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118 Cards in this Set

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some ideas on what initiates labor
uterine distention
aging of placenta
mom's hormones change increase estrogen and prosteglandins and decreased progesteron
fetal hormone may play apart
what are fetal fibronectin
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
Signs preceding Labor
lightening
increased braxton hicks
bloody show/mucous plug
GI-n/v, diarrhea
SROM
Burst of energy (nesting)
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
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
critical factors affecting labor
Pelvic dimensions
Fetal dimensions-size and flexability of sutures
uterine contractions-strength and regulartiy
THE 5 P'S
Passageway
passenger
powers
position of mother
psychological response
PASSAGEWAY; bony pelvis and soft tissues
Gynecoid-(normal) round
Android-heart shaped-may rq C/S
Anthropoid-oval-usually OK to SVD
platypelloid- flattened round
Passenger-fetal head
biparietal diameter-largest
sutures- sagital, coronal, lambdoidel
fontanelles;anterior (largest) Posterior (smallest
Molding- can be extensive, returns to normal w/i 3d
PASSENGER:fetal lie
relationship of the long axis of the fetus to the long axis of the mom
Transverse(need c/s)
Longitudinal(head or feet first)
Fetal attidude
relationship of the fetal body parts to each other
flexion-desirable
military-straight down/not flexed
brow
face
PASSENGER:Fetal presentation
presenting part which first enters pelvis
1. Cephalic:vertex, military, brow face
2. Breech:complete, frank, footling
3. shoulder
describe the different types of breech presentation
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
PASSENGER: fetal position
relationship of presenting part to 4 quadrants of moms pelvis. Document in three letters
PASSENGER: fetal position

L/R
Document whether on maternal right side (R) or left side (L)
PASSENGER: fetal position
fetal presentation
O- occiput
M- mentum-chin
S-sacrum
SC-shoulder
PASSENGER: fetal position
Maternal abdominal quadrant
A- anterior
P- Posterior
T- transverse
PASSENGER:Station
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
what must you consider when determining station
If infant has a caput then it may feel like a +3 station when in fact the head is station 0
POWERS-primary
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)
POWERS-secondary
abdominal muscles
Factors affecting duration of labor
parity-more babies the faster
position of fetus
position of woman
level of activity of mom
fetal size
maternal emotions
what is the intrauterine resting tone and why is it important
the space between contractions, gives the mom time to rest and reoxygenates infant
FACTORS AFFECTING PSYCHOLOGICAL RESPONSE
culture
previous experience
preparation, childbirth educ
anxiety and fear
How does fear and anxiety affect labor?
it increase pain, which increase adrenaline which leads to a decreased production of oxytocin which decreases endorphins
How does lack of knowledge contribute to fear
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
INFLUENCES ON EXPERIENCE OF PAIN
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
PAIN OF L&D
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
WHAT CAUSES DISCOMFORT OF LABOR
Ischemia of muscles and dilitation and effacement of cervix
MANAGEMENT OF DISCOMFORT
chidbirth education
water, position change, effleurage(massage of abd)
hypnosis, acupuncture, tens
medications;nubain, demerol
anesthesia;epidural, spinal
Childbirth education
dick-Read method
lamaze method-relaxation and breathing patters
bradley method-envionment plays huge part
Position of MOM
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
Pharmacologic measures
Narcotics
ex demerol of fentanyl:short acting, may cause resp depression in NB if given close to birth
Pharmacologic measures
agonist-antagonist compounds
ex. nubain
less resp depression
Tend to not stop labor so less interventions needed
pharmacologic measures
regional anesthesia
advantages
epidural or spinal: adv- good pain relief, mother awake and alert, partial motor paralysis. dose may be modified
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
Nursing care with epidural
start iv give bolus as order
assist with positioning
monitor FHR
monitor contractions
assess for bladd distention
have O2 available
Why do you worry about bladder distention?
a full bladder can stop descent of head stalling labor
GENERAL ANESTHESIA
used only in emergency c/s
serious resp distress in NB
80% of obstetric anesthesia related mortality associated with obesity
STAGES OF LABOR
FIRST STAGE
3 PHASES
LATENT
ACTIVE
TRANSITION
Myometrial activity
EFFACEMENT- shortening and thinning of the cervix 0%-100%
DILITATION- enlargement or widening of the cervical opening closed to 10cm
Mechanism/cardinal movements
enagement
descent- icreases 5-7cm
flexion
internal rotation
extension
restitution
external rotation
Intial assessment of mom when enters hospital
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
Admission assessment of the fetus
FHR 120-160
Leopolds maneuvers
What is the purpose of leopolds maneuver?
to determine position of baby, palpate for head//rump and small body parts. see if head is engaged
Electronic fetal monitoring-external, US transducer, toco
ultrasound transducer-reads FHR
tocodynamometer-reads contractions
Internal-spinal elctrode, intrauterine pressure catheter IUPPC
pressure catheter-accurate measure of strength of contraction
done with high risk preg or if can't get reading with external
FETAL HEART RATE PATTERNS
BASELINE
normal 120-160
brady <110 for 10min
tachy >160 x10min
BASELINE VARIABILITY
how much pulse rate changes
minimal <5bpm
moderate 6-25 bpm (ideal)
marked > 25bpm
What might you see with decreased variability?
hypoxia, CNS depression, narcotic use, fetal sleep, congenital anomolies
when might you see with marked variabilities?
mild hypoxia, contractions, activity of mother, fetal stimulation
what may decreased variability with late deceleration indicate?
fetal acidosis
PERIODIC AND NON-PERIOCIC CHANGES
periodic associated with contractions
non-periodic assoc with no contraction
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
Assessments-interventions
fetal scalp stimulation->115bpm FHR-reassuring
Fetal blood sampling-assess ph, po2 pco2
fetal pulse oximetry-sensor placed vaginally 30%-70% normal
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
NSG CARE CONTINUED
CONT TO ASSESS:length, freq and strength of contractions, FHR, VS, support to mom, status of membranes and vaginal exam
Time frame for assessing VS in a low risk, normal progression pregnancy
latent- q 30-60min
active-q30min
transition- q15 min
Bloody show
Mucous plug, may come out day before or during labor
may or may not notice
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)
PROM
premature (?) rupture.
>18h increased risk for infection standard of care ususally c/s if not in active labor at 18h
What must you ALWAYS check after ROM
1. Check FHR
2. note color and odor of fluid. clear vs. green ]
merconium
AROM
Artificial rupture of membrane- membrane does not rupture on own, done with amni hook
STAGE 2 Labor
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
what is Feergerson reflex
stretch receptors which when stimulated may cause urge to push
Third stage of labor
birth of baby to birth of placenta: wait for placental seperation, considered retained if >1h, repair epis/laceration, palpate fundus, adm oxytocin prn
what are the signs of placental separation
uterus becomes globular shaped
umbilical cord becomes longer
sudden gush of blood
should you pull on the cord
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
What is a nuchal cord
The cord gets wrapped around the neck of infant
PLACENTA
made of cotyledon, examine placenta to make sure all there. otherwise some of placenta may still be attached inside
CORD
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
EPISIOTOMY
EPI ONLY DONE IF INDICATED
midline/mediolateral
WHAT ARE THE INDICATIONS FOR AN EPISIOTOMY?
really large baby
hx of 4th degree laceration
forcep or vacuum delivery
if you want out quickly
Types of Lacerations
1st- thru skin, not muscles
2nd- thru muscles
3rd- thru anal sphinchter
4th- involves anterior rectal wall-very uncomfortable
fourth stage of labor
first hour or two after birth
stabilization of mother and baby
Estimated Blood Loss
vaginal-500cc
c/s-1000cc
hard to est acurrately so check H&H
highest risk for hemorrhage first hour, next first 24h
INDUCTION OF LABOR
Indications
post-dates
DM
PIH
IUGR
social
INDUCTION OF LABOR
methods
cervical ripening agents, oxytocin, amniotomy (AROM)
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
CERVICAL RIPENING
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
Reasons not to use cervical ripening
non-reactive stress test
positive contraction stress t
vaginal bleeding
strong regular contraction
AMNIOTOMY
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
OXYTOCIN INDUCTION
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
what do you do if having and emergency while using pitocin
TURN IT OFF
turn to L side (or R if already on L)
Contraindications for pitocin
cephalopelvic diportion
prolapsed cord
placenta previa
SE of Pitocin
water intoxication(retain lots of water) hyperstimulation tetanic w/o relaxation could cause hypoxia and amniotic fluid emboli(fatal)
Immediate care of the newborn
suction as necessary
wipe dry and put skin to skin with mother
apgars
What is an external cephalic version?
attempt to turn a breech baby so SVD can happen. Done after 37wk
why is a cephalic version done after 37wk
may cause mother to go into labor, may cause bleeding, may turn back
what must be assessed prior to a cephalic version?
ultrasound to verify position, no previa, no oligiohyramus, Rh status, will need shot of rhogam due to risk of blood mixing
What is tocolysis
medications given to supress preterm labor, to aid in external cephalic versions and for hyperstimulationt
what are some examples of meds used for tocolysis?
ritodrine(only one FDA approved)
Terbutaline
mag sulfate
nifedipine
indomethacin-steroid stimulates surfactant
What is one thing important to assess?
make sure to check pulse
Indications for forcep delivery
2nd stage exhaustion, fetal distress, strong epidural, need to get baby out fast
what are the three kinds of forceps?
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
What should you monitor and what are side effects of forceps application?
Monitor FHR
SE- bruising on cheek of infant and lacerations for mom
Vacuum extraction
Indications
same as forceps: 2nd stage exhaustion, fetal distress, strong epidural, need to get baby out fast
why may a vacuum extraction be used as opposed to forceps?
less injury to mom and baby
side effects of vacuum extraction
cephelhematoma
may also see caput
DONT ATTEMPT MORE THAN 3X
Prolapse of cord definition
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
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
Interventions for prolapsed cord
cover cord with wet saline (wharton jelly will dry out)
call for assistence
give O2 to mom
monitor FHR
C/S
What is dystocia?
long, difficult or abnormal labor
what causes dystocia?
dysfunctional labor, alteration in pelvic structure, fetal position, mom position, psychologica
when would you suspect dystocia?
lack of progress in effacement, dilitation or descent or all three
normal vs abnormal contractions
normal- flat resting tone, peaks then rest etc
hypotonic-irregular contractions not well defined
hypertonic-doesn't return to resting tone in between
Hypertonic uterine dysfunction
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
Hypotonic uterine contractions
ACTIVE PHASE; contractions become weak and ineffective
R/O CPD or malpositions
RX: ambulation,h2o,ROM, oxytocin
Cephalopelvic disproportion
large size of fetus or small contracted pelvis. Fetal size usually >4000gm (9lb)
what may be some causes of cephalopelvic disporportion
macrosomia due to maternal diabetes, obesity, multiparity or large parent
Shoulder Dystocia
define
head is born but the anterior shoulder cannot pass under the pubic arch
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
what are signs and complications of shoulder dystocia
turtle sign-head comes out but pulls back in, external rotation does not occur
Complicaitons: fetal asphyxia, clavicle fx, brachial plexus injury
VBAC criteria
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
Cesarean birth
28% national rates
VBAC- TOL- 60-90% success
Indications for C/S with regards to Newborn
fetal distress, CPD, mlapositions, previa, cord prollapse, dysfunctional labor, multiple gestation
Indications for C/S with regards to mother
PIH/HELLP, Herpes, HIV, DM, elective
C/S incisions
class- lateral or midline- use only in emergency
Low lying
<blood loss, <infections, <subsequent uterine ruptrues