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118 Cards in this Set
- Front
- Back
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some ideas on what initiates labor
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uterine distention
aging of placenta mom's hormones change increase estrogen and prosteglandins and decreased progesteron fetal hormone may play apart |
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what are fetal fibronectin
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protein found in cervical mucous produced by the fetus. If not present when tested 98% done deliver w/i next 2 weeks, does not work other way. Mostly used for Negative prediction
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Signs preceding Labor
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lightening
increased braxton hicks bloody show/mucous plug GI-n/v, diarrhea SROM Burst of energy (nesting) |
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True Versus False labor
TRUE |
True
reg. progressive contractions increase in freq, duration and dilitation of cervix result in effacement and dilatation of cervix do not disappear with activity result in |
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True Vs false labor
FALSE |
Occur at irregular intervals
don't increase in freq, duration or intensity do not result in effacement and dilatation disappear with activity |
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critical factors affecting labor
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Pelvic dimensions
Fetal dimensions-size and flexability of sutures uterine contractions-strength and regulartiy |
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THE 5 P'S
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Passageway
passenger powers position of mother psychological response |
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PASSAGEWAY; bony pelvis and soft tissues
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Gynecoid-(normal) round
Android-heart shaped-may rq C/S Anthropoid-oval-usually OK to SVD platypelloid- flattened round |
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Passenger-fetal head
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biparietal diameter-largest
sutures- sagital, coronal, lambdoidel fontanelles;anterior (largest) Posterior (smallest Molding- can be extensive, returns to normal w/i 3d |
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PASSENGER:fetal lie
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relationship of the long axis of the fetus to the long axis of the mom
Transverse(need c/s) Longitudinal(head or feet first) |
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Fetal attidude
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relationship of the fetal body parts to each other
flexion-desirable military-straight down/not flexed brow face |
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PASSENGER:Fetal presentation
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presenting part which first enters pelvis
1. Cephalic:vertex, military, brow face 2. Breech:complete, frank, footling 3. shoulder |
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describe the different types of breech presentation
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Frank: thighs are flexed on hips, knees are extended
Complete: thighs and knees are flexed Incomplete: foot extends below the buttocks Incomplete: knee extends below the buttocks |
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PASSENGER: fetal position
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relationship of presenting part to 4 quadrants of moms pelvis. Document in three letters
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PASSENGER: fetal position
L/R |
Document whether on maternal right side (R) or left side (L)
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PASSENGER: fetal position
fetal presentation |
O- occiput
M- mentum-chin S-sacrum SC-shoulder |
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PASSENGER: fetal position
Maternal abdominal quadrant |
A- anterior
P- Posterior T- transverse |
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PASSENGER:Station
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engagement:presenting part passes thru pelvic outlet
Station: telationship of presenting part to ischial spines. Level -5 to -1 Level 0-head at ischial spine Level +1-+5 |
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what must you consider when determining station
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If infant has a caput then it may feel like a +3 station when in fact the head is station 0
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POWERS-primary
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Contractions-primary
FREQ: beginning of one contraction to beginning of next DURATION: beginning to end of contraction INTENSITY: strength at peak(only definitive w/ internal monitoring) |
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POWERS-secondary
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abdominal muscles
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Factors affecting duration of labor
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parity-more babies the faster
position of fetus position of woman level of activity of mom fetal size maternal emotions |
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what is the intrauterine resting tone and why is it important
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the space between contractions, gives the mom time to rest and reoxygenates infant
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FACTORS AFFECTING PSYCHOLOGICAL RESPONSE
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culture
previous experience preparation, childbirth educ anxiety and fear |
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How does fear and anxiety affect labor?
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it increase pain, which increase adrenaline which leads to a decreased production of oxytocin which decreases endorphins
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How does lack of knowledge contribute to fear
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Not knowing what is coming next. Expecially during transition when mom may feel like giving up, if she knows it is the shortest part of labor she has more comitment
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INFLUENCES ON EXPERIENCE OF PAIN
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support system
past experiences pain tolerance physical condition at onset of labor(how tired is mom) expectation preperations length of labor flexibility-just don't know what is going to happen |
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PAIN OF L&D
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Contractions: intermittent, begin in back, radiates over abd, diminishes during rest
Lower uterine and pelvic pressure: nerves and organs compressed, tissues stretched. pressure can extend into rest periods |
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WHAT CAUSES DISCOMFORT OF LABOR
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Ischemia of muscles and dilitation and effacement of cervix
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MANAGEMENT OF DISCOMFORT
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chidbirth education
water, position change, effleurage(massage of abd) hypnosis, acupuncture, tens medications;nubain, demerol anesthesia;epidural, spinal |
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Childbirth education
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dick-Read method
lamaze method-relaxation and breathing patters bradley method-envionment plays huge part |
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Position of MOM
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frequent change of position and activity increases stregth of contractions
If have back pain use counter pressure, knee to chest, sterile water sq robozo method |
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Pharmacologic measures
Narcotics |
ex demerol of fentanyl:short acting, may cause resp depression in NB if given close to birth
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Pharmacologic measures
agonist-antagonist compounds |
ex. nubain
less resp depression Tend to not stop labor so less interventions needed |
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pharmacologic measures
regional anesthesia advantages |
epidural or spinal: adv- good pain relief, mother awake and alert, partial motor paralysis. dose may be modified
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pharmacologic measures
regional anesthesia Disadvantages |
must have IV access, may cause serious hypotension, may impede pushing, statistically increases c/s rate, increase use of pitocin and vacuum, urinary retention
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Nursing care with epidural
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start iv give bolus as order
assist with positioning monitor FHR monitor contractions assess for bladd distention have O2 available |
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Why do you worry about bladder distention?
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a full bladder can stop descent of head stalling labor
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GENERAL ANESTHESIA
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used only in emergency c/s
serious resp distress in NB 80% of obstetric anesthesia related mortality associated with obesity |
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STAGES OF LABOR
FIRST STAGE |
3 PHASES
LATENT ACTIVE TRANSITION |
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Myometrial activity
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EFFACEMENT- shortening and thinning of the cervix 0%-100%
DILITATION- enlargement or widening of the cervical opening closed to 10cm |
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Mechanism/cardinal movements
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enagement
descent- icreases 5-7cm flexion internal rotation extension restitution external rotation |
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Intial assessment of mom when enters hospital
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EDC- is this preterm?
FHR-is it WNL Onset of labor/freq of contractions-gauge of progres Gravida, para- time frame status of membranes-how much time you have to deliver VS-temp and BP most important Comfort level preg complicaitons-pih,gd birth plan |
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Admission assessment of the fetus
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FHR 120-160
Leopolds maneuvers |
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What is the purpose of leopolds maneuver?
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to determine position of baby, palpate for head//rump and small body parts. see if head is engaged
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Electronic fetal monitoring-external, US transducer, toco
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ultrasound transducer-reads FHR
tocodynamometer-reads contractions |
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Internal-spinal elctrode, intrauterine pressure catheter IUPPC
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pressure catheter-accurate measure of strength of contraction
done with high risk preg or if can't get reading with external |
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FETAL HEART RATE PATTERNS
BASELINE |
normal 120-160
brady <110 for 10min tachy >160 x10min |
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BASELINE VARIABILITY
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how much pulse rate changes
minimal <5bpm moderate 6-25 bpm (ideal) marked > 25bpm |
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What might you see with decreased variability?
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hypoxia, CNS depression, narcotic use, fetal sleep, congenital anomolies
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when might you see with marked variabilities?
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mild hypoxia, contractions, activity of mother, fetal stimulation
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what may decreased variability with late deceleration indicate?
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fetal acidosis
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PERIODIC AND NON-PERIOCIC CHANGES
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periodic associated with contractions
non-periodic assoc with no contraction |
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decelerations
what may they indicate |
early-fetal head compression-wouldn't worry during pushing phase only in early preg or labor
Late: uteroplacental insufficiencey- generally not good Variable-compression of the umbilical cord-not always ominous. change position to see if it goes away |
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Assessments-interventions
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fetal scalp stimulation->115bpm FHR-reassuring
Fetal blood sampling-assess ph, po2 pco2 fetal pulse oximetry-sensor placed vaginally 30%-70% normal |
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IMPLEMENTATION:NURSING CARE
STAGE 1 ONSET OF LABOR |
latent phase- beginning of labor to 3cm dilated. mom usually excited and sociable
2.active- 3cm-7cm effacement copleter, decend begins, more uncomfortable,nn more support 3.transition-8-10cm, intense contractions, irritable, n/v, leg trmors usually doens't last long. nn LOTS of support |
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NSG CARE CONTINUED
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CONT TO ASSESS:length, freq and strength of contractions, FHR, VS, support to mom, status of membranes and vaginal exam
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Time frame for assessing VS in a low risk, normal progression pregnancy
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latent- q 30-60min
active-q30min transition- q15 min |
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Bloody show
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Mucous plug, may come out day before or during labor
may or may not notice |
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RUPTURE OF MEMBRANES ROM
SROM |
may occur before labor or during stage one or 2. if unsure if occured test with nitrazine paper (turns blue) or fern test (fluid takes fern shape when seen under microscope)
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PROM
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premature (?) rupture.
>18h increased risk for infection standard of care ususally c/s if not in active labor at 18h |
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What must you ALWAYS check after ROM
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1. Check FHR
2. note color and odor of fluid. clear vs. green ] merconium |
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AROM
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Artificial rupture of membrane- membrane does not rupture on own, done with amni hook
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STAGE 2 Labor
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full dilation to birth of baby
wait for urge to push use gravity with position pushing before 10cm> cervical edema or laceration usually > parity= <perineal laceration |
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what is Feergerson reflex
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stretch receptors which when stimulated may cause urge to push
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Third stage of labor
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birth of baby to birth of placenta: wait for placental seperation, considered retained if >1h, repair epis/laceration, palpate fundus, adm oxytocin prn
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what are the signs of placental separation
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uterus becomes globular shaped
umbilical cord becomes longer sudden gush of blood |
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should you pull on the cord
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NO, do not pull on cord to try and pull placenta out quicker,cord can snap or can pull the uterus inside out b/c placenta doesn't seperate
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What is a nuchal cord
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The cord gets wrapped around the neck of infant
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PLACENTA
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made of cotyledon, examine placenta to make sure all there. otherwise some of placenta may still be attached inside
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CORD
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Look for three vessels
2 arteries 1 vein if 1 and 1 may be indicitive of anomolie esp of kidneys Wharton Jelly contracts blood vessels |
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EPISIOTOMY
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EPI ONLY DONE IF INDICATED
midline/mediolateral |
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WHAT ARE THE INDICATIONS FOR AN EPISIOTOMY?
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really large baby
hx of 4th degree laceration forcep or vacuum delivery if you want out quickly |
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Types of Lacerations
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1st- thru skin, not muscles
2nd- thru muscles 3rd- thru anal sphinchter 4th- involves anterior rectal wall-very uncomfortable |
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fourth stage of labor
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first hour or two after birth
stabilization of mother and baby |
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Estimated Blood Loss
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vaginal-500cc
c/s-1000cc hard to est acurrately so check H&H highest risk for hemorrhage first hour, next first 24h |
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INDUCTION OF LABOR
Indications |
post-dates
DM PIH IUGR social |
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INDUCTION OF LABOR
methods |
cervical ripening agents, oxytocin, amniotomy (AROM)
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INDUCTION OF LABOR
bishops scale assess |
readiness to induce
dilitation effacement station cervical consistency cervical position if none present loooong induction w/ high risk c/s |
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CERVICAL RIPENING
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purpose:to soften and thin cervix to facilitate induction with oxytocin
prostaglandin gel or insert placed in vagina SE: headache, n/v, hypotenstion, hyperstimulation of uterus, fetal passage of merconium |
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Reasons not to use cervical ripening
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non-reactive stress test
positive contraction stress t vaginal bleeding strong regular contraction |
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AMNIOTOMY
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AROM
induce labor or augment if slowing, commitment to birth w/i 24h, fetus should be engaged, IMMEDIATELY CHECK FHR, note color and odor, check temp q 2h b/c risk for infection |
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OXYTOCIN INDUCTION
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HORMONE PRODUCED by the posterior pituitary. Pitocin 10u in 1000cc IV solution use pump! Increase slowly Assess FH pattern, mom vs contraction pattern and resting tone, I&O
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what do you do if having and emergency while using pitocin
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TURN IT OFF
turn to L side (or R if already on L) |
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Contraindications for pitocin
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cephalopelvic diportion
prolapsed cord placenta previa |
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SE of Pitocin
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water intoxication(retain lots of water) hyperstimulation tetanic w/o relaxation could cause hypoxia and amniotic fluid emboli(fatal)
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Immediate care of the newborn
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suction as necessary
wipe dry and put skin to skin with mother apgars |
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What is an external cephalic version?
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attempt to turn a breech baby so SVD can happen. Done after 37wk
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why is a cephalic version done after 37wk
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may cause mother to go into labor, may cause bleeding, may turn back
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what must be assessed prior to a cephalic version?
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ultrasound to verify position, no previa, no oligiohyramus, Rh status, will need shot of rhogam due to risk of blood mixing
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What is tocolysis
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medications given to supress preterm labor, to aid in external cephalic versions and for hyperstimulationt
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what are some examples of meds used for tocolysis?
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ritodrine(only one FDA approved)
Terbutaline mag sulfate nifedipine indomethacin-steroid stimulates surfactant |
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What is one thing important to assess?
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make sure to check pulse
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Indications for forcep delivery
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2nd stage exhaustion, fetal distress, strong epidural, need to get baby out fast
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what are the three kinds of forceps?
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Outlet- must have head on perineum. most common type
Low- +2 station mid- engaged dont see mid/low because a c/s would be performed instead |
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What should you monitor and what are side effects of forceps application?
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Monitor FHR
SE- bruising on cheek of infant and lacerations for mom |
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Vacuum extraction
Indications |
same as forceps: 2nd stage exhaustion, fetal distress, strong epidural, need to get baby out fast
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why may a vacuum extraction be used as opposed to forceps?
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less injury to mom and baby
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side effects of vacuum extraction
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cephelhematoma
may also see caput DONT ATTEMPT MORE THAN 3X |
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Prolapse of cord definition
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premature expulsion of a loop of umbilical cord into the cervical or vaginal canal during labor beofre engagment of the present part. see in 1:400 birhts
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Interventions for prolapsed cord
pressure relief |
Releive pressure-vaginally by pushing head up and away from cord. Trendlenberg or gravity. raise hops or knee chest position
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Interventions for prolapsed cord
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cover cord with wet saline (wharton jelly will dry out)
call for assistence give O2 to mom monitor FHR C/S |
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What is dystocia?
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long, difficult or abnormal labor
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what causes dystocia?
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dysfunctional labor, alteration in pelvic structure, fetal position, mom position, psychologica
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when would you suspect dystocia?
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lack of progress in effacement, dilitation or descent or all three
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normal vs abnormal contractions
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normal- flat resting tone, peaks then rest etc
hypotonic-irregular contractions not well defined hypertonic-doesn't return to resting tone in between |
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Hypertonic uterine dysfunction
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painful freq contraction in LATENT phase. originates in mid section of uterus (VS fundus in normal) exhausts the woman. RX: water and meds to rest
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Hypotonic uterine contractions
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ACTIVE PHASE; contractions become weak and ineffective
R/O CPD or malpositions RX: ambulation,h2o,ROM, oxytocin |
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Cephalopelvic disproportion
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large size of fetus or small contracted pelvis. Fetal size usually >4000gm (9lb)
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what may be some causes of cephalopelvic disporportion
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macrosomia due to maternal diabetes, obesity, multiparity or large parent
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Shoulder Dystocia
define |
head is born but the anterior shoulder cannot pass under the pubic arch
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Shoulder dystocia
Treatment/intervention |
McRoberts maneuver-push moms legs back towards hear head-helps to open pelvic arch
Gaskin maneuver-on all fours Corkscrew-manually place hands in to move baby Suprapubicpressure-helpspop shoulder out |
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what are signs and complications of shoulder dystocia
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turtle sign-head comes out but pulls back in, external rotation does not occur
Complicaitons: fetal asphyxia, clavicle fx, brachial plexus injury |
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VBAC criteria
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must be able to get C/S in 1/2 hour or less
reason for first c/s type of incision give trail of labor |
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Cesarean birth
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28% national rates
VBAC- TOL- 60-90% success |
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Indications for C/S with regards to Newborn
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fetal distress, CPD, mlapositions, previa, cord prollapse, dysfunctional labor, multiple gestation
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Indications for C/S with regards to mother
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PIH/HELLP, Herpes, HIV, DM, elective
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C/S incisions
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class- lateral or midline- use only in emergency
Low lying <blood loss, <infections, <subsequent uterine ruptrues |
