Module 7-1 Flashcards
reasons for families to show up at triage
- rupture of membranes 2. decreased fetal movement 3. regular, frequent uterine contractions 4. vaginal bleeding
when should you not do a vaginal assessment on admission?
if the women has excessive bleeding on admission or episodes of painless bleeding in 3rd tri. May have had placental previa, vaginal assessment could cause copious bleeding
what do you do if the FHR is auscultated at 110 bpm?
immediately apply electronic fetal monitor to obstain additional data. Do mothers vital signs ASAP
Normal characteristics of labour process
Contractions 1. frequency not less than 2 mins, duration of less than 75 secs 2. uterus relaxes bw contractions FHR rate of 110-160, variability and no late decelerations ROM clear fluid with no odour
how much proteinuria needs to be present to worry about preeclampsia?
+1
latent phase (temp)
- monitor temp q4h unless highers than 37.5 (then hourly), when ROM monitor q2h
latent phase (vitals)
bp, hr, resp q4h contractions feel every 15-30 mins
latent phase (fetal assessment)
FHR is auscultated every 30 mins if normal listen during a contraction and then 15 secs after to monitor for deccelerations **if decelerations apply electronic monitoring
nursing interventions for pain management in first stage
if not contradicted 1. ambulating (upright positions promote labour) 2. continue moving 3. distractions 4. offer fluids 5. warm or cold packs 6. paced breathing (dont hold breath) 7. meds if asked for 8. decrease anxiety 9. empty bladder, can cause pain with contractions 10. birthing balls 11. massage ** know plan before this
active phase monitoring mom
bp, hr, resps every hour if in normal range contractions palpated every 15-30 mins
active phase monitoring fetus
FHR every 30 mins for low risk moms and every 15 for high risk mom
transition phase monitoring mom
bp, hr, resps every 15-30 mins contractions palpated at least every 15-30 mins
transition phase monitoring fetus
FHR every 15-30 mins if normal
active phase contractions
frequency= 2-5 mins duration = 60-90 secs moderate intensity remind to void often because it effects decent of fetus
cervical dilation active phase
4-7 cm
latent / early phase dilation
0-4 cm
latent phase contractions
can be 1 min long with 5-1–30 mins between
transition phase contractions
frequency: 2-3 mins duration: 60- 90 secs
transition phase dilation
8-10 cm
mental state during transition stage
- drawn inward - less aware of whats around her - high sense of touch, may not want others touching her - very aware of her contractions - harder to communicated needs
what do you do if FHR is below 110 bpm?
- call physician - vag exam for prolapsed cord - turn to side lying or on hands and knees - admin O2 - discontinue pitocin
second stage, FHR
assessed every 5 mins, some protocols with every contraction
birthing postions
- recumbent postion (stirups) bad for decreased bp, not gravity, may increased laceration or episiodomy chance 2, left lateral sims position 3. squatting 4. semi fowlers 5. sitting 6. hands on knees
..
cleaning the perineum
sponges (sterile tray**)
- mons pubis and lower abdomen
- inner groin and thigh of one leg
- other leg
- last three are for labia, vestibule with one downward sweep each
friedmans curve- labour process curve
created the “normal” parameters for first and second stage of labour. If not done in the time of the curve c/s will happen
LOA; left occiput anterior *
ROA: right occiput anterior *
LOP: left occiput posterior
ROP: right occiput posterior
** most common
