Intrapartum test Flashcards
1
Q
First Stage (Dilation) - when does it start and end?
A
Longest, beginning with the first true contraction and ends with full dilation of the cervix
2
Q
Latent Phase - dilation, contractions - how often and how long? (latent at 10-30)
A
(0-6 cm dilation). Effacement from 0 - 40%; nullipara lasts up to 20 hrs, multipara lasts up to 14 hrs; contractions every 5-10 minutes, lasting 30-45 seconds;
3
Q
Active phase (6-10 cm dilation) (we’re active from 2-60)
A
Effacement from 40 -100%; nullipara lasts up to 6 hrs, multipara lasts up to 4 hrs; contractions every 2-5 minutes, lasting 45-60 seconds; intensity moderate to palpation
Dilation begins more rapidly and predictably; active labor generally dilates at a rate of 1.2-1.5 cm/hr
4
Q
Second stage (Expulsive- active pushing) (how long are contractions?)
A
Begins when the cervix is completely dilated and ends with birth of the newborn. Can last from minutes to hours. Contractions typically 2-3 minutes, lasting 60-90 seconds; contraction intensity strong by palpation; strong urge to push during the later perineal phase; stage may last up to 3 hrs
5
Q
Second stage (Expulsive- active pushing) - adverse outcomes (think long labor)
A
Longer duration of this stage of labor is associated w/ adverse maternal outcomes, such as higher rate of puerperal infections, third- and fourth- degree perineal lacerations, and postpartum hemorrhage
6
Q
Second stage (Expulsive- active pushing) pain (in control on the second stage)
A
During this stage, mother feels more in control and less irritable/agitated
Maternal urge to push is felt when there is direct contact of the fetus to the pelvic floor; stretch receptors in the wall of the rectum, vagina, and perineum communicate the pressure of the the fetus descending the birth canal, along with increased abd pressure
7
Q
Second stage (Expulsive- active pushing) - pushing?
A
Pushing: spontaneous (mothers urge) or directed (by caregiver)
8
Q
Third stage (Placental) - how does it end?
A
Starts after the newborn is born and ends w/ the separation and birth of the placenta; typically expelled within 5-30 minutes
9
Q
placental separation - 3rd stage
A
(detached from uterine wall), uterus continues to contract strongly after baby is born, causing the placenta to pull away.
10
Q
placental expulsion - 3rd stage - how long does it take?
A
(coming outside the vaginal opening), expelled within 2-30 minutes; once expelled, the uterus is massaged briefly until firm and uterine blood vessels constrict, minimizing hemorrhage.
11
Q
Fourth stage (Restorative)- fundus and lochia?
A
Lasts 1-4 hrs after birth; when mothers body begins to stabilize, initiates the postpartum period
Fundus should be firm and well contracted , typically located midline; lochia is red initially
12
Q
What are nursing priorities at admission (3 things) (heart dilates and ruptures on admission)
A
Highest priority: FHR, assessing cervical dilation and effacement, and determining whether membranes have ruptured or are intact
13
Q
What is are the nursing priorities immediately after a vaginal birth? What is the number one priority? (3 things - think about the birth you saw)
A
Placing newborn on mothers chest for skin-to-skin contact
APGAR 1 and 5 minutes
Make sure entire placenta has been delivered to prevent hemorrhage
14
Q
True Labor vs. False Labor - what is the difference? (what about the cervix)
A
False labor is a condition occurring during the latter weeks of some pregnancies when irregular uterine contractions are felt, but the cervix is not affected. In contrast, true labor is characterized by contractions occurring at regular intervals that increase in frequency, duration, and intensity. True labor contractions bring about progressive cervical dilation and effacement.
15
Q
first stage - what type of pain is it? (migraine and abby on 1st stage)
A
During the first stage of labor, women usually perceive the visceral pain of diffuse abdominal cramping and uterine contractions.
16
Q
first stage of labor - pain
A
is primarily a result of the dilation of the cervix and lower uterine segment, and the distention (stretching) of these structures during contractions.
17
Q
second stage of labor -pain (second pressure)
A
During this expulsive stage, the mother usually feels more in control and less irritable and agitated. overwhelming urge to push, rectal pressure.
18
Q
fourth stage - pain (cramping at 4th base)
A
Her bladder is hypotonic, and thus she has limited sensation to acknowledge a full bladder or to void. The woman will be feeling cramp-like discomfort during this time due to the contracting uterus.
19
Q
What is intermittent auscultation
A
Intermittent auscultation is a primary method of fetal surveillance in labor. It is the practice of using a handheld Doppler or fetoscope for periodic assessment of the FHR. The handheld Doppler device uses ultrasound waves that bounce off the fetal heart, producing echoes or clicks that reflect the rate of the fetal heart.Intermittent auscultation of the FHR is an acceptable option for low-risk laboring women, yet it is underutilized in the hospital setting.
20
Q
intermittent auscultation - disadvantages (intermittment decelerates)
A
the pressure of the device during a contraction is uncomfortable and can distract the woman from using her paced-breathing patterns. it cannot detect variability and types of decelerations, as electronic fetal monitoring (EFM) can.
21
Q
FHR - location
A
FHR is heard most clearly at the fetal back. In a cephalic presentation, the FHR is best heard in the lower quadrant of the maternal abdomen. In a breech presentation, it is heard at or above the level of the maternal umbilicus. As labor progresses, the FHR location will change accordingly as the fetus descends into the maternal pelvis for the birthing process. To ensure that the maternal heart rate is not confused with the FHR, palpate the client’s radial pulse simultaneously while the FHR is being auscultated through the abdomen.
22
Q
Tachysystole (5, 10, 30)
A
more than 5 contractions in 10 min averaged over 30 min. Leopolds maneuver
23
Q
Leopolds maneuver - 1 (start at the top)
A
What fetal part (head or buttocks) is located in the fundus (top of the uterus)?
24
Q
Leopolds maneuver - 2 (back 2 leopolds)
A
On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the back of the fetus.)
25
Leopolds maneuver - 3 (present at 3!)
What is the presenting part?
26
Leopolds maneuver - 4 (4 the head flex)
Is the fetal head flexed and engaged in the pelvis?
27
Ballotment (bounce on ballotment)
A method of diagnosing pregnancy, in which the uterus is pushed with a finger to feel whether a fetus moves away and returns again.
28
External Version (move externally)
strategically placing the hands on the gravid abdomen and applying pressure to encourage the fetus to move into the vertex position. This can be attempted for fetuses in the breech, transverse, or oblique positions and has the potential to decrease cesarean delivery rates.
29
What are the signs and symptoms of pre-term Labor - pelvis and back (pre term is pre-low)
Pelvic pressure (pushing-down sensation)
Low, dull backache
Feeling of pelvic pressure or fullness
30
What are the risk factors for pre-term labor? (age, race, diabetes)
Maternal age extremes (<16 years and >40 years old)
African American race (doubles the risk)
Low socioeconomic status
Alcohol or other drug use, especially cocaine
Poor maternal nutrition
Maternal periodontal disease
Cigarette smoking
Low level of education
History of prior preterm birth (triples the risk)
Uterine abnormalities, such as fibroids
Low pregnancy weight for height
Preexisting diabetes or hypertension
Multiple pregnancy
Premature rupture of membranes
Late or no prenatal care
31
What is the Fetal Fibronectin test?
glycoprotein, It acts as biologic glue, attaching the fetal sac to the uterine lining.
32
What are indicated reasons for a C-section?
The leading indications for cesarean births are previous cesarean birth, breech presentation, dystocia, and fetal distress. specific indications include active genital herpes, fetal macrosomia, fetopelvic disproportion, prolapsed umbilical cord, placental abnormality (placenta previa or placental abruption), previous classic uterine incision or scar, gestational hypertension, diabetes, positive human immunodeficiency virus (HIV) status, and dystocia.
33
What are contraindications for C/S?
Placental abruption.
Prior classical hysterotomy.
Prior full-thickness myomectomy.
History of uterine incision dehiscence.
Invasive cervical cancer.
Prior trachelectomy.
Genital tract obstructive mass
Abnormal placentation (such as placenta previa, placenta accreta)
34
What is CPD?
Cephalopelvic disproportion is a rare childbirth complication. It occurs when your baby's head doesn't fit through the opening of your pelvis. It's more likely to happen with babies that are large or out of position when entering the birth canal. The shape of your pelvis can also be a factor
35
HYPOTONIC LABOR (think hypo)
during active labor (dilation more than 5 to 6 cm) when contractions become poor in quality and lack sufficient intensity to dilate and efface the cervix.
36
HYPOTONIC LABOR- manifestations (hypo fingertip) - are contractions weak or strong?
Clinical manifestations of hypotonic uterine dysfunction include weak contractions that become milder, a uterine fundus that can be easily indented with fingertip pressure at the peak of each contraction, and contractions that become more infrequent and briefer (King et al., 2019)
37
HYPOTONIC LABOR - #1 complication?
The major risk with this complication is hemorrhage after giving birth because the uterus cannot contract effectively to compress blood vessels
38
HYPERTONIC LABOR
the uterus never fully relaxes between contractions. Subsequently, contractions are ineffectual, erratic, and poorly coordinated because they involve only a portion of the uterus and because more than one uterine pacemaker is sending signals for contraction.
39
Shoulder Dystocia
the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has been delivered. The incidence of shoulder dystocia is increasing due to increasing birth weight.
40
Shoulder Dystocia - risk factors
Postpartum hemorrhage secondary to uterine atony, vaginal lacerations, anal tears, and uterine rupture are major complications to the mother.
41
dystocia assessment
Assess the woman’s vital signs. Note any elevation in temperature (suggesting a potential infection) or changes in heart rate or blood pressure (potential hypovolemia). Evaluate the uterine contractions for frequency and intensity. Ask the woman about any changes in her contraction pattern, such as a decrease or increase in frequency or intensity, and report these. Assess FHR and pattern, reporting any abnormal patterns immediately. assess the woman’s fluid balance status. Check skin turgor and mucous membranes
42
dystocia assessment - cont
Monitor intake and output. Also monitor the client’s bladder for distention at least every 2 hours and encourage her to empty her bladder often. In addition, monitor her bowel status. A full bladder or rectum can impede descent. Continue to monitor fetal well-being. If the fetus is in the breech position, be especially observant for visible cord prolapse and note any variable decelerations in heart rate. If either occurs, report it immediately.
43
dystocia nursing management
The nurse should provide physical and emotional support to the client and her family. The final outcome of any labor depends on the size and shape of the maternal pelvis; the quality of the uterine contractions; and the size, presentation, and position of the fetus. Thus, dystocia is diagnosed after labor has progressed for a time, not at the beginning of labor.
44
Fetal Station
the relationship of the presenting part to the level of the maternal pelvic ischial spines. Measured in cm and referred to as - or + (cervix is normally 3cm)
45
Fetal Engagement - when is fetus engaged?
the largest diameter of the fetal presenting part (usually the head) into the smallest diameter of the maternal pelvis. Fetus is said to be engaged in the pelvis when the presenting part reaches 0 station.
46
Dilation: opening (0, 5 and 10)
0 cm: external cervical os is closed
5 cm: external cervical os is halfway dilated
10 cm: external os is fully dilated and ready for birth passage
47
Effacement: thinning (effacing in 2, 1, 0)
0%: cervical canal is 2 cm long
50%: cervical canal is 1 cm long
100%: cervical canal is obliterated
48
Fetal position
the relationship of the presenting part to the four quadrants of the mothers pelvis
49
Lie (lie on your spine)
the relationship of the spine of the fetus to the spine of the mother ex. longitudinal/vertical, transverse, oblique
50
Attitude (attitude w/ yourself)
the relationship of fetal parts to itself ex. General flexion (curled up: legs/arms at abd, head down), or extension (makes it difficult to push baby out)
51
Presenting part:
is the part of the fetal body felt first on cervical exam
52
Presentation (presenting the pelvis)
is the part of the body that enters the pelvic inlet first ex. Cephalic Vertex-head), breech (bottom, arms, legs), shoulder
53
Under what conditions are Vaginal Exams contraindicated
Avoid doing vaginal examinations in the woman with placenta previa because they may disrupt the placenta and cause hemorrhage.
54
Placenta Previa - and what about low lying?
Placenta previa is the complete or partial covering of the uterine internal os of the cervix with the placenta, typically identified during the second or third trimester of pregnancy. All placentas covering the os to any degree are termed placenta previa; placentas close to but not covering the os are referred to as low-lying.
55
placenta previa - s/sx: is bleeding painful?
Maternal signs and symptoms of placenta previa include sudden, painless bleeding (that may be heavy enough to be considered hemorrhaging), anemia, pallor, hypoxia, low blood pressure, tachycardia, soft and nontender uterus, and rapid, weak pulse.
56
PLACENTAL ABRUPTION:
Placental abruption refers to premature separation of a normally implanted placenta from the maternal myometrium.
57
UTERINE RUPTURE
Uterine rupture is a catastrophic tearing of the uterus at the site of a previous scar into the abdominal cavity.
58
uterine rupture - s/sx - most important symptom (rupture the baby)
Its onset is often marked only by sudden fetal bradycardia, and treatment requires rapid surgery for good outcomes. Generally, the first and most reliable symptom of uterine rupture is sudden fetal distress. Other signs may include acute and continuous abdominal pain with or without an epidural, vaginal bleeding, hematuria, irregular abdominal wall contour, loss of station in the fetal presenting part, and hypovolemic shock in the woman, fetus, or both
59
What are the priority diagnosis of someone with Placenta Previa
monitoring maternal vital signs, intake and output, vaginal bleeding, and physiologic status for signs of hemorrhage, shock, or infection; closely monitoring fetal heart tones for distress (e.g., bradycardia, tachycardia, baseline changes); and treating fetal distress as ordered. Administer prescribed intravenous fluids, packed red blood cells, platelets, and frozen plasma for transfusion if ordered; Rho(D) immune globulin if the client is Rh-negative; intravenous augmented oxytocin (Pitocin) to induce labor if needed; and in cases of preterm labor, tocolytics to inhibit uterine contractions and corticosteroids to enhance fetal lung maturity. Follow facility presurgical and postsurgical protocols if the woman becomes a surgical candidate (e.g., for cesarean section); reinforce presurgical and postsurgical education and ensure completion of facility’s informed consent documents; closely monitor the woman postsurgically for bleeding, infection, and other complications; assess her anxiety level and coping ability; and provide emotional support and reassurance.
60
What are the priority diagnosis of someone with Placental Abruption (abruptly in shock)
Monitor maternal vital signs and observe for hypotension and tachycardia, which might indicate hypovolemic shock. Assist in preparing for an emergency cesarean birth by alerting the operating room staff, anesthesia provider, and neonatal team. Insert an indwelling urinary catheter if one is not in place already. Inform the woman of the seriousness of this event and remind her that the health care staff will be working quickly to ensure her health and that of her fetus. Remain calm and provide reassurance that everything is being done to ensure a safe outcome for both.
- Typically, once the diagnosis is established, the focus is on maintaining the cardiovascular status of the mother and developing a plan to deliver the fetus quickly.
61
What is a prolapsed cord
rare obstetric emergency that occurs when the cord precedes the fetus out. Increased risk when the presenting part does not fill the lower uterine segment, as is the case with incomplete breech presentations, (5% to 10%), premature infants, hydramnios, and multiparous women. Cause is unclear. Perfusion decreases rapidly.
62
prolapsed cord - s/sx (think lack of O2)
Often the first sign of cord prolapse is a sudden fetal bradycardia or recurrent variable decelerations that become progressively more severe.Call for help immediately and do not leave the woman.
63
prolapsed cord - nursing interventions (just hold on)
When membranes are artificially ruptured, assist with verifying that the presenting part is well applied to the cervix and engaged into the pelvis. If pressure or compression of the cord occurs, assist with measures to relieve the compression. Typically, the examiner places a sterile gloved hand into the vagina and holds the presenting part off the umbilical cord until delivery. Changing the woman’s position to a modified Sims, Trendelenburg, or knee–chest position also helps relieve cord pressure.
64
prolapsed cord - nursing interventions - con't
Do not attempt to replace the cord in the uterus. Monitor FHR, maintain bed rest, and administer oxygen if ordered. Provide emotional support and explanations as to what is going on to allay the woman’s fears and anxiety. If the mother’s cervix is not fully dilated, prepare the woman for an emergency cesarean birth to save the fetus’s life if that is the intervention planned for by her health care provider.
65
Fentanyl
pain management, helps decrease the amount of motor block obtained. Is given IV or epidurally Can cause maternal hypotension, maternal and fetal respiratory depression. Rapidly crosses placenta.
66
Betamethasone - at what age is it used? (I was the alpha and beta at 34)
Promotes fetal lung maturity by stimulating surfactant production; prevents or reduces risk of respiratory distress syndrome and intraventricular hemorrhage in the preterm neonate less than 34 weeks’ gestation. Monitor for maternal infection or pulmonary edema. Educate parents about potential benefits of drug to preterm infant. Assess maternal lung sounds and monitor for signs of infection.
67
MgSo4 (magnesium
prophylaxis and treatment of seizures in preeclamptic and eclamptic clients for almost 100 years. Assess vital signs and deep tendon reflexes (DTRs) hourly; report any hypotension or depressed or absent DTRs. Monitor level of consciousness; report any headache, blurred vision, dizziness, or altered level of consciousness. Perform continuous electronic fetal monitoring; report any decreased FHR variability, hypotonia, or respiratory depression. Monitor intake and output hourly; report any decrease in output (<30 mL/hr). Assess respiratory rate; report respiratory rate <12 breaths/min; auscultate lung sounds for evidence of pulmonary edema. Monitor for common maternal side effects, including flushing, nausea and vomiting, dry mouth, lethargy, blurred vision, and headache. Assess for nausea, vomiting, transient hypotension, and lethargy. Assess for signs and symptoms of magnesium toxicity, such as decreased level of consciousness, depressed respirations and DTRs, slurred speech, weakness, and respiratory and/or cardiac arrest. Have calcium gluconate readily available at the bedside to reverse magnesium toxicity.
68
Terbutaline (turbulent heart)
used for abnormal FHR - tachycardia, half-life=3 hours, smooth muscle relaxant. can cause fetal tachycardia, but it is transient. this is NORMAL.
69
Nefedipine (nifty stops calcium)
Blocks calcium movement into muscle cells, inhibits uterine activity to arrest preterm labor. Use caution if giving this drug with magnesium sulfate because of increased risk for hypotension. Monitor blood pressure hourly if giving with magnesium sulfate; report a pulse rate >110 bpm. Monitor for fetal effects such as decreased uteroplacental blood flow manifested by fetal bradycardia, which can lead to fetal hypoxia. Monitor for adverse effects, such as flushing of the skin, headache, transient tachycardia, palpitations, postural hypertension, peripheral edema, and transient fetal tachycardia. Contraindicated in women with cardiovascular disease or hemodynamic instability.
70
Indomethacin (stop the indolence)
- Inhibits prostaglandins, which stimulate contractions; inhibits uterine activity to arrest preterm labor.Continuously assess vital signs, uterine activity, and FHR.
Administer oral form with food to reduce gastrointestinal irritation. Do not give to women with peptic ulcer disease. Schedule ultrasound to assess amniotic fluid volume and function of ductus arteriosus before initiating therapy; monitor for signs of maternal hemorrhage. Be alert for maternal adverse effects such as nausea and vomiting, heartburn, rash, prolonged bleeding time, oligohydramnios, and hypertension. Monitor for neonatal adverse effects, including constriction of ductus arteriosus, premature ductus closure, necrotizing enterocolitis, oligohydramnios, and pulmonary hypertension. Contraindicated in >32 weeks’ gestations, fetal growth restriction, history of asthma, urticaria, or allergic-type reactions to aspirin or nonsteroidal antiinflammatory drugs.
71
Nitrous Oxide
pain relief during labor. self-administration - also acts as a safety mechanism because it is almost impossible to overdose when it is self-administered Potential side effects of N2O/O2 include nausea and vomiting, dizziness, and dysphoria, although these are rare. No FHR abnormalities have been attributed to its use.
72
Misoprostol - what to monitor for? (think bleeding)
Stimulates uterine contractions to terminate a pregnancy and to evacuate the uterus after abortion to ensure passage of all the products of conception. Assess vaginal bleeding, and report any increased bleeding, pain, or fever. Monitor for signs and symptoms of shock, such as tachycardia, hypotension, and anxiety.
73
Oxytocin - what is a common side effect? (oxy works too well)
potent endogenous uterotonic agent used for both artificial induction and augmentation of labor.The most common adverse effect of oxytocin is uterine hyperstimulation, leading to fetal compromise and impaired oxygenation.
74
Methergine (meth makes me stop bleeding)
Stimulates the uterus to prevent and treat postpartum hemorrhage due to atony or subinvolution.
75
Hemabate (heman power over oxy)
Stimulates uterine contractions/to treat postpartum hemorrhage due to uterine atony when not controlled by other methods Stimulates uterine contractions to reduce bleeding when not controlled by the first-line therapy of oxytocin.
76
Duramorph
morphine. May be given IV or epidurally Rapidly crosses the placenta, causes a decrease in FHR variability Can cause maternal and neonatal CNS depression Decreases uterine contractions
77
epidural nursing considerations
Nurses need to evaluate for ambulation safety that includes no postural hypotension and normal leg strength by demonstrating a partial knee bend while standing; they also need to assist with ambulation at all times.
78
complications of epidural (think fentanyl)
Complications include maternal hypotension, intravascular injection, accidental intrathecal blockade, postdural puncture headache, pruritus, inadequate or failed block, maternal fever.
79
General anesthesia
General anesthesia - General anesthesia is typically reserved for emergency cesarean births when there is not enough time to provide spinal or epidural anesthesia or if the woman has a contraindication to the use of regional anesthesia.
80
General anesthesia - disadvantages - does it cross the placenta?
cross the placenta and affect the fetus. The primary complication with general anesthesia is fetal depression, along with uterine relaxation and potential maternal vomiting and aspiration. General anesthesia complications are usually due to maternal aspiration or the inability to intubate the woman.
81
What do successful inductions depend on
Perform an ultrasound to evaluate fetal size, position, and gestational age and to locate the placenta; engaged presenting fetal part; pelvimetry to rule out fetopelvic disproportion; a nonstress test to evaluate fetal well-being; a phosphatidylglycerol (PG) level to assess fetal lung maturity; confirmation of category I FHR pattern; complete blood count and urinalysis to rule out infection; and a vaginal examination to evaluate the cervix for inducibility. Accurate dating of the pregnancy is also essential before cervical ripening and induction are initiated to prevent a preterm birth
82
cervical ripening
Cervical ripening: Cervical ripening is a process by which the cervix softens via the breakdown of collagen.
83
mechanical methods to induce labor - advantages
Potential advantages of mechanical methods compared with pharmacologic methods may include simplicity or preservation of the cervical tissue or structure, lower cost, and fewer side effects.
84
mechanical methods to induce labor - disadvantages
The risks associated with these methods include infection, bleeding, membrane rupture, and placental disruption. Ex of mechanical - indwelling catheter - The catheter is placed in the uterus, and the balloon is filled, direct pressure is applied and likely releases prostaglandins.
85
Hygroscopic dilators (hygro seaweed)
absorb endocervical and local tissue fluids; as they enlarge, they expand the endocervix and provide controlled mechanical pressure. laminaria, a type of dried seaweed) and synthetic dilators containing magnesium sulfate (Lamicel, Dilapan). good choice bc they are outpatient basis and no fetal monitoring is needed. As many dilators are inserted in the cervix as will fit, and they expand over 12 to 24 hours as they absorb water. Absorption of water leads to expansion of the dilators and opening of the cervix. Reliable when prostaglandins are not available.
86
surgical methods: (surgical hook)
stripping of the membranes and performing an amniotomy. This motion causes the membranes to detach. involves inserting a cervical hook (Amniohook) through the cervical os to deliberately rupture the membranes. This stimulates local prostaglandins.
87
pharmacologic methods:
use of prostaglandins. A drawback of prostaglandins is their ability to induce excessive uterine contractions, which can increase maternal and perinatal morbidity. ex include - dinoprostone gel (Prepidil), dinoprostone inserts (Cervidil), and misoprostol (Cytotec). Misoprostol (Cytotec), a synthetic PGE1 analog, is a gastric cytoprotective agent used in the treatment and prevention of peptic ulcers. Oxytocin is a potent endogenous uterotonic agent used for both artificial induction and augmentation of labor, symptoms to watch for include headache and vomiting. Oxytocin has many advantages: it is potent and easy to titrate, it has a short half-life (1 to 5 minutes), and it is generally well tolerated.
88
Evaluation for oxytocin
Apply an external electronic fetal monitor or assist with placement of an internal device. Obtain the mother’s vital signs and the FHR every 15 minutes during the first stage. Evaluate the contractions (frequency, duration, and intensity) and resting tone, and adjust the oxytocin infusion rate accordingly. Monitor the FHR, including baseline rate, baseline variability, and decelerations to determine whether the oxytocin rate needs adjustment. Discontinue the oxytocin and notify the health care provider if uterine hyperstimulation or a category II or III FHR pattern occurs. Perform or assist with periodic vaginal examinations to determine cervical dilation and fetal descent; cervical dilation of 1 cm per hour typically indicates satisfactory progress. Continue to monitor the FHR continuously and document it every 15 minutes during the active phase of labor and every 5 minutes during the second stage. Assist with pushing efforts during the second stage. Measure and record the intake and output to prevent excess fluid volume. Encourage the client to empty her bladder every 2 hours to prevent soft tissue obstruction.
89
Bishops Score? (induct the bishop)
The Bishop score helps identify women who would be most likely to achieve a successful induction. The duration of labor is inversely correlated with the Bishop score; a score over 8 indicates a successful vaginal birth. Bishop scores of less than 6 usually indicate that a cervical ripening method should be used prior to induction.
90
AROM
artificial
Spontaneous rupture of membranes and labor does not start
Large size fetus not expected to navigate the maternal pelvis
Fetal growth restriction (FGR) with which external intervention is needed
Fetal health in jeopardy if remaining in utero
91
SROM
spontaneous
92
PROM
premature rupture of membrane before onset of labor
93
PPROM - how many weeks?
membrane rupture before 37 weeks
94
What are the risks of AROM (if it breaks, what happens?)
can lead to birth of an infant too early, a long labor, exposure to a high-alert medication with its potential side effects, unnecessary cesarean birth, and maternal and neonatal morbidity. elective induction of labor may increase the risk of cesarean birth, especially for nulliparous women. Elective induction of labor in nulliparas is associated with increased rates of cesarean, postpartum hemorrhage, neonatal resuscitation, and longer hospitalizations without improvement in neonatal outcomes.
95
What are nursing interventions when meconium stained amniotic fluid is observed
prevent meconium aspiration syndrome, which can lead to respiratory distress. This would necessitate suctioning after the head is born before the infant takes a breath and perhaps direct tracheal suctioning after birth if the Apgar score is low. In some cases, an amnioinfusion (introduction of warmed, sterile normal saline or Ringer’s lactate solution into the uterus) is used to dilute moderate to heavy meconium released in utero to assist in preventing meconium aspiration syndrome
96
Nitrazine + Pooling + Fern (pattern on strip test) Te
this means their water broke.
97
Speculum exam
Cervical fluid collected and viewed under microscope
98
Ferning (crystal ferns and salt)
Crystallization of proteins + salt
99
precipitous birth - how long?
labor that is completed in less than 3 hours from the start of contractions to birth. Not only can labor be too slow, but it can be abnormally rapid
100
precipitous birth - maternal complications
Maternal complications are rare if the maternal pelvis is adequate and the soft tissues yield to a fast fetal descent. However, if the fetus delivers too fast, it does not allow the cervix to dilate and efface, which leads to cervical lacerations and the potential for uterine rupture.
101
precipitous birth - fetal complications
head trauma, such as intracranial hemorrhage or nerve damage, and hypoxia due to the rapid progression of labor
102
precipitous birth - risk factors
Vaginal delivery previously and/or precipitous labor; smaller baby; strong and efficient contractions, birth canal is soft and flexible, mother has high BP, labor induced w/ prostaglandins
103
precipitous birth - nursing interventions (not much)
-Continuous monitoring, frequent updates on labor progress, pain management, and reassurance to assist anxiety
104
DIC
A bleeding disorder characterized by an abnormal reduction of blood clotting factors resulting from widespread intravascular clotting.
105
DIC manifestations (DIC is thrombin and lycin)
loss of balance btw the clot-forming activity of thrombin and the clot-lysing activity of plasmin. Too much thrombin, client develops clots; too much lysis resulting from plasma formation and the client will hemorrhage
106
DIC complications (think clots)
acute kidney failure, hepatic dysfunction, cardiac tamponage, gangrene and loss of digits, shock, and death; high mortality and morbidity rates
107
DIC - lab diagnosis
no single test is specific enough to diagnose DIC definitively; the following assist in diagnosis, decreased fibrinogen and platelets; prolonged PT and aPTT, positive D-dimer tests and fibrin (split) degradation products
108
DIC nursing interventions
monitor VS and bleeding, administer fluids and blood products; practice bleeding precautions, wound care; provide respiratory support (*from google)
109
DIC s/sx - heart rate?
bleeding gums, tachycardia, oozing from IV insertion site, petechiae
110
what stage does fetal membrane rupture?
1st stage usually
111
pain in 1st stage (migraines come first)
Perceived visceral pain of diffuse abd cramping and uterine contractions
Pain during this stage is primarily a result of cervical and lower uterine dilation, and distention (stretching) of structures during contraction
112
latent phase - pain (latentcy press down and talking)
intensity mild to palpation; women remain talkative during
Assessment of intensity evaluated by pressing down on fungus during contraction to see if it dents with the nurses fingers. Ability to indent the fungus at peak of contraction typically indicates mild contractions
113
what to do immediately after 3rd stage?
Immediately place baby on mothers abdomen after birth for skin-to-skin contact
114
what stage do Postpartum hemorrhages occur?
mostly during the 3rd stage of labor, active mgmt can prevent it
115
3rd stage - Signs placenta is ready to deliver are (rise to the placenta and trickle the cord)
uterus rises upwards, umbilical cord lengthens, sudden trickle of blood from vagina, and uterus changes shape to globular
116
3rd stage - placental expulsion - blood loss - how much?
Normal blood loss is 500 mL for vaginal birth and 1,000 mL for C-section. **make sure all of the placenta is expelled or pieces left in the uterus can interfere with contracting back to normal
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fetal indications for c-section
Fetal indications include malpresentation (nonvertex presentation), congenital anomalies (fetal neural tube defects, hydrocephalus, abdominal wall defects), and fetal distress
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hypotonic labor - factors (think big)
Factors associated with this abnormal labor pattern include overstretching of the uterus, a large fetus, multiple fetuses, hydramnios, multiple parity, bowel or bladder distention preventing descent, and excessive use of analgesia.
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hypertonic labor - physical - what phase and how many cm? (hyper is latent at 2)
Women in this situation experience a prolonged latent phase, stay at 2 to 3 cm, and do not dilate as they should.
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hypertonic labor - effects on mother (hyper is too exhausting)
These hypertonic contractions exhaust the mother, who is experiencing frequent, intense, and painful contractions with little progression.
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Do nulliparous women or multiparous women have hypertonic labor? (null is hyper)
This dysfunctional pattern occurs in early labor and affects nulliparous women more often than multiparous women.
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shoulder dystocia - fetal injuries
Transient Erb or Duchenne brachial plexus palsies and clavicular or humeral fractures are the most common fetal injurides encountered with shoulder dystocia.
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dystocia - interventions (what drug is given?)
Be prepared to administer a labor stimulant such as oxytocin (Pitocin) if ordered to treat hypotonic labor contractions. Anticipate the need to assist with manipulations if shoulder dystocia is diagnosed. Prepare the woman and her family for the possibility of a cesarean birth if labor does not progress.
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epidural - Complications
Complications include nausea and vomiting, hypotension, fever, pruritus, intravascular injection, maternal fever, allergic reaction, and respiratory depression.
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epidural - effects on fetus
Effects on the fetus during labor include fetal distress secondary to maternal hypotension (Milton, 2019).
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epidural - mother's positioning
Ensuring that the woman avoids a supine position after an epidural catheter has been placed will help minimize hypotension.
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during the restorative (4th phase) monitor mother for what?
Monitor mother closely to prevent hemorrhage, bladder distention, and venous thrombosis; bladder is hypotonic, has limited sensation to void; monitor VS, lochia (amount and consistency), and uterine fundus every 15 minutes for first hour
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signs of preterm labor - gastro
Gastrointestinal upset like nausea, vomiting, and diarrhea
General sense of discomfort or unease
Intestinal cramping with or without diarrhea (Jordan et al., 2019)
Change or increase in vaginal discharge with mucous, water, or blood in it
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signs of preterm labor - legs and uterus - how many contractions an hour? (preterm at 6 yrs old)
Heaviness or aching in the thighs
Uterine contractions with or without pain
More than six contractions per hour
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signs of preterm labor - bladder
Menstrual-like cramps
Urinary tract infection symptoms
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preterm labor - risk factors - cervix and stds and time in between pregnancies
Short cervical length
Sexually transmitted infections: gonorrhea, chlamydia, trichomoniasis
Bacterial vaginosis (50% increased risk)
Chorioamnionitis
Hydramnios
Gestational hypertension
Cervical insufficiency
Short interpregnancy interval (<1 year between births)
Placental problems, such as placenta previa and abruption placenta
Maternal anemia
Urinary tract infection
Domestic violence
Stress, acute and chronic
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fetal fibronectin - what does an negative test mean? (no nectin, no preterm)
Conversely, a negative fetal fibronectin test is a strong predictor that preterm labor in the next 2 weeks is unlikely. Interpretation of fetal fibronectin results must always be viewed in conjunction with the clinical findings; it is not used as a lone indicator for predicting preterm labor.
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what does a fetal fibronectin test tell us? (what measurement) (fiber makes me rupture)
The test is a useful marker for impending membrane rupture within 7 to 14 days if the level increases to more than 0.05 mcg/mL. The accuracy of fetal fibronectin is decreased in the presence of lubricants, blood, recent intercourse, or cervical manipulation within the previous 24 hours.
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fetal position - presenting part
Three letters:
Side of the pelvis, Left (L) or Right (R)
Presenting part (occiput (O), mentum (M), sacrum (Sa), or scapula or acromion process (A)
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fetal position - relation to (PAT is relation)
Relation to Anterior (A, pubis), Posterior (P, coccyx), or Transverse (T)
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placenta previa - type of bleeding?
Bleeding may be episodic with spontaneous initiation and cessation. In some cases, placenta previa is asymptomatic because there is intrauterine bleeding only without external signs
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misoprostol - side effects (the usual)
Monitor for side effects such as diarrhea, abdominal pain, nausea, vomiting, and dyspepsia.
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1st stage of labor - what are the 2 phases?
The first stage is divided into two phases: latent and active. Latent:
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how are women during the latent phase?
Many women remain talkative during this period, perceiving their contractions to be similar to menstrual cramps.
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how are women during the active phase?
The woman’s discomfort intensifies (moderate to strong by palpation).
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side effect of oxytocin? (you want this) and does it cross placenta?
oxytocin has an antidiuretic effect, resulting in decreased urine flow that may lead to water intoxication. Symptoms to watch for include headache and vomiting. side effects (water intoxication, hypotension, and uterine hypertonicity), but because the drug does not cross the placental barrier, no direct fetal problems have been observed.
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methagrine - how often to assess and side effects?
Assess baseline bleeding, uterine tone, and vital signs every 15 minutes or according to protocol. Monitor for possible adverse effects, such as hypertension, seizures, uterine cramping, na Hemabate usea, vomiting, and palpitations. Report any complaints of chest pain promptly. Contraindications: Hypertension.
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hemabate - side effects? (heman has asthma)
Assess vital signs, uterine contractions, client’s comfort level, and bleeding status as per protocol. Monitor for possible adverse effects, such as fever, chills, headache, nausea, vomiting, diarrhea, flushing, and bronchospasm. Contraindications: asthma or active cardiovascular disease Same as above Contraindications: active cardiac, pulmonary, renal, or hepatic disease
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epidural complications - how to treat fetal hr changes?
Hypotension and associated FHR changes are managed with maternal positioning (semi-Fowler position), IV hydration, and supplemental oxygen
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ripe cervix - measurements
on average, the cervix is approximately 50% effaced and 2 cm dilated at the onset of labor, though wide differences do exist.
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ripe cervix - shape (short and ripe)
A ripe cervix is shortened, centered (anterior), softened, and partially dilated. An unripe cervix is long, closed, posterior, and firm.
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reasons for AROM (arom is 42)
A pregnancy of more than 42 weeks’ gestation
Maternal hypertension, diabetes, or lung disease
Uterine infection (March of Dimes, 2019)
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causes of DIC - (the big one)
Can occur secondary to placental abruption, amniotic fluid embolism, endotoxin sepsis after an abortion, retained dead fetus, posthemorrhagic shock, hydatidiform mole, HELLP syndrome, and gynecologic malignancies
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hypertonic labor - what happens to the fetus? (too much fluid squeezes)
Placental perfusion becomes compromised, thereby reducing oxygen to the fetus.
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Cat. 1 tracing (Normal)
Predictive of normal fetal acid–base status and do not require intervention
Baseline rate (110–160 bpm)
Baseline variability: moderate
No late or variable decelerations
early decelerations: absent or present
accelerations: present or absent
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Cat 2. Tracing (indeterminate)
Not predictive of abnormal fetal acid–base status, but require evaluation and continued surveillance
* Bradycardia (<110 bpm) not accompanied by absent baseline variability
*tachycardia
FHR variability - minimal baseline variabilty, absent baseline variability w/ no recurrent deccelerations, marked baseline variability.
accelerations: absent
*recurrent variable deccelerations w/ minimal or moderate baseline variabiliy
*prolonged deceleration more than 2 min, less than 10 min
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Cat 3 tracing (abnormal)
Predictive of abnormal fetus acid–base status and require intervention
* Fetal bradycardia
* Recurrent late decelerations
* Recurrent variable decelerations—declining or absent
* Sinusoidal pattern (looks like a sawtooth)
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on fetal monitoring - NST - big lines
big lines are 1 min (the red lines)
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on fetal monitoring - NST - small squares
10 seconds
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flexion is
curled up
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fetal monitoring starts at what age?
24 weeks
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hypertonic - how many cm? and what stage of pregnancy?
prolonged latent, stay at 2-3 cm
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hypotonic - how many cm and what stage of pregnancy?
5-6 cm, during active labor.
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hyptonic - give what med?
oxytocin (if ordered)
