Part III Flashcards
(24 cards)
What are the stages of labor and birth?
- Latent Phase: 0-6 cm; contraction frequency every 5-10 mins; contraction duration-30-45 seconds.
- Active Phase: 6-10 cm; contraction frequency every 2-5 mins; contraction duration 40-60 seconds.
What is considered the first stage of labor? What is the nurses role?
First Stage: Cervical Change
- Onset of true labor to cervical dilatation of 10 cm (Latent and active phase)
Nurses Role:
- keep pt vertical as much as possible (use gravity)
- keep her bladder empty
What is the second labor stage? what is the nurses role?
Second Labor Stage - Pushing through Baby’s Birth
- Begins with complete dilatation and ends with birth of baby.
- Can take up to 2-3 hours. Longer for the primipara typically
- Contractions with a frequency of every 2-3 mins, contraction duration 60-90 seconds.
What is the nurse doing for the patient to move the labor forward? Moving pt around
What is the third labor stage? what is the nurses role?
Third Labor Stage-Placenta Delivery; From birth of the neonate until complete delivery of the placenta
- Should take no more than 30 minutes after birth of baby!
s/s placental separation: globular-shaped uterus; rise of the fundus in the abdomen; sudden gush of blood vaginally; elongation of the cord.
Third stage should take no longer than _____ minutes.
Should take no more than 30 minutes after birth of baby!
What are some s/s of placental separation?
s/s placental separation: globular-shaped uterus; rise of the fundus in the abdomen; sudden gush of blood vaginally; elongation of the cord.
What is the fourth labor stage? what is the nurses role?
Fourth Labor Stage - Immediate Recovery
- Immediate recovery period that lasts between 1-4 hours following birth-Focused assessments to watch for hemorrhage!!
- Typically, 500 mL of blood lost from vaginal delivery.
- Fundus between symphysis pubis & umbilicus at first
- N & V usually cease
- Shaking chill is thought to be from the exertion of labor.
- Urinary retention not atypical assist with elimination as needed
What is the focused assessment to watch for hemorrhage?
- monitor bleeding: too much bleeding if pt is going through a maxi pad an hour
- palpate the fundus (we want the uterus to be firm and small)
- take BP and HR
- etc.
What is the nurses role in the immediate baby recovery following birth?
Assessment/APGAR at 1 and 5 mins.
o Facilitation of cardiopulmonary status/thermoregulation/blood glucose
o Administer Vitamin K, erythromycin ophthalmic ointment, ID bands, bonding.
How is APGAR scored?
*Know this for final exam
- Breathing (we want them to be screaming)
- Reflex Response (measured by flicking foot and response)
- Heart Rate
- Color (if blue fingers/toes, take off one pt… even though normal)
- Muscle tone/activity
*Score 0-2 (perfect score is 10 but not always realistic 1 minute after birth)
What is the nurses role in the immediate recovery for mom following birth?
Mom
o Administer oxytocin IV as ordered (gets tired uterus to cramp down)
o Assess vitals, fundus, lochia (bleeding on pad) every 15 minutes the first 1-2 hours per policy
o Heart rate, blood pressure, lochia and fundal assessments are extremely valuable for hemorrhage consideration
o Also, assessments of LOC, pain, bladder distention. Keep ice on perineum and change cold pack frequently to reduce swelling/pain.
o Ice pack should be placed on the perineum as soon as possible following delivery and any perineal repair!!
What are some Non-Pharmacologic Pain Management methods?
o Positioning (position changes help with pain and labor progress)
o Heat and cold
o Personal comfort
o Providing information
o Easing anxiety
o Breathing techniques
o Relaxation\Distraction
Discuss the following Pharmacologic Pain Management Type: Systemic Analgesia
Systemic Analgesia
o IV push nalbuphine or butorphanol often given between 3-7 cm dilatation.
o Helps mom cat nap and takes edge off of the pain.
o Can slow labor if not in a good pattern yet
o Will cause decreased fetal heartbeat to beat variability because of CNS depression-NOT surprising!!!
o Risky because these meds immediately go to baby causing CNS depression. Timing is critical!
o Assess mother for addiction history!
o Never okay if non-reassuring fetal heart tones (NRFHT) are present or recent pattern of such.
Discuss the following Pharmacologic Pain Management Type: Epidural (regional anesthesia)
Epidural
o Often used for vaginal delivery (about 65% of women)
o Placed in the epidural space meaning on top of the dura, NOT in the spinal canal or spinal fluid.
o Can be placed even close to delivery if progressing slowly enough.
o Does require 20-30 minutes to take full effect.
o Causes loss of pain but leaves pressure sensation intact to help with pushing.
o 500-1000 mL LR bolus administered prior to epidural to prevent hypotension.
o Most women are in bed and unable to walk from an epidural.
o Small catheter remains in the back allowing the care provider to increase or decrease medication.
o Meds often controlled through a PCA by the patient.
o Can be used for a cesarean section if necessary.
o Can be positional meaning only one side of the patient becomes numb.
o Nurse must continue to monitor the mother’s vital (especially blood pressure). Nurse might need to administer more IV fluids
Discuss the following Pharmacologic Pain Management Type: Spinal (regional anesthesia)
*A few differences from the epidural (This is used for C-section)
o Not used for vaginal delivery as pain and pressure sensation are eliminated making pushing very challenging.
o Risk of spinal headache as the dura is punctured and spinal fluid can leak out.
o Spinal requires a smaller volume of fluid and takes effect almost immediately.
o Hypotension risk is present and even greater! Bolus is given prior to administration just like epidural!!
What are some main commonalities and differences between a spinal and an epidural?
- Both cause severe hypotension (fluid bolus given)
- Both offer pain relief
Spinal - Takes away pain and pressure
Epidural - Takes away pain but leaves pressure
Discuss the following Pharmacologic Pain Management Type: Local Anesthesia
Local Anesthesia
o Local blocks
o Used for interventions such as episiotomy, forceps, or vacuum.
o Used for repair following delivery.
What is a potential concern with system analgesia?
- can slow labor when given too early
- Med goes right to baby (respiratory depression risk… often avoided with advanced dilation)
Clinical Breast Exams are recommended annually at age ________.
age 40
Describe Fibrocystic Breast Changes.
Fibrocystic Breast Changes
- Common, benign, tenderness, “lumpiness”, influenced by the menstrual cycle. (mostly in women 30-50 years of age)
- Sometimes this can be associated with Methylxanthines (caffeine products - coffee, tea, cola, chocolate and some medications)
Treatments: Avoid caffeine, NSAIDS, maintain healthy weight
Describe Breast Self-Exams (BSE).
Inspection:
o Three different positions (Standing arms at sides, hands above head, leaning forward with hands on hips).
o Look at the size, symmetry, shape contours and direction, look for changes in the skin, check the nipples.
Palpation:
o While lying down, then repeat while sitting.
o Press lightly feeling for abnormalities or changes.
ACOG recommends that Clinical Breast Exams are done how often?
o Every 1-3 years for women aged 25-39 years.
o Every year for women aged 40 years and older.
Mammography should be done annually starting at age ______.
45
Discuss facts about Breast Cancer.
Breast Cancer
o 2nd leading cause of cancer death in women. (men can also get breast cancer)
o Women have a 1 in 8 chance of developing breast cancer.
o Breast cancer is most common in Non-Hispanic, White women.
Treatment will depend on:
o Stage and specific type of cancer
o Optimal treatment for that stage/type
o The woman’s age
o Personal preferences
o Risks and benefits of treatment
o Treatment may include surgery, chemotherapy, radiation or a combination.
