting d/t pressure change
61
What occurs with perinatal asyphyxia
blood shunted to heart/brain
all organs eventually become hypoxic
metabolic acidosis occurs
combo of acidosis/hypoxia results in cardiac/resp depression
low apgar score
62
effects of benzodiazepines during pregnany
risk of cleft lip/palate
63
effects of acutane during pregnancy
structural/sensory damage (neck&cranial region)
64
effects of aspirin during pregnancy
risk of abruption
65
effects of ibuprofen during pregnancy
can cause closure of the ductus arteriosus
66
effects of cocaine during pregnancy
urinary tract defects
67
effects of alcohol during pregnancy
skeletal abnormalities, heart defects, cleft palate, vision/hearing problems
68
causes of low birth weight
preterm
| IUGR
69
two types of IUGR
hypoplastic: early in gestation, decrease in number of cells, small head/body, symmetrical
hypotrophic: later in gestation, decrease in size of cells, big head/small body, asymmetrical
70
SGA maternal causes
PIH (decreased blood flow to placenta)
malnutrition
maternal drug use (decreased blood flow to placenta)
71
SGA intrauterine causes:
placenta previa (decreased perfusion of nutrients d/t improper implantation of placenta)
small placenta (decreased perfusion)
teratogens (inhibit fetal growth)
72
SGA fetal causes
genetic defects resulting in decreased growth
73
preterm risk factors
maternal medical/past-preg hx
diabetes
HTN
renal disease
abortion
pre-term birth
uterine abnormalities
```
current preg hx
multiple gestation
placenta previa/abruption
abd. surgery
febrile illness
```
socioeconomic factors: single, poor, lack of education
74
Why are preterm infants more at risk for hypothermia?
```
less brown fat
less subcutaneous tissue
immature CNS-> inadequate temp. regulation
fewer nutrient stores
thinner skin
```
etc.
75
what does surfactant do?
prevents alveoli from collapsing
preterm infants have less surfactant resulting in atelectasis/increased work of breathing
76
F&E imbalances in preterm infants
increased total body water (80–85% of body weight).
increased extracellular water.
immature renal function.
++ Water losses d/t:
skin immaturity (evaporation)
increased body SA: body mass
77
why is absorption of protein/fat/carbs in the GI tract difficult for preterm infants
Feeding:
unable to coordinate sucking/ swallowing/ & breathing
impaired gag/cough reflexes
GI tract:
impaired cardiac sphincter-> gastroesophageal reflux
delayed gastric emptying
incompetent ileocecal valve
impaired rectosphincteric reflec.
78
Why is it difficult for preterm infants to deal with fluid overload/restriction
Overload: kidneys immature, so low GFR, unable to filter extra fluid
Restriction: immature kidneys cannot concentrate urine, water not easily reabsorbed
79
what are post-term infants at risk for?
```
asphyxia
meccnium aspiration syndrome
dysmaturity syndrome
hypoglycemia
polycythemia
respiratory distress
```
80
```
pre-mature
late preterm
term
post-term
post mature
```
pre-mature: 42
| post mature: >42 with S&S of placental insufficiency
81
fetal/maternal blood exchange
NO mixing of blood unless break in cell membranes
O2/nutrients/toxins go through "sieve" aka cell membranes that line the outside of the chorionic villi
82
Fetal circulation adaptations
```
organ of gas exchange lungs
PO2 60-80
CO2 50
Low pulmonary resistance
High systemic resistance
L to R shunting/pressure gradient
Forman ovale closes
Ductus arteriosus closes
```
83
Fetal assessment
| 5
```
FHR
fetal movement
palpation
fetal growth
gestational age
```
84
When can women offer preconception education to child-bearing women?
Public health nurses
Anytime in contact with child-bearing women
Visiting school nurse i.e. sex education
Perinatal nurses i.e. healthy eating, lifestyle choices
85
low birth weight
1500-2499
very low if <1500 (100x mortality)
86
dietary consideration
folic acid/folate (0.4) reduces NTD
Iron (16-20) for RBC producion
Fish for omega3 (150g)
87
why are pregnant women more at risk for anemia
increase in circulating volume when pregnant, specifically plasma. Increase in RBC is not as great as plasma, and d/t low hgb/hct at risk for anemia.
88
optimal weight gain
6.8-18.2kg
or 0.4kg/week
89
recommendations for vegetarians
Increase calories
| Take Vit B12
90
3 positive signs of pregnancy
Visualization of the fetus by ultrasound
auscultation of fetal heart tones
palpation or visualization of fetal movement.
91
4 signs of pregnancy often noted by women
Fatigue
nausea
breast tenderness or tingling
urinary frequency
92
When would supine hypotension occur?
2nd trimester
93
What is the couvade syndrome
When men experience S&S of pregnancy such as stress, weight gain, N&V
94
what does antenatal care include?
```
pre-conception counselling
assessing risk factors
assessment of fetus/complications
educate
birth care options
```
95
How often should parents have Dr. appointments?
seen first within 12w of LMP
then q4-6w until 30w
then q2-3w until 36
then qweek
96
Benefits of birth plans
communication tool for parents
good for when nurses switch during breaks/shift change
97
Disadvantages of birth plan
it is an *ideal* plan and if things dont go as planned it can cause dissapointment
98
Difference between breast feeding and breast milk feeding?
breast milk feeding does not promote bonding
does not stimulate release of hormones via skin-to-skin/suckling (Critical for maintaining breastfeeding)
99
when does lightening occur?
between weeks 38-40
fundus drops as fetus descends into the bony pelvis
AKA "the fetus is engaged"
100
operculum
mucus plug formed in cervix
when plug loosens, tiny blood vessels may become torn aka "bloody show"
101
How to confirm PROM
either a nitrazine test (for pH)
or ferning test (glass slide shows fern)
VE avoided d/t risk for infection/injury
102
management criteria for prom
afebrile
normal FHR
engaged fetus
<18h labour
103
True vs. False labour
contractions of true:
regular, increase in freq/intensity, continue in despite of comfort measure, more intense with activity
false: decrease with activity, decrease with comfort measures
cervix in true labour: softens/effaces/dialtes, bloody show, anterior position
false: soft, no effacement/dilation, posterior position
fetus in true labour: PP engaged
false labour: not well engaged
104
Parity
number of pregnancies carried to stage of fetal viability
105
fetal viability
capacity of fetus to live outside of uterus
| 22-25 weeks
106
Nullipara
Multipara
Primipara
not completed any pregnancies to stage of viablity
carried multiple pregnancies to stage of viability
carried one pregnancy to stage of viability
107
gravida
| also can be Nul/Primi/Multi
of pregnancies
108
What is the presentation of a fetus?
part of fetus that enters pelvic inlet first
3 types: cephalic, breech, vertex
109
What is the position of a fetus?
relationship of the PP to the four quadrants of mothers pelvis
can be:
Left/Right
Occiput/Sacrum
Anterior/posterior/tranverse
i.e. LOA
110
What is the lie of a fetus?
relationship of the spine of fetus to spine of mother
can be longitudinal (vertical) /horizontal (transverse)/oblique
111
What is the attitude of the fetus?
relationship of fetus body parts to each other
i.e. flexed, extended, deflexed
112
What is the presenting part?
Part of fetus felt first during vaginal exam
113
cephalic presentation
head first
114
vertex presentation
occiput first
115
breech presentation
buttocks first
116
5 P's of L&D
```
Passenger
Passage
Position
Power
Psychological factors
```
117
Posterior/Anterior fontanelle closure
Posterior: 6-8w, triangle
Anterior: 18m, diamond
118
6 bones of fetal skull
two temporal
two parietal
occipital
frontal
119
What suture connects the anterior/posterior fontanelle?
sagittal suture
120
What is the diameter of the head when it is flexed?
| What happens to diameters when not flexed?
there are two diameters:
1) biparietal (transverse)= 9.25 cm
2) suboccipitobregmatic (anteroposterior)=narrowest part of head
when not well flexed suboccipitobregmatic diameter widens
121
What are the 4 bones in the pelvis?
ischium
ilium
pubic bone
sacrum
*all fused together
122
what are the 4 joints in the pelvis?
symphysis pubis
R/L sacroiliac joints
sacrococcygeal joint
123
3 cavities of the pelvis
inlet
mid pelvis
outlet
124
Where are the ischial tuberosities found?
on the outlet of the pelvis
125
most common type of pelvis
gynecoid
126
gynecoid vs. android pelvis
gynecoid brim is round, android heart shaped
gynecoid cavity wider, android narrower diameter
gynecoid sacrum is deep/curved, android is straight and beak-like
gynecoid favorable for birth, android results in delayed L&D/assisted birth
127
what tissues are found in the soft pelvis?
lower uterine segment, the pelvic floor muscles, the vagina, and the introitus.
128
what is the Ferguson reflex?
the urge to push
129
what will decrease contractions in early labour?
1) narcotics
2) water therapy
3) epidural analgesia
130
advantages of changing positions in labour?
increase comfort
increase circulation
relieve fatigue
gravity
131
Most common birthing positions
semirecumbant
side lying
squatting
lithotomy
132
7 cardinal movements in L&D
```
(Occurs in first stage of labour)
Engagement
Flexion
Descent
Internal rotation
```
(Occurs in second stage of labour)
Extension
Resituation and external rotation
Explusion
133
4 stages of labour
First stage (latent/active/transition)
Second stage (passive/active)
Third stage stage
Fourth
134
Times included on partogram
```
onset of labour (contractions Q5m)
rupture of membranes
10 cm dilation
pushing commenced
birth of baby
apgar scores (1min/5min/10min)
birth of placenta
```
135
when to start partogram
recommended during active phase of labour (4-7cm)
136
when does SROM occur?
usually in transition stage of labour (7-10cm)
137
When does ARM usually have to be done?
second stage of labour
| passive/active pushing
138
what can occur if membranes not ruptured?
caul birth
| born with amniotic sac
139
When should 1:1 nursing be commenced?
in active phase (4-7cm)
140
Peri-natal nurse assessment for pt. who just arrived at hospital
```
assess contractions
cervical changes
fetal descent (VE)
leopolds maneuvers
fetal well-being
```
141
how to assess contractions
palpate (preferred)
EFM (not good for strength)
IUPC (last resort d/t ++ invasive
strength/duration/freq
142
How to assess cervical changes
VE in dorsal position
assessing: effacement/dilation/membrane status
fetal position/station/PP/caput&molding
* be careful not to rupture membranes! to nitrazine/ferning test before to see if ruptured
143
How often should FHR be assessed?
every 15-30mins in first (active) stage
| every 5 mins in second stage
144
benefits of entonox
self-administered
rapidly excreted- minimal side effects
portable
145
choices of narcotics
Morphine IM for first time moms
Demerol if ALRG to morphine
Fentanyl for multiparous women d/t short acting
146
disadvantages of narcotics
half life longer in fetal system d/t immature system so can cause side effects (it crosses the placental-blood barriers)
should set up rescuitation equipment if administered close to birth (Narcan)
147
Demerol vs. Morphine
no detectable morphine in umbilical cord after 3h d/t no active metabolites
demeral active metabolites remains in system for longer
148
when can an epidural be used?
>3cm
149
disadvantages of epidural
```
slower progression
higher risk of c-section
decreased mobility
at risk for nerve injury
requires IV fluids
risk for infection
```
etc.
150
narcotic scenarios
review in module 5A!
151
What to do if couple in second stage of labour, actively pushing, first baby, attached to EFM, coping well.
Dr. wants to do vacuum assisted birth, mom tired but still pushing well. What would you do?
- detach women from EFM, and change positions? (i.e. gravity enhancing positions)
- educate re: ferguson reflex and tell mom to only push when she has an urge
-tell Dr. to wait if mom is still coping
152
What to do if cord wrapped around neck?
coach mom to pant until cord cut
153
Risk for mom in stage 3 of labour.
| How to prevent?
PPH
(hemostasis/involution do not occur)
Administer uterotonic agents (Oxytocin IV/IM)
154
S&S of detached placenta
firm fundus
gush of blood
lengthening umbilical cord
vaginal fullness on VE
155
2 approaches to 3rd stage of labour
expectant care: don't cut cord until stops pulsing, no oxytocin, placenta separated/delivered spontaneously
active care: cut/clamp cord, oxytocin, apply traction to cord until placenta delivered
156
Two approaches for PROM
expectant management (wait for labour-> induce after 12-18h)
or
induce labour right away
157
How to determine if cervix is ripe or not?
Bishop score! >8 for primigravida, >6 for multigravidas
- effacement
- dilation
- station (head in relation to pelvis)
- position of cervix (more anterior)
- cervix softer to touch
158
how is labour induced?
for unripe cervix, PE2 intra-vaginally OR amniotomy
| for ripe cervix, oxytocin
159
1. You are working in the labor and birthing unit and receive a call from Lori. This is her first baby and she is 40 weeks pregnant. Lori tells you that her membranes have ruptured and wonders what she should do. What would you advise her?
Tell her to come to hospital for assessment, and bring underwear soaked in drainage so it can be assessed.
160
assessments for rupture of membranes history
- confirm rupture: assess discharge (amount, colour, smell, nitrazine/ferning test)
- record time of rupture
- Leopolds maneuver: to determine fetal lie, position, engagement of PP
- FHR
- presence of contractions: strength/duration/freq
* Avoid VE unless maternal/fetal distress
161
recommendations for caring for women who are in labour and membranes ruptured
assess for S&S of infection
prevent ascending ninfection (pericare, change pads)
assess drainage
Maternal temp/pulse Qhour
FHR Q15m
Limit VE
162
Loris membranes ruptured 24 hours ago, she is now 8 cm, her temperature is 38°C, and the FHR 160. Have you concerns regarding the present clinical picture? Why?
Yes I would be concerned of chorioamnionitis (infection)
Look back at partogram to compare changes
Since Loris membranes have been ruptured for over 24 hours now, and there are indications of infection I would contact the Dr. to suggest inducing labour? (Oxytocin)
163
List 3 concerns of 'the passenger' during L&D
macrosomia
deflexed head
malpresentation *any position that is not vertex (breech, brow, face, shoulder)
malposition
164
Common malposition
| S&S
occiput posterior
needs to be rotated into anterior position before birth
S&S: backache, prolonged labour, exhausted, uncoordination contrtaction
165
Interventions for OP
positions for rotation: hands-knees, squat
oxytocin
epidural
assisted birth
166
form of fetal head deflexion
asynclitism (head tilted to side, suture no midline)
results in wider skull diameter-> prolonged birth
167
positions to facilitate rotation of fetus in second stage of labour
Squatting
The use of a birthing stool
The lateral lying position, upper leg held by labor supporter.
pushing on toilet (early second stage)
Water birth
168
S&S of breech
Leopolds maneuver: head at top of abdomen, softer pp
Meconium drainage
VE: bulge of membranes, fetal toes/feet felt
169
S&S of shoulder dystocia
| Interventions
slow progress of L&D
caput formation
turtle sign
no external rotation
Interventions: BE CALM
170
What is the mcRoberts maneuver
maneuver used for shoulder dystocia to enlarge to pelvic diameter
171
after brachial plexus injury when should the infant be referred to neurologist
6-12 months
172
BE CALM
for shoulder dystocia
Breathe/pant, do not push
Elevate legs into McRoberts position
Call for help
Apply suprapubic pressure (NOT fundal pressure)
Largen the vaginal opening via episiotomy
Maneuvers (Rubins)
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3 pelvic variations in labour
full bladder/bowel
small diameter
hx of cervical surgery
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Most common reason for C-section after onset of labour
Cephalopelvic disproportion (CPD) is the term used to describe fetal and pelvic alterations
e.g. head too big to fit through pelvis
175
small pelvic diameter results in...
pelvic dystocia
zero engagement/descent, prolonged labour
176
what is a rigid/edematous cervix
often result of cervical lip
often associated with OP
strong urge to push prior to 10cm due to PP forced onto lip leading to edema and increased resistance to dilation
177
interventions for rigid cervix
manually place lip over PP, decrease pushing until lip absent, gravity enhancing position, epidural
178
uterine actictivity
can be hypotonic (decrease in freq/strength/duration)
or hypertonic (uncoordinated- more than 5 contractions in 10 minutes or contractions lasting longer than 120 seconds)
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what can hypertonic uterus lead to
Interventions:
freq but inefficient contractions -> prolonged labour -> placental insufficiency-> fetal distress/placenta abruption
intervetions: decrease or stop Oxytocin
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what would you want to know if labour was not progressing?
changes in contractions?
changes in dilation/fetal descent?
what is hampering labour? (maternal/fetal factors)
maternal/fetal responses
Have the parents been updated on their progress?
181
amniotomy
only performed if head engaged and when c-section can be performed
aka artifical rupture of membranes
first choice usually
182
what is oxytocin
natural hormone secreted from. post pituitary
causes smooth muscles to contract
183
3 vacuum assisted birth risks
maternal laceration
fetal scalp laceration
facial nerve palsies
184
3 forceps assisted birth risks
bruising/lacerations at blade sites
fetal skull fracture
intracranial hemorrhage
185
04.00 Vali, accompanied by her partner Doug, arrives at a very busy hospital birthing suite. Vali is 39 weeks pregnant with her first baby. She has had a healthy pregnancy and started having contractions six hours ago. She has not been able to sleep.
The admitting nurse does a full assessment of Vali and her fetus. The nurse finds the fetus in an LOA position and engaged. Contractions are every 8 minutes, lasting 40 seconds. VE reveals a cervix that is 2 cm dilated, 1.5cm long, and the presenting part at spines with the membranes intact. The FHR is normal. Also noted is that Vali is very tired and tearful and not handling her contractions well.
What care would you recommend for Vali at this time?
The assessment findings indicate that Vali is still in early labor. Although she is tired and finding contractions difficult to deal with the best recommendation for her at this time is discharge home until contractions are more frequent. Vali and Doug should be reassured that labor has commenced but is still early and offered suggestions for comfort techniques that will help in dealing with contractions. Suggestions may include various breathing techniques, bathing, or showers. The couple should also be given the telephone number of the birthing suite so they can call if they have any concerns or to verify that they should return to the hospital.
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The physician looking after Vali recommends a therapeutic sleep and orders 10 mg IM of Morphine. Vali is admitted to the birthing unit and given the prescribed Morphine. The EFM is attached to monitor the fetus.
06.00 The nurse doing assessments notes that Vali has managed to get some sleep. The EFM shows that contractions are now every 10 minutes, lasting 40 seconds and that the fetal heart is 130 with decreased variability. The nurse calls Dr. Jones to inform him of the decreased variability and the spacing of contractions. Dr. Jones says to continue monitoring and he will be in around 7 am.
What is your opinion of the care that has been given to this point?
Morphine should not have been ordered this early in labour, should have been offered other pain management options (entonox/non-pharmacological)
narcotics this early in labour (First stage-latent) will inhibit contractions, slow labour/FHR.
Does not require EFM monitoring... In this stage should only be monitored Q15m
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12.00 Dr. Jones returns to the unit to see how Vali is doing. Contractions are now 5–6 minutes apart, lasting 50 seconds, and palpate as moderate. VE finds the cervix to be 3 cm, 1cm long, and the presenting part at spines. The amniotic fluid draining is clear. Dr. Jones tells Vali and Doug that labor progress is slow and thinks that an oxytocin augment would be a good idea to speed up the labor progress. Since Vali is tired and finding it difficult to handle her labor, Dr. Jones recommends that Vali has an epidural prior to the oxytocin augmentation. Vali and Doug agree with their doctor’s recommendations.
Give your opinion on the above recommendations.
You may think that Dr. Jones is being a little hasty in his decision to offer more medical interventions. This is a time when the nurse should advocate for more time for Vali to labor without further interventions. Vali and Doug do not seem to be well involved with the decisions that are been made. Have they been informed of the risks and benefits involved for the interventions that have been suggested so far?
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Suggest some other approaches to care that may have facilitated a more normal birthing process
sending Vali home until labor is better established
not administering narcotics in early labor
not using the EFM for assessments after narcotic administration.
buying more time for Vali’s labor to become established before an ARM is performed.
using ambulation, labor enhancing positions, and lots of support and encouragement to help labor progress.
buying more time before an augmentation and epidural are considered.
189
What interventions may impact c-section rates?
inducement
pain management
dystocia management
EFM
190
What are some predictors of a positive birth experience for women?
awareness
being with baby within 1h
support
degree of control
191
How long will it take to recover from c-section?
wait 8-10 weeks following cesarean section before resuming vigorous activity.
Generally woman should be advised that recovery from cesarean section takes longer than from vaginal birth, and that heavy lifting or physical exertion should be avoided for 6 weeks post partum.
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If mother says she doesnt know if she can do this again... what to say
provide resources for support/debriefing
educate re: VBAC (increasing success rate)
how multigravidas L&D often tens to be shorter than first time
193
care for c-section after 24h
Joanne is 24 hours post-op which means her dressing, urinary catheter and IV can all be removed.
assess fundus
vaginal flow
incision
mobility
support skin to skin/BF
shower
reg diet
194
if mom hesistant to BF after taking anaglesics (post-op c section)
educate re: benefits of taking medications (better able to care for infant when pain managed)
educate re: colostrum is in small quantity, so only small amount of medication will be passed to baby
educate re: research has shown no evidence of post-op pain meds having an impact on baby
195
concern for VBAC
```
uterine rupture:
constant pain
no contractions
vag bleeding
blood in urine
maternal shock
abnormal FHR
```
196
resp rate of newborn
30-60
| shallow/irrreg/apnea may be present
197
3 cardinal signs of resp distress
nasal flare
grunt
chest retractions
198
APGAR
```
Appearance
Pulse
Grimacing
Activity
Respirations
```
199
factors stimulating newborn to take first breath
no placenta blood flow, cutting off PE2 which inhibits breathing
Chemical factors (low O2, high CO2, low pH) stimulating resp centre in brain
release of pressure off babies head stimulating resp center
release of pressure off of chest, allowing chest expansion
external stimuli stimulating resp center
200
Sheena weighs 3.3 kg and is 39 weeks gestation. She was given positive pressure ventilation in the delivery room with 21% oxygen for several minutes before she began breathing on her own. Her one minute Apgar was 3. Her five minute Apgar was 9 and she has done well since she was admitted into your care. You have read her chart and the only remarkable information is that the amniotic membranes were ruptured for two weeks prior to delivery. Otherwise the pregnancy was normal.
What, if anything, are you concerned about? Think about Sheena’s gestational age, Apgar score, and antenatal history.
Sheena is a full-term AGA infant so there are no risks related to gestational age or her weight.
She had a low one-minute Apgar and for this reason she should be monitored for several hours to ensure that she does not develop problems associated with perinatal asphyxia.
The amniotic membranes were ruptured for two weeks prior to delivery, placing Sheena at risk for sepsis. Microorganisms may have ascended the birth canal and entered the amniotic fluid.
201
how to assess gest. age
looking at 6 physical, 6 neurological features and rating degree of maturity for each one
should be done in conjunction with newborn assessment
202
5 subsytems that newborns use to continuously interact with environment ****
1) autonomic (resps/color/organs)
2) motor (tone/posture/movement)
3) state (alertness/consciousness)
4) interactive state (response to stimuli)
5) self-regulatory system (maintain homeostasis)
203
6 basic states of infant
drowsy
light sleep
deep sleep
active alert
quiet alert
crying
204
what is habituation
tuning out stimuli d/t overload & boredom
205
when does baby start hearing us
characteristics of hearing
24w gestation
prefers familiar/high-pitched voices
sudden noise=startle
prolonged noise=habituation
gradual noise=alert state
206
when is growth hormone secreted
in active sleep states
207
newborn sight
The ability to fix, follow, and alert is present at birth and indicates a normal CNS. Infants can see best 810 inches away and at birth can see mother, as this is the cradle-in-arms distance. Infants prefer human faces, black and white, and patterned objects. They are sensitive to bright light. Color discrimination develops at around three months of age.
208
Brazeltons assessment tool
contains 6 newborns abilities to assess newborn behaviors
1) habituation
2) orientation to sight/sound stimuli
3) motor control/coord
4) responsiveness
5) state regulation
6) self-consoling
209
Why is it difficult for critically ill infants to express needs?
don't have energy to show behaviors that express different things
210
what state of sleep is characterized by facial twitching
light(active) sleep
211
what could cause periods of apnea
resp issues: blocked airway, hypoventilation hypoxia
stress
sepsis
prematurity: lacks autonomic control of respirations that full-term infants have d/t neurobehavioural immaturity
212
what could cause seizure like behaviour in a pre-mature infant
Active sleep state
neurobehavioural immaturity
213
What is being communicated:
baby is drowsy, returns to sleep when not stimulated
crying, arching back
Virginia is communicating that she wants to sleep. It is important not to wake an infant from deep sleep because it is during this state that brain growth occurs. Infants who are woken from a deep sleep feed poorly and can actually demonstrate a disorganized sucking pattern. They are drowsy, disinterested in feeding, and fall asleep at the breast. Parents’ persistence at trying to get their infant to feed is usually in vain.
When Virginia is not able to return to sleep she begins to show stress cues. It is likely that Virginia was demonstrating several more subtle stress signals as Lorraine was trying to wake her. Crying and arching are potent stress signals. Virginia is saying stop what you are doing. I need a change or timeout. In this case timeout is returning to sleep.
214
Alerting behaviours.
| What states does this occur in?
eyes wide/bright
focused attention on stimuli
states: active alert, quiet alert, drowsy
215
what state is optimal for visual responses in newborn
quiet alert
216
self consoling behaviours
thumb sucking
sucking on hand/fingers/fist
paying attention to voices/faces around them
changes in position
217
how long should caregivers wait before offering consoling ?
15 secs of crying
218
What is sensory threshold
level of tolerance of stimuli that an infant can respond to appropriately
if threshold reach, stress response
219
stress response
```
Irritable
Disorganized sleep-wake states
Gaze aversion*
Frowning
Sneezing
Yawning*
Hiccupping
Irregular respirations
Apnea*
Increased oxygen requirements
Heart rate changes
Finger splaying*
Arching/stiffening*
```
220
stability cues
```
regular vitals
consoled easily
sucking
focused gaze
smooth movements
self consolling behaviours
```
221
What can you do to help infants get enough sleep and maintain circadian rhythms?
not waking an infant from deep sleep
gently waking infants from active sleep
assess infant/provide care right before feeds so infant has good resting time in between
cluster care
afternoon nap-time during which the lights are dimmed, noise levels reduced, and handling minimized
222
What are the implications for caregiving when touching is either a postive and/or a negative experience for infants?
Be gentle but firm
Maternal touch
what can cause negative associations:
excessive handling
repeated painful procedures
223
3 benefits of BF for mom/baby
mom:
increases confidence
increases successful BF
increases bonding
baby:
increases sleep
physiological stability (temp, RR, HR)
decreases stress
224
How to educate parents re: concern of molding
explain modling
focus on positive aspect (how amazing it is that this happens)
reassure that it will return to normal in a few days
225
father concerned about babies head after vacuum assisted birth. Baby cries after father touches it. What would you do.
I would assure Ross that his baby is okay, but that he had a hard time making his way through Paula’s pelvis. I would point out both the areas of molding and the swelling on the baby’s head (without touching them). I would explain to him the difference between caput and hematoma, and reassure him that both a caput and a hematoma would resolve over the next days and weeks. In the meantime, I would suggest that he handle the baby’s head with care and avoid touching the swollen or bruised areas.
226
common newborn challenges
| 5
Pink: TTN, meconium in amniotic fluid
Warm: Hypothermia
Sweet: Hypoglycemia (<2.6mmol/L)
Organized: sleepy/floppy from narcotics/hypoxia
Attached
227
High risk newborn challenges
Pink: resp. distress syndrome (lack of surfactant)
Warm: Hypothermia (cold stress)
Sweet: Hypoglycemia
Organized: Intraventricular hemorrhage d/t fragile blood vessels , increased pressure/hypoxia damages these
Attached
228
Why is a newborn at risk for hypoglycemia
```
1. Decreased availability of glucose:
•Intra-uterine growth retardation
Glycogen storage disease
Inborn errors (e.g., fructose intolerance)
Prematurity
Prolonged fasting without IV glucose
```
2. Hyperinsulinemia:
Diabetic moms
3. Other endocrine abnormalities:
•Pan-hypopituitarism •Hypothyroidism
•Adrenal insufficiency
4. Increased glucose utilization:
cold stress
sepsis
229
common concerns about breastfeeding
if mother returns back to work
bad previous experience
concern about no success
breast surgery: implantation usually not as difficult as breast reduction d/t interference with milk ducts- causes nerve damage & removes glandular tissue.
230
composition of breast milk
0-3 days colostrum
3-10 days transitional milk
mature milk
231
composition of colostrum
| 0-3
high protein/fat-soluable vits/minerals/antibodies
thick & yellow
small volume
232
composition of transitional milk
| 3-10
high fat/calories/lactose/vitamins
creamy
breasts are bigger/firmer
milk gradually changing to mature milk
233
composition of mature milk
| ~ 2 weeks
high fat/lactose/h20, lower protein compared to colostrum
high volume
thinner
contains foremilk & hindmilk
234
foremilk
initial milk
| high in proteins, vitamins, h20
235
hindmilk
end of breast feeding
| ++ fat
236
AM milk
high in volume, low in fat
237
4 common contraindications to BF
Breast ca tx
HIV/AIDS
recreational drug use
prescription drugs
238
Process of BF
baby suckles
mechanoreceptors send signal to hypothalamus
hypothalamus:
1) stimulates release of oxytocin from the post. pituitary: myoepithelial cells contract
2) stimulates prolactin release from ant. pituitary: increased milk production (lactogenesis)
239
how does lactogenesis occur right after birth?
delivery of placenta
decreased estrogen/progesterone/human placental lactogen
increase prolactin
resulting in lactogenesis
240
what is galactopoiesis
ongoing milk production
impacted by sensory stimulation (pituitary gland), breast emptying, supply & demand, let down reflex
241
how does breast emptying stimulate galactopoiesis
via pressure and feedback inhibitor of lactation
the more milk, the more pressure & feedback inhibitor of lactation (small protein), stopping cells from secreting more milk
242
What is the let-down relfex
stimulated by oxytocin release
(contraction of myoepithelial cells to expel milk)
enhanced when mom relaxed so focus on decreasing stress!
243
What is milk transfer dependent on
Compression: far back in mouth where palates meet
Suction: negative pressure forms teat
Tongue action: wave like action
244
How often should baby feed
8-12 feeds Q24H
usually Q2-3h in day, Q3-4h at night
245
2 principles of BF
positioning & latching technique
| Knowledge of freq & duration of feeds
246
what to do if mom notices signs of rooting
```
C-hold
wait until mouth wide open
lead with chin
draw baby firmly to breast
nipple in between tongue & upper lip
lower-jaw as far back as possible
hold baby close
```
247
S&S of good latch
tugging sensation- no pinching
mouth wide open
nose & chin touching breast
cheeks round
248
S&S of good suck
no clicking, clacking, smacking
starts with quick sucks then when let down, deep and rhythical
comfortable
ends feed on own
249
How to help mother with first feed
assess learning needs of mom, and ASK if she would like help and if so with what
give positive reassurance to reinforce
ask mom to focus on what the latch feels like (tugging)
limit distractions & promote relaxation
250
How do narcotics impact BF
delay (decreased suck, coord, rooting, swallowing)
depends on drug, dose, route, peak, timing, newborns metabolizing abilities
can administer narcan if depressed
251
Psychosocial & BF behaviours
| Day 1 PP
Psychosocial: Quiet alert state, long sleep
BF: may or may not feed immediately, sleepy, just learning to BF
252
Psychosocial & BF behaviours
| 1 month
Psychosocial: follows objects with eyes, reacts to noise by stopping behaviour or by crying
BF: efficient at suckling, feeds last 17mins, feeds 8-16 times per day
253
Psychosocial & BF behaviours
| 2 months
psychosocial: smiles, vocalizes
BF: easily calmed by BF
254
Psychosocial & BF behaviours
| 3 months
pyschosocial: grasps objects, increase in interest of surroundings, vocalizes when spoken to, turns head & eyes in response to moving objects
BF: will interrupt feed to focus on moving object, growth spurt
255
Psychosocial & BF behaviours
| 4-5 months
Psychosocial: shows interst in strange settings, smiles at mirror images
BF: enjoys freq feedings, may be distracted
256
Psychosocial & BF behaviours
| 6 months
Psychosocial: laughs, increase awareness of stangers vs. parents, distress if caregiver leaves
BF: solids offered, fewer feeds, may wake to BF more at night, growth spurt
257
Psychosocial & BF behaviours
| 7-8 months
Psychosocial: imitates actions & noises, responds to name and no, enjoys peek a boo
BF: will breast feed anytime, attempts to BF
258
Psychosocial & BF behaviours
| 9-10
Psychosocial: distressed by new situations or people, waves bye, reaches for toys out of reach
BF: easily distracted, may hold breast while feeding
259
Psychosocial & BF behaviours
| 11-12
Psychosocial: drops objects purposely, speaks few words, interested in picture books
BF: acrobatic BF
260
Psychosocial & BF behaviours
| 12-15
Psychosocial: fears unfamiliar situations, but will explore. Shows emotions, speaks several words
BF: uses top hand to play while feeding, playes with hair, pinches nipple. Will pat chest when wants to BF, may have code word forBF
261
Psychosocial & BF behaviours
| 16-20
Psychosocial: temper, imitates parents, speaks 6-10 words
BF: verbalizes delight with BF, will lead mom to nursing chair
262
Psychosocial & BF behaviours
| 20-24
Psychosocial: fewer temper tantrums, engages in play, small sentences, uses 15-20 words
BF: stands up while nursing at times, nursing for comfort, feeds before bed, weaning.
263
Elimination patterns
day 3= 3-4 wet diapers
day 4= 6-8 wet diapers
meconium within 24h
day 3-4= 3-6 stools per day
264
How much weight loss is a red flag
8-10% within first few days
265
normal term weight
2500-4000
266
when should birth weight be attained by
2 weeks
weight loss usually stabilizes at 3-4 days, starts gaining weight at 5 days (20-30g per day)
267
1. Walker states that breast milk is higher in antioxidant capacity than formula. Why is this important to a late preterm infant?
Breast milk will neutralize oxidative stress (i.e. intraventricular hemorrhage, chronic lung disease)
268
3 barriers to BF late pre-term infant
insufficient sucking patterns
reduced alertness and stamina
inability to self-regulate
269
Common BF challenges
See chart!! Module 7
270
3 concepts to overcome BF**
Nurse early and often
Nipple and areola in babies mouth
BF on demand
271
5 indications for supplementation
hypoglycemia
dehydration
ill mothers
prescriptive meds
metabolism issues
272
if not BF when will start ovulating again
4-9 w
273
BF scenario
look at module 7
