Module 3 Exam Flashcards
(87 cards)
1
Q
What are the 5 Ps of labor?
A
Passageway Passenger Psyche Powers Position
2
Q
Passageway
A
pelvic canal: the inlet, the pelvic cavity (midpelvis), the outlet
3
Q
What are the 4 types of pelvis?
A
Gynecoid: female, most common, + vaginal delivery
Android: - vaginal delivery, pelvic descent slow, fetal head enters in transverse or posterior position, arrest of labor
Anthropoid: + vaginal delivery
Platypelloid: - vaginal delivery, fetal head engages in transverse position, difficult descent through midpelvis, delay of progress at the outlet of the pelvis.
4
Q
Passenger
A
- the fetus
- sufficient passage of the passenger depends on: fetal head, fetal attitude, fetal lie, and fetal presentation
5
Q
Fetal head
A
- the least compressible and largest part of the fetus.
- fetal skull has 3 parts: face, base of the skull, vault of cranium (roof)
- bones of the base are not fused, allowing the head to mold as it passes through the narrow portions of the pelvis.
6
Q
Fetal attitude
A
- refers to the relation of the fetal parts to one another.
- it is the fetal position
- it is how the baby is flexed
- normal attitude is moderate flexion of the head, flexion of the arms onto the chest, and flexion of the legs onto the abdomen (fetal position)
7
Q
Fetal lie
A
- refers to the relationship of the cephalocaudal (spinal column) axis of the fetus to the cephalocaudal axis of the woman
- the fetus will assume either a longitudinal or a transverse lie.
- longitudinal is vertex or breech
- transverse is shoulder presentation
8
Q
Fetal presentation
A
- determined by fetal lie and by the body part of the fetus that enters the pelvic passage first.
- this portion of the fetus is referred to as the presenting part
- fetal presentation may be cephalic, breech, or shoulder
- most common presentation is cephalic
- breech and shoulder presentations are associated with difficulties during labor; called malpresentations
9
Q
Vertex presentation
A
- most common
- head flexed to the chest, occiput is presenting part
- Suboccipitobregmatic diameter is 9.5 cm
- occiput is the area of the fetal skull occupied by the occipital bone, beneath the posterior fontanelle.
10
Q
Sinciput presentation
A
- the fetal head is not flexed or extended
- top of head is presenting part
- “military presentation”
- Bregma (anterior fontanelle) is the large diamond-shaped anterior fontanelle
- occipitofrontal diameter is 11.75 cm
11
Q
Brow presentation
A
- fetal head is partially extended
- sincipt or forehead is presenting part
- largest AP diameter
- occipitomental diameter is 13.5 cm
- sinciput is the anterior area known as the brow.
12
Q
Face presentation
A
- the fetal head is hyperextended
- face is presenting part
- submentobregmatic diameter is 9.5 cm
- sphenoid fontanelle is right behind the eyes and the sinciput
13
Q
Complete breech presentation
A
- knees and legs are flexed
- buttocks and feet are presenting parts
14
Q
Frank Breech presentation
A
- hips flexed, knees extended
- buttocks presenting part
- baby appears to be folded in half with feet by face and butt presenting
15
Q
Footling breech presentation
A
- hips and legs are extended
- foot/feet are presenting part
- this baby appears to be standing
16
Q
Engagement
A
- occurs when largest diameter of the presenting part reaches or passes through the pelvic inlet
- an engaged fetus will not move
17
Q
Ballottable
A
-fetus is not engaged and can be easily moved
18
Q
Station
A
- the relationship of the presenting part to the maternal ischial spines.
- Zero station is at the level of the ischial spines
- Above spines is negative
- Below spines is positive
- *Fetal position is the relationship of the fetal presenting part (ie head) and the maternal pelvis.**
19
Q
Landmarks of the presenting part are:
A
O - occiput (vertex position)
M - mentum (face presentation)
S - sacrum (breech)
A - acromion (shoulder presentation)
A - anterior
P - posterior
T - transverse
20
Q
Powers/Physiologic Force
A
Primary Force: contractions that contribute to cervix dilation and effacement
Secondary Force: abdominal muscles pushing
21
Q
Phases of a contraction
A
- increment - build up
- acme - the peak
- decrement - letting up
22
Q
Characteristics of contractions
A
Frequency (min) Duration (seconds) Intensity (measured during acme) ** you want 5 or less per 10 minutes** **timed from beginning of contraction to beginning of contraction**
23
Q
Contraction Assessment
A
Palpation: feeling with hands the frequency, duration and intensity. Mild: nose, Moderate: chin, Strong: forehead
External monitoring: TOCO. Provides continuous contraction frequency and duration.
Internal monitoring: IUPC. Measures all 3 (F/D/I)
24
Q
Psyche
A
- a woman’s emotional readiness for the labor process
- Can affect entire experience
- Includes fears, anxieties, birth fantasies, level of support, preparedness
25
Progesterone Withdrawal Hypothesis
- Progesterone is decreased toward the end of pregnancy
| - Available estrogen is now the dominant hormone and causes uterine muscle contractility
26
Prostaglandin Hypothesis
- prostaglandin release from the membranes stimulate ctx
| - manual release or synthesis related to increased estrogen and decreased progesterone levels
27
Corticotropin-Releasing Hormone Hypothesis
- released from hypothalamus
- increases near the end of pregnancy
- stimulates synthesis of prostaglandins
28
Leopold's Maneuver 1st
- palpate the fundus
- fetal head is firm, hard and round
- the buttocks is softer and has bony prominences
- should start feeling at about 30 weeks gestation
29
Leopold's Maneuver 2nd
- determine location of fetal back
- fetal back will feel firm and smooth
- fetal extremities will feel small and knobby
30
Leopold's Maneuver 3rd
- determine which fetal part is lying in the pelvic outlet
| - grasp abdomen just above symphysis pubis, should confirm opposite what was found with 1st maneuver.
31
Leopold's Maneuver 4th
- Attempt to locate the cephalic prominence
| - A fetal head that is well flexed, will have the cephalic prominence on the opposite side of the back
32
Where is the external EFM placed in relation to Leopold's/fetal position?
- FHR hears most clearly at the fetal back
- Cephalic: lower quadrants of maternal abdomen
- Breech: at or above maternal umbilicus
- Transverse: just above or below maternal umbilicus
33
What is a nurse feeling/assessing for when performing a sterile vaginal exam (SVE) as part of the intrapartum nursing assessment?
- cervical effacement
- dilation
- fetal station
- presenting part
- fetal descent
- position of the fetus
34
FHR baseline
- the average FHR rounded to increments of 5 bpm observed during a 10-minute period of monitoring.
- excluded episodic changes, marked variability, and segments that differ by more than 25 bpm.
- you need at least 2 min w/in 10 min and they do not need to be consecutive.
- Normal FHR 110-160
35
FHR variability
- Absent: amplitude undetectable
- Minimal: amplitude detectable but less than 5 bpm
- Moderate(normal): amplitude 6 to 25 bpm <-- desired
* *reduced variability is the best single predictor for determining fetal compromise.
* *fetal acidosis and subsequent hypoxia are highest in fetuses that have absent or minimal variability.
36
Why is moderate variability so important?
- moderate variability tells us the baby is doing well and is well oxygenated
- reduced variability is the best single predictor for determining fetal compromise.
37
Accelerations
- an abrupt increase of at least 15 bpm in FHR above the baseline that lasts at least 15 seconds. 15 x 15
- in pregnancies less than 32 weeks, accelerations are defined as an increase of 10 x 10.
38
Prolonged Acceleration
- lasts for 2 minutes or more during a 10 minute period.
| - Accelerations that are 10 minutes or longer are considered a baseline change.
39
Decelerations
Early: good/ok
Late: bad
Variable: bad
Prolonged: bad
40
Early decelerations
- defined as a usually symmetrical, gradual decrease in FHR and return to baseline associated with uterine ctx.
- Nadir of the deceleration usually occurs at the same time of the peak of the ctx.
- usually caused by head compression
41
Late decelerations
- defined as a usually symmetrical, gradual decrease in FHR and return to baseline associated w/ uterine ctx.
- Nadir of the decal usually occurs after the peak of the ctx
- This is a sign of uteroplacental insufficiency
42
Variable decelerations
- defined as an abrupt decrease in FHR below the baseline which may or may not be associated with uterine ctx
- can occur at any time
- u, v, or w shaped
- sign of cord compression
43
Prolonged deceleration
- defined as a decrease in FHR below the baseline lasting for 2 minutes or more
- prolonged decel lasting more than 10 minutes is a change from baseline
44
V C
E H
A O
L P
Variable......cord compression
Early.............head compression
Accel............OK
Late..............placental insufficiency
45
Sinusoidal
- smooth, sine-like undulating wave pattern with 3 to 5 bpm and lasting for at least 20 minutes.
- Sign of m/f hemorrhage, twin/twin transfusion, ruptured umbilical vessels
- Pseudo sinusoidal: fetal thumb sucking and meds like stadol/fentanyl
46
Category 1 tracing
- things are ok
- normal FHR range
- normal variability in the moderate range
- absence of late decels
- early decels may or may not be present
47
Category 2 tracing
Provide interventions
48
Category 3 tracing
- rushing to C-section
- absent variability in baseline FHR
- recurrent late decels
- recurrent variable decels
- bradycardia
- sinusoidal for more than 20 minutes
49
How do we manage non-reassuring FHR tracings?
- prompt evaluation
- expeditiously resolve the abnormal FHR pattern
- maternal O2
- change maternal position
- discontinuation of labor stimulation
- tx of maternal hypotension
- C-section
50
Dysfunctional uterine contractions
- dysfunctional or uncoordinated uterine contractions
- result in a prolonged labor
- typically irregular in strength, time, or both
- not effective in producing dilation or effacement
51
True labor
- progressive dilation and effacement of the cervix
- ctx occur regularly
- ctx increase with frequency, duration, and intensity
- ctx start in back and radiate to abdomen
- ctx not relieved by ambulation
52
False labor
- no progressive dilation or effacement
- ctx irregular, do not increase in F/D/I
- ctx felt in lower abdomen and groin
- ctx relieved by ambulation, position changes, hydration, rest
53
Premonitory (early) signs of labor
- lightening
- Braxton hicks contractions
- cervical changes
- ROM
- nesting
- increased backache
- weight loss of 1 to 3 pounds
- diarrhea
- indigestion
- N and/or V
54
First stage of labor (phases)
Latent phase
active phase
transition phase
55
Latent phase
- begins with onset of regular ctx that increase
- ctx are 10 to 30 minutes apart and mild (nose)
- cervix 0-3 cm
- mom anxious but excited
56
Active phase
- ctx become more frequent and increase to moderate (chin) intensity
- ctx occur less than ever 5 min
- cervix 4-7 cm
- mom has to focus and work though ctx
- mom may feel that she's losing control
57
Transition phase
- ctx have increased to every 1.5 to 2 min, strong (f.head)
- cervix 8-10 cm
- mom may feel increased rectal pressure, need to push
- mom may be restless and cannot get comfortable
- mom focused internally and exhausted
- mom wants company but to be "left alone"
58
Second stage
- pushing
- begins with complete cervical dilation and ends with birth of infant
- average time P: 2-3 hrs M: 15-30 min
- crowning
- mom has new found sense of purpose and strength
59
Third stage
- placenta
- beings with delivery of infant and ends with delivery of placenta
- this stage should not last for more than 30 minutes
60
Fourth stage
- recovery
- 1 to 4 hours after birth
- mother's body begins to recover
- VS return to normal
- increased hunger and thirst r/t exhaustion from labor
- shaking r/t physical exertion
61
Which fetal presentation would you most like to see a fetus in?
ROA, LOA, OA. Vertex
62
How will you manage a patient who presents with a fetus in a malpresentation?
Malpresentations usually result in a C-section.
63
What is a TOLAC?
Trial of labor after C-section
64
What influences a successful TOLAC?
- one previous C-section
- low transverse uterine incision
- clinically adequate pelvis
- 2 previous C-sections with a successful vaginal delivery
- must be able to do C-section within 30 min
- dr, staff, anesthesia, must be readily avail for C-section
* *classic(vertical) or T uterine incision is a contraindication to VBAC!!**
65
What is an external cephalic version (ECV)?
the fetus is changed from a breech to a cephalic presentation by external manipulation of the maternal abdomen.
66
What are the criteria for an ECV?
- 36 wks gestation or more
- reactive NST right before procedure
- fetal breech not engaged
- adequate AFI
- single fetus
67
What are contraindications for an ECV?
- maternal problems: uterine anomalies, uncontrolled preeclampsia or 3rd trimester bleeding
- complications of pregnancy: ROM, oligohydramnios, hydramnios, placenta previa, vasa previa
- multiple gestations
- nonreassuring FHR
- fetal abnormalieis: IUGR or nuchal cord
68
How can nurses help prevent the need for an episiotomy?
- perinatal massage during pregnancy for nulliparous women
- natural pushing during labor
- avoiding the lithotomy position
- side-lying position for pushing
- warm or hot compress on the perineum
- firm counterpressure
- push, breath, push, breath
- avoid immediate pushing after epidural placement
69
What defines (PTL) preterm labor?
Labor that occurs between 20 and 36 completed weeks of pregnancy.
70
What tocolytics are used for preterm labor?
-Beta-adrenergic agonists (Beta-mimetics
-magnesium sulfate
-cyclooxygenase (prostaglandin synthesis) inhibitors
-calcium channel blockers
**most widely used are terbutaline sulfate (Brethine) and magnesium sulfate
Also used are nifedipine/Procardia, indomethacin/Indocin
71
Describe fetal fibronectin.
- fFN is a protein normally found in the fetal membranes and decidua.
- it is in cervicovaginal fluid in early pregnancy but is not usually present in significant quantities between 22 and 37 weeks gestation
- + fFN puts mom at increased risk for PTL
- Negative fFN is associated with a very low risk of birth within 7 to 14 days.
- test is over 99% accurate for predicting no preterm birth within 7 days.
72
What is the ultimate goal of PTL management?
Delay birth long enough for corticosteroids to be administered, ideally 48 hours.
73
Polyhydramnios
- also called hydramnios
- More than 2000 mL of amniotic fluid
- 500 mL is normal
- exact cause is unknown
- often occurs in cases of major congenital anomalies
74
Oligohydramnios
- less than normal amniotic fluid; less than 500 mL
- exact cause unknown
- common in postmaturity of fetus, maternal HRN, IUGR from placental insufficiency, fetal renal malformations
75
What do you watch for with polyhydramnios and oligohydramnios?
Polyhydramnios: mom for SOB, edema in LE, compression of vena cava. Placental abruption with ROM, postpartum hemorrhage
Oligohydramnios: fetal adhesions, cord compression, respiratory issues at birth, skin and skeletal abnormalities due to restricted movement.
76
Placenta previa
when placenta is implanted in the lower uterine segment rather than the upper portion of the uterus
77
Abruption placenta
the premature separation of a normally implanted placenta from the uterine wall.
78
Non-pharmacological/physical pain management
- back rub
- counter pressure
- showers/tub
- cool cloths
- ambulation/position change
- hypnobirth
79
Systemic medications for pain management
- analgesia
- stadol/dutophanol (don't give with HTN)
- nubain/nalbuphine
- Demerol/meperdine
- sublimaze/fentanyl
- morphine
80
Regional anesthesia
- provide temporary loss of sensation by preventing nerve impulse transmission.
- most common meds used are Marcaine and Naropin
81
Pudendal block
- provides perineal anesthesia for the latter part of the first stage of labor, the 2nd stage, birth, and episiotomy repair.
- does not provide relief from the pain of contractions
82
What side-effects may you see after an epidural?
Mild: palpations, tinnitus, metallic taste
Moderate: N/V, hypotension (most common, IV bolus)
Severe: respiratory depression, cardiac arrest, coma
83
Think about the most common side effect of an epidural. how might that influence the FHR pattern?
It can cause fetal bradycardia.
84
What is a Bishop score?
- a scoring system that is helpful in predicting the potential success of induction.
- Ratings are 0, 1, 2, and 3
- Components evaluated are cervical dilation, effacement, consistency, and position, as well as station of the fetal presenting part.
- higher score = more likely that labor will occur.
85
How would you manage an unfavorable cervix?
- attempt cervical ripening
- this is softening and effacing of the cervix
- pharmacologic methods of cervical ripening include the use of prostaglandin agents and Cytotec.
86
What are some medications/methods used for cervical ripening & induction of labor?
-Misoprostol (Cytotec) is a synthetic PGE analogue that can be used to soften and ripen the cervix and to induce labor.
-Dinoprstone (Cervidil or Prepidil)
Induction of labor: oxytocin (Pitocin)
87
What is the nurses role in an "operative vaginal birth?"
- Documentation: type of instrument, duration of application, number of contractions, fetal and maternal response.
- Stop the line: if duration/use exceeds guidelines, vacuum pop-offs, chain of command.
