OB Unit 3 Flashcards
0
Q
During the first stage latent phase
A
- you assess the Mothers Heart rate, resp. rate and blood pressure every 30 to 60 minutes,
- you check the mothers temp every 4 hours until the rupturing of the membranes then it is checked every 2 hours.
- Check the fetal heart rate and pattern every 30 to 60 min.
- Check uterine activity and vaginal show every 30 to 60 min.
- Do a vaginal exam and check fetal station as needed to check progress
- monitor I&O every 8 hours and check bladder distention
- ## Mom should void every 2 hours
1
Q
The first stage of labor and delivery is
A
- the latent phase
- the active stage
- and the transition stage
2
Q
During the first stage active phase
A
- Check moms Heart rate, resp. rate, and blood pressure every 30-60 min.
- Check moms temp every 4 hours until the rupture of the membrane and then check it every 2 hours
- Check the fetal hart rate and pattern every 15-30 mins.
- Check uterine activity and vaginal show every 15-30 mins.
- Do a vaginal exam and check fetal station as needed to check progress
- Monitor I&O every 8 hours and assess bladder distention.
- Mom should coin every two hours
3
Q
During the first stage Transition
A
- Assess mothers HR, RR, And BP every 15-30 minutes
- Assess fetal Heart rate and pattern every 15-30 min.
- Check uterine activity and vaginal show every 10-15 mins.
- Do a vaginal exam and check fetal station as needed to check progress
- Monitor I&O every 8 hours and assess bladder distention
- Mom should void every 2 hours
4
Q
During the second stage of labor and delivery
A
- Check the mothers HR, BP, RR every 5-30 minutes
- Check moms temp every 2 hours until the rupture of the membrane then check it every 2 hours
- Check fetal heart rate and pattern every 5-15 mins.
- Assess every 5-15 minutes to assess contraction and bearing down effort
- Do a vaginal exam and check fetal station at least every 30 min.
- For I&O just check bladder distention
5
Q
During the third stage of labor and delivery
A
- monitor the mothers HR, BP, and RR every 15 minutes
- FHR and pattern are not appl. at this point
- Assess for signs of placental separation, and check the amount of bleeding
- No more vaginal exam at this point
- Don’t worry about I&O at this point
6
Q
During the fourth stage of labor and delivery
A
- Assess the mothers BP, RR, and HR every 15 minutes for the first hour; after 1 hour if it is within normal limits check once in the second hour.
- Check her temp at the beginning and the end of the first hour
- with the fetus you will assist with the APGARS and initiate neonatal transition care
- assess bladder distention
7
Q
With assessment
A
- Remember that pain assessment, psychological assessment, and comfort measures are continuous.
8
Q
Analgesic medication in labor includes
A
- Meperidine (demerol)
- Butorphanol (stadol)
- Nalbuphine (Nubian)
- Sublimaze (fentanyl)
- Sufenta (sufentanil)
9
Q
Meperidine (Demerol)
A
- can give 50-100 mg IM or 25-50 mg IV q 3-4 hours
- class/ action
- *****opioiod agonist
- **-effective analgesic, feeling of well-being, no amnesiac effect
- **-may aid progress as cervical relaxation occurs
- **-will halt labor contractions if given too early
- Side effects
- *****CNS depression
- *****neonatal respiratory depression
- *****decreases gastric emptying and increase nausea and vomiting
- *****bladder and bowel elimination can be inhibited
- *****bradycardia, tachycardia, hypotension
- Nursing implications
- *****avoid use when close to delivery(about 1 hour)
- *****usually given between 4-7 cm
10
Q
Butorphanol (stadol)
A
- Class/Action
- **opioid agonists-antagonists
- **moderate to severe labor pain and postoperative after cesection
- **mild maternal sedation
- can give 1mg-4mg IM every 3-4 hours PRN, or 0.5mg-2mg IV every 3-4 hours PRN
- Side effects
- **No respiratory depression in women or neonate
- **less N/V than opioid agonists
- **confision, sedation, hallucinations, floating feeling, dizziness, sweating, difficulty with urination (retention, urgency)
- Nursing implications
- **check maternal history for drug abuse
- **do not give to drug dependent women due to possible precipitation of sudden withdrawal response in women and baby
- **encourage voiding every 2 hours
11
Q
Nalbuphine (Nubian)
A
- Class/Action
- **opioid agonists-antagonists
- **moderate to severe labor pain and postoperative after cesection
- **mild maternal sedation
- can give 1mg-4mg IM every 3-4 hours PRN, or 0.5mg-2mg IV every 3-4 hours PRN
- Side effects
- **No respiratory depression in women or neonate
- **less N/V than opioid agonists
- **confision, sedation, hallucinations, floating feeling, dizziness, sweating, difficulty with urination (retention, urgency)
- Nursing implications
- **check maternal history for drug abuse
- **do not give to drug dependent women due to possible precipitation of sudden withdrawal response in women and baby
- **encourage voiding every 2 hours
12
Q
Sublimaze (fentanyl)
A
- can be given as 50-100mg IM or 25-50mcg IV; 1 to 2 mcg with 0.125% bupivacaine at 8 to 10 ml/hr epidurally
- class/action
- ** short acting opioid agonists
- **rapid action, short duration
- **relieve moderate to severe pain and postoperative pain after cesection
- Side effects
- **FHR changes, hypotension, respiratory depression, dizziness, drowsiness, rash/pruritus, nausea/vomiting, and urinary retention
- Nursing implications
- **sufentanil use is increasing because it has more potent analgesic action and less crosses the placenta
13
Q
Sufenta (sufentanil)
A
- can give 10-15 mcg with 0.125% bupivacaine at 10 ml/hr epidurally
- class/action
- ** short acting opioid agonists
- **rapid action, short duration
- **relieve moderate to severe pain and postoperative pain after cesection
- Side effects
- **FHR changes, hypotension, respiratory depression, dizziness, drowsiness, rash/pruritus, nausea/vomiting, and urinary retention
- Nursing implications
- **sufentanil use is increasing because it has more potent analgesic action and less crosses the placenta
14
Q
When giving analgesic medications during labor and delivery the nurse should
A
- assess fetal heart rate, mothers vital signs, and cervical status prior to and after administration
- give analgesics at peak of contraction so less medication will transfer to baby
- assess for effectiveness/side effects
- provide for safety, especially of LOC expected to be altered
- Narcotic reversal
- **Naloxone Hydrochloride (narcan); can be used for mom or neonate to reduce respiratory depression; mom 0.4-2mg IV/IM/subQ every 2-3 minutes up to 10mg; neonate 0.1 mg/kg/im/subQ every 2-3 minutes up to 3 doses
15
Q
Types of Anesthesia in Labor and Delivery
A
- Local
- Regional: Pudenal block
- Regional: Epidural block
- Regional: Spinal block
- General
16
Q
Local Anestetics
A
- Are injected into the perineum at the episiotomy site
- **Inject 10-20 mL of 1% lidocaine into skin the SubQ region to be anesthetized
- Time to be given
- **Second stage of labor, immediately before delivery if no regional anesthesia
- Action
- **Anesthetizes local tissue for episiotomy and repair
- **Rapid anesthesia
- Adverse effects
- *****Risk of hematoma
- *****Risk of infection
- Nursing Implications
- **Monitor for:
- *******Return of sensation to area
- *******Increased swelling at site of injection
17
Q
Regional: Pudenal block
A
- Is an Anesthetic injected in the pudendal nerve (close to the ischial spines)
- **Drug used: xylocaine
- **Should be administered 10-20 minutes before perineal anesthesia is needed
- Time to be given
- *****Second stage of labor, prior to time of delivery
- Action
- *****Anesthetizes vulva, lower vagina and part of perineum for episiotomy and use of forceps or vacuum
- *****Third stage for episiotomy or laceration repair
- *****Rapid effect
- Adverse effects
- *****Risk of local anesthetic toxicity
- *****Risk of hematoma
- *****Risk of infection
- *****Bearing-down reflex is lessened or lost completely
- Nursing implications
- **Monitor for:
- **Return of sensation to area
- **Increased swelling
- **Signs and symptoms of infection
- **Urinary retention
18
Q
Regional: Epidural block
A
- Is an Anesthetic injected in the epidural space (located outside the dura mater between the dura and spinal canal via an epidural catheter)
- **Drugs used: xylocaine, marcaine, fentanyl
- Time given
- *****First stage and/or second stage of labor
- Action
- *****Can be used for both vaginal and cesarean births
- *****Has the potential of 100% blockage of pain
- *****Can be used with some opioids to allow walking during first stage of labor and effective pushing in second stage of labor
- *****Rapid onset in minutes; lasts 60-90 minutes
- *****Loss of pain perception for labor contractions and delivery
- Adverse effects
- *****Most common complication is hypotension
- *****Other side effects include nausea, vomiting, pruritis, respiratory depression, alterations in FHR
- *****Could slow labor if given too early; obliterates pushing feeling so second stage may be prolonged
- Nursing implications
- **Pre-anesthesia care:
- **Obtain consent
- **Check lab values-especially for bleeding or clotting abnormalities, platelet count
- **IV fluid bolus with Normal Saline or Lactated Ringer’s (1500 cc’s)
- **Ensure emergency equipment is available
- **Do time-out procedure verification
- **Post-procedure care:
- **Monitor maternal VS and FHR every 5 minutes initially and after every re-bolus then every 15 min and manage hypotension or alterations in FHR
- **Urinary retention is common and catheterization may be needed
- **Assess pain and level of sensation and motor loss
- **Position woman side-lying
- **Assess for itching, nausea, vomiting, and headache and administer meds prn
- **When catheter discontinued, note intact tip when removed
19
Q
Regional: Spinal block
A
- Is an Anesthetic injected in the subarachnoid space
*****Drugs used: Xylocaine, Marcaine - Time Given
****Second stage of labor or for cesarean section
Rapid acting (5-10 minutes) with 100% blockage of sensation and motor functioning below insertion site (nipple to feet). - Action
****Can last 1-3 hours depending on agent used - Adverse effects
****Adverse effects are similar to the epidural with the addition of a spinal headache. - Nursing implications
**Before injection, VS and a 20-30 min FHR strip is obtained and evaluated
**Bolus of 500-1000 mL’s LR or NS, 15-30 min prior to injection
**Assist with maternal positioning for placement
**Maternal BP, HR, RR, FHR evaluated q 5-10 minutes
***Must be coached when to push
***Monitor site for leakage of spinal fluid or formation of hematoma
**Observe for headache
20
Q
General anesthesia
A
- Is the Use of IV injection and/or inhalation of anesthetic agents that render the woman unconscious
- **Drug used: Thiopental; Nitrous oxide and oxygen mix 50:50
- Time given
- *****Used mainly in emergency cesarean birth
- Action
- **Rapid onset
- **Rapid recovery
- **ET intubation required
- Adverse effects
- *****Risk for fetal depression
- *****Risk for uterine relaxation
- *****Risk for maternal vomiting and aspiration
- Nursing implications
- *****Obtain consent
- *****Ensure woman is NPO
- *****IV with large-bore needle
- *****Place indwelling urinary catheter
- *****Administer meds to decrease gastric acidity (Tagamet, Zantac, Reglan)
- *****Place wedge under hip to prevent vena cava syndrome
- *****Assist with supportive care of newborn
21
Q
Nursing summary for anesthesia
A
✓ Preload of IV fluids
✓ Preop meds before c/s
✓ Positioning during procedure of epidural and spinal anesthesia
✓ Displace uterus after procedure for better placental circulation
✓ Monitor VS according to hospital policy, usually q 15 minutes
✓ Repositioning for even block
✓ Bladder assessment and catheterization as needed
✓ Continued assessment of pain relief and communication with provider
22
Q
Cardiovascular response to labor
A
- Increase cardiac output
- Increase BP (especially during UC)
- Increased heart rate
- Supine hypotensive syndrome
- Stage 2 - Valsalva maneuver
23
Q
Respiratory response to labor
A
- Increased respiratory rate
- Increased oxygen demand and consumption
- Hyperventilation + fall in PaCO2 result in respiratory alkalosis
24
Gastrointestinal response to labor
* Gastric motility decreased
* Gastric emptying prolonged
* Increased risk of aspiration with anesthesia
25
Body Temp response to labor
* Slight elevation due to muscle activity
* Temperature over 100.4 –sign of infection
* Assess every 2 hours after rupture of membranes
* Increase fluid loss from sweating and mouth-centered breathing
26
Fluid and electrolytes during labor
* Diaphoresis
| * Hyperventilation
27
Blood values during labor
* Increased WBC (may be 15,000 or higher)
* Increased fibrinogen
* Decreased blood glucose
* Slight proteinuria
28
FETAL RESPONSE TO LABOR
* Positive effects:
* ****Decrease respiratory tract secretions
* Potential adverse effects:
* ****Decreased placental perfusion
* ****Hypoxia
29
THE PASSAGE = PELVIS & BIRTH CANAL
* Type/shape of pelvis
* ****Gynecoid (most common)
* Ability of cervix to change
* ****Efface
* ****Dilate
* Ability of vaginal canal and external opening of the vagina (introitus) to distend
30
THE PASSENGER = FETUS & PLACENTA
* Fetal head
* Fetal attitude
* Fetal lie
* Fetal presentation
* Fetal position
* Placenta implantation site
31
Fetal Position
* Determines type of delivery
* Affect nursing care given to patient
* Abnormal positions may lead to difficult delivery
* Can change up until “engagement” occurs
* Ballotable
* Determined by Leopold’s Maneuvers and ultrasound
32
Relationship of passage and passenger
* Engagement
* *****Occurs when the largest diameter of fetus reaches or passes thru the pelvic inlet
* *****In primigravida usually occurs 2 weeks before term
* *****Multipara may occur several weeks before labor or during labor
* *****Confirms the adequacy of the pelvic inlet (not midpelvis or outlet)
* Station
* *****Relationship of presenting part to an imaginary line drawn btw ischial spines of maternal pelvis
* *****Narrowest diameter
* *****Designated as “0” station
* *****Higher than ischial spines - - number
* *****Lower than ischial spines - + number
33
The Powers
* Primary force is uterine muscular contractions
* ****Begins in fundus where greatest concentration of muscle fibers are located
* Causes dilation and effacement of cervix
* Causes changes in station
* Secondary force is use of abdominal muscles to “PUSH”
34
THE POSITION (OF THE LABORING WOMAN)
* Upright position recommended
* ****Walking, sitting, kneeling, or squatting
* Lateral position when lying down
* Encourage and allow mom to listen to her body cues
35
Pre-Labor signs
* Lightening
* Braxton-Hicks Contractions
* ****Irregular, intermittent, painless
* ****Become painful as term approaches
* ****Described as “drawing” sensation
* “Ripening “of cervix
* Bloody show - pink tinged secretions from cervical capillaries
* ****Labor usually results in next several weeks
* Burst of energy
* Diarrhea, nausea and vomiting
* Increased backache and sacroiliac pressure
* ****Result of hormones
* 1 to 3 pound weight loss
* ****Result of fluid loss and electrolyte shift
36
True Labor
* Contractions regular
* Interval btw UC gradually shorten
* Increase in duration and intensity of UC
* Discomfort begins in back and radiates to abdomen
* Intensity increases with walking
* PROGRESSIVE cervical dilation and effacement
37
False Labor
* Contractions irregular
* No change in duration and intensity of UC
* Discomfort usually in abdomen
* Walking has no effect on contractions, or actually lessens severity of UC
* NO CERVICAL CHANGE
38
First stage of labor
* from beginning of labor to complete dilation and effacement of cervix
* Latent or early phase (0-3cm)
* Active phase (4-7cm)
* Transition phase (8-10cm)
39
Interventions for first stage of labor
○ Complete Admission Assessment and Review History
○ Assessment: Maternal VS, Response to Labor and Pain, FHR and UC, Cervical Changes, Membrane Status, Fetal Position and Descent
○ Diet and Hydration: Clear Liquids
○ Activity and Rest: Frequent Position Changes/Ambulation
○ Elimination: Frequent Emptying
○ Comfort: Meds and Non-Pharmacologic Strategies
○ Support: Keep Family Involved
○ Education: About Labor, Procedures, Policies
○ Safety: Safe and Friendly Environment
○ Documentation
40
Second stage of labor
- begins with complete dilation of cervix and ends with birth of baby “PUSHING”
- S&Sx = sudden increase in bloody show, uncontrolled bearing down efforts, bulging of the perineum
* Crowning
* Episiotomy
* ****Midline
* ****Mediolateral
41
Interventions for 2nd stage of labor
```
○ Support and Encourage Spontaneous Pushing Efforts
○ Monitor for Fetal Response to Pushing
○ Provide Comfort Measures
○ Position Changes as needed
○ Perineal Hygiene as needed
○ Give Praise and Encouragement
○ Encourage Rest between Contractions
○ Teach Breathing Technique
○ Teach Pushing Technique
○ Meds as ordered
○ Assist the Support Person
○ Advocate on Woman’s Behalf
○ Documentation
```
42
Third stage of labor
- begins with birth of the baby and ends with delivery of placenta
– Should deliver within 30 minutes
– Considered a “retained placenta” if greater than 30 mins.
– May need to remove manually
43
Interventions for 3rd stage of labor
```
○ Maternal VS per protocol
○ Encourage Breathing
○ Encourage Rest
○ Encourage Bonding with Neonate
○ Meds as ordered
○ Documentation
```
44
Fourth stage of labor
* initial recovery time
* First 1-2 hours after delivery of placenta
* Expected amount of blood loss - 250 - 500 ml for vaginal delivery
* Essential for uterus to remain contracted
* Priority problems during this stage
* Risk for hemorrhage
* Risk for hypotonic bladder
45
Interventions for 4th stage of labor
○ Maternal VS
○ Assess Uterus: Position, Tone, Location
○ Assess Lochia: Color, Amount, Clots
○ Monitor Perineum for Swelling or Hematomas
○ Meds as ordered
○ Assist with Laceration/Episiotomy Repair
○ Apply Ice to Perineum
○ Monitor for Bladder Distention
○ Assess for motor-sensory function return if spinal or epidural used
○ Encourage Bonding with Neonate
○ May Eat and Drink Immediately if Vaginal Delivery
○ Documentation
46
Pain relief options for labor
- Relaxation techniques
- Cutaneous stimulation
- Breathing techniques
- Patient hygiene/comfort measures
- Systemic analgesia
- Pudendal block
- Local anesthesia
- Regional analgesia/anesthesia
- General anesthesia
47
Relaxation techniques include
* Muscle tension causes fatigue and increased oxygen demands
| * Comfortable position
48
Cutaneous stimulation
* Massage of large muscle groups stimulates gate-control theory
* “Effleurage”
* Heating pad / warm shower / bath
* Counter-pressure to lower back
49
Breathing techniques
* A form of distraction
* Enhances relaxation
* Provides good O2 exchange
* Teach slow deep breathing if no prenatal education
50
Systemic analgesia
* Nubain – drug of choice
* Recommended to wait until labor established
* IM, Subq, or IV
* Should not be given within a few hrs of birth because it may depress neonatal respirations
51
Pudendal block
* provides perineal numbness
| * Used during 2nd stage
52
Local anesthesia
* Used during 2nd stage to provide perineal numbness
53
Regional analgesia/anesthesia
* Epidural - major side effect - hypotension
* *****Bolus of fluid prior to procedure, monitor BP q 5 mins after procedure, side-lying position, monitor for urinary retention
* *****Used for labor and delivery
* Spinal - major side effect - hypotension
* *****Immediate effects
* *****Used during 2nd stage
* *****Tilt patient to side during C/S to lessen hypotensive effects
54
General anesthesia
* Only used in emergency situations!
| * High risk of fetal depression
55
assessment of laboring patient
* Maternal assessment
****** Review of prenatal history
******Identify risk factors
******Maternal vital signs, labor status, uterine activity, fetal status and lab values
******Don’t forget assessment of pain and psychosocial status!!!
Standard Precautions
56
Fetal malposition/malpresentation
* The Posterior position most common; brow, face, breech, shoulder presentations
* Causes Labor length increased
* Increased need for intervention
* EXTERNAL VERSION MAY BE ATTEMPTED
* ****Usually attempt to turn the fetus from breech to cephalic presentation
* ****Significant risk of cord compression &/or entanglement
* ****NEVER do with multiple gestation
* ****Medicated with tocolytic (terbutaline) prior to procedure to relax uterus
57
Amniofusion
* Infusion of warmed, sterile fluid into the uterine cavity thru intrauterine catheter
* Oligohydramnios, thick, meconium stained fluid, variable decelerations
* Monitoring, comfort measures, peri-care, bedrest
58
Induction of labor
* Artificial stimulation of labor
* NOT recommended to induce “electively” PRIOR to 39 weeks gestation
* Reasons for induction
* *****Medical condition of mother / fetus
* *****Post-dates
* *****Decreased amniotic fluid
* *****Non-reassuring antenatal testing
* *****Large infant
* Assess
* *****Position, presentation of fetus, gestation
* *****The more “favorable” the cervix; the more likely the induction will be successful
59
Types of induction
- Amniotomy
| - Pharmachological
60
Amniotomy
- Note color, odor, amount
61
Pharmacological
- Oxytocin major complication is tacky systole
* ****more than 5 contractions in10 min or less than 30 sec. rest period
* ****Risk of Abruptio placenta or uterine rupture
* ****Assess for signs of fetal distress
- Cervical ripening agents
* ****PROSTAGLANDIN GEL – prepidil & cervidil
* ****MISOPROSTAL - cytotec
62
Nursing responsibilities with induction
* Monitor vital signs of mother
* Monitor fetal response to contractions
* ****FHR baseline
* ****Variability
* ****Presence of decelerations
* Monitor contraction pattern
* Monitor intake and output
* Major concern is tachysystole resulting in
* ****Fetal distress
* ****Uterine rupture
68
Adjunct Medications
- Promethazine (phenergan)
- Hydroxyzine (vistaril)
- Meroclopramide (reglan)
- Ondansetron (zofran)
- Diphenhydramine (Benadryl)
68
Promethazine (phenergan)
- Can give 50 mg in early labor; when labor is established, additional doses of 25–75 mg may be given 1–2 times at 4-hr intervals (should not exceed 100 mg/24 hr).
- Class/Action
* ****Phenothiazines:
* ********Decrease anxiety and apprehension, increase sedation, reduce nausea and vomiting
68
Hydroxyzine (vistaril)
- Can give 25-100mg IM
- Class/action
* ****Antihistamines:
* *******Decrease anxiety and apprehension, increase sedation, reduce nausea and vomiting, potentiate opioid effects
68
Meroclopramide (reglan)
- Can give PO, IM, IV 10–15 mg 30 min before meals and at bedtime (not to exceed 0.5 mg/kg/day). A single dose of 20 mg may be given preventively. Some patients may respond to doses as small as 5 mg.
- Class/Action
* ****Antiemetics:
* *******Cause little sedation and can potentiate the effects of analgesics
* *******Relieves N/V, and accelerates gastric emptying
68
Ondansetron (zofran)
- Can give IM, IV 4 mg before induction of anesthesia or postoperatively.
- Class/Action
* ****antiemetics
* *********Cause little sedation and can potentiate the effects of analgesics
* *********Relieves N/V, and accelerates gastric emptying
68
Diphenhydramine (Benadryl)
- Can give IM / IV 25–50 mg q 4 hr as needed (may need up to 100-mg dose, not to exceed 400 mg/day).
- Class/Action
* *****Antiemetics
* ********Relieves N/V, mild sedation, decreases anxiety, relieves itching
* ********Alternative of local anesthetics in patients with history of hypersensitivity to local anesthetics
