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114 Cards in this Set
- Front
- Back
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Labor
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The process of moving the fetus, placenta and membranes out of the uterus and through the birth canal.
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Signs preceding labor
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lightening, braxton hicks contractions, ripening, bloody show, ROM or SROM, sudden burst of energy, weight loss, diarrhea n/v, and indigestion
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lightening
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fetus descends down into the pelvis about 2 weeks before term in a nullip – woman feels less congested, and can breathe more easily, but will have more bladder pressure (may not happen until actual labor in a multip)
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ripening
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softening of cervix
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bloody show
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mucous plug is expelled resulting in a small amount of blood loss from exposed cervical capillaries. Sign of labor in 24 to 48 hours.
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Causes of onset of labor:
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1. Estrogen stimulates uterine muscle contractions which lead to softening of cervix. 2. Decrease in progesterone 3. Increase of prostaglandins. 3. Increase in corticotrophin releasing hormone (CRH)
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Fetal fibronectin (fFN
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is a protein found in cerviovaginal secretions before the onset of labor. Used to assess preterm labor
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Effacement
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with each contraction, the cervix then shortens and thins pulling up into the uterus and becoming part of the lower uterine wall.
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First stage
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lasts from the onset of regular uterine contractions to full dilation (10 cm) of the cervix. Can be hard to determine actual time of onset. Usually longer than second and third stages combined. In a first pregnancy can take up to 20 hours; in some multips, may be less than 1 hour. Made of three phases: latent, active, and transition
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Latent-1st stage
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begins with onset of contractions, more effacement of contractions with little increase in decent
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Active- 1st stage
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when mom's anxiety increases and discomfort. Dilation from 4 to 7 cm.
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Transition- 1st stage
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even more anxiety and tiredness. Dilation from 8 to 10cm but at a very slow rate. Increased rate of descent.
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Second Stage
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lasts from the time that cervix is fully dilated (10cm) to the birth of the fetus. Average of 20 to 50 minutes, but may take as long as 3 hours (with epidural anesthesia). Two phases: 1. Latent 2. Active
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Latent- 2nd stage
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complete dilation of cervix, but contractions are weak and no urge to push (more effective if they feel the earge to push!! Do not force pushing)
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Active - 2nd stage
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contractions resume, the woman is making strong bearing-down efforts and fetal station is advancing (moving from 2-1-0)
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Crowning
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fetal head is encircled by the external opening of the vagina and means birth is imminent
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Third Stage
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"from the birth of the fetus until the placenta is delivered (if placenta is not delivered in at least one hour she has a risk for hemorrhage) Placenta normally separates after third or fourth strong contraction – will deliver with the next strong contraction. Can be as short as 3-5 minutes; up to 1 hour is considered within normal limits
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Fourth Stage
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"arbitrarily lasts for 2 hours after delivery of the placenta. Period of immediate recovery. Homeostasis is reestablished. Important period of observation for complications, such as abnormal bleeding
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Schultze mechanism
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"shiny" placenta separates from the inside to the outer margins first, fetal side presents as it comes out
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Cardinal Movements
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"(7) Engagement, Descent, Flexion, Internal rotation, Extension, External rotation (restitution), Expulsion
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Duncan mechanism
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"dirty" placenta separates from the outer margins inward presents sideways showing the maternal side first.
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Decent
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4 forces: 1. Pressure of the amniotic fluid 2. Direct pressure of the fundus of the uterus on the breech of the fetus. 3. Contraction of stomach muscles. 4. Extension and straightening of the fetal body. Head enters inlet.
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Flexion
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as fetal head descends and meets resistance for the muscle pelvic floor and cervix, the fetal chin flexes downward into chest.
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Internal rotation
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as the occiput meets resistance from the levator ani muscles, the occiput rotates left to right and the sagittal suture aligns with the anterposterior pelvic diameter.
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Extension
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from resistance of the pelvic floor and movement of the vuvla opening anteriouly and forward, assist ____ of head as it passes under the symphysis pubis.
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Resistution
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Neck becomes twisited as the shoulders remain oblique while the head rotates anterposterior. Once head emerges and is free from pelvic resistance the neck untwists.
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External Rotation
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As the shoulders rotate anteroposterior position, the head is turned farther to one side.
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Expulsion
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the anterior shoulder meets the undersurface of the symphysis pubis and slips under it, lateral flexion, then anterior shoulder born before posterior shoulder- body quickly follows.
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fetal adaptations to labor, circulation
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most healthy fetuses are able to compensate for the stress of pressure – umbilical cord blood flow is usually undisturbed
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Fetal adaptations to labor, HR:
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provides reliable and predictive information about fetal condition related to oxygenation
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fetal adaptations to labor, respirations
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stimulation of chemoreceptor in aorta and carotid bodies prepare fetus to initiate respirations immediately – fetal lung fluid is cleared from air passages during labor and vaginal birth
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Maternal CO in labor
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increases 10-15% in first stage; 30-50% in second stage, (which is why women with cardiac problems may not be allowed to go into labor)
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Maternal HR in labor
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"Heart rate increases slightly in first and second stages. Systolic BP increases during contractions in first stage; systolic and diastolic. BP increase during contractions in second stage
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Maternal respirations in labor
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RR increases
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Maternal adaptations in WBC, temp, GI, blood glucose?
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"WBC count increases-. Temperature may elevate slightly- (know difference when it is a fever or infection). Proteinuria (1+) may occur. Gastric motility and absorption of solid food is decreased; nausea/vomiting may occur during transition to second stage. Blood glucose level decreases- using glucose supplies for energy
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Visceral causes of pain
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predominates first stage pain from 1. Dilation of cervix 2. Hypoxia of uterine muscle cells during contraction 3. Stretching of the lower uterine segment 4. Pressure from adjacent structures.
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referred pain
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Usually only during contractions- – radiates from uterus to the abdominal wall, lumbosacral area, iliac crests, gluteal area and thighs
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somatic pain
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"during second stage. Described as intense, sharp, burning and well-localized. Caused by stretching and distention of perineal tissues and the pelvic floor, distention and traction on the peritoneum and uterocervical supports during contractions and from lacerations of the soft tissue (cervix, vagina and perineum). from expulsive forces and pressure on bladder, bowel and other sensitive structures.
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Third stage pain
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are similar to those of first stage, derived from uterine sources
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Pain impulses are transmitted via
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pudendal nerve through S2 to S4 spinal nerves, and the parasympathetic system
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physiological pain expression
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increased HR, BP; hyperventilation; pallor/diaphoresis; nausea/vomiting (common in active labor); placental perfusion and uterine activity may decrease (prolonging labor)
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Sensory qualities of pain expression
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prickling, stabbing, burning, bursting, aching, heavy, pulling, throbbing, sharp, shooting, stinging, cramping
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Affective qualities of pain expression
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tiring, exhausting, annoying, sickening, nauseating
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pain expression behaviors
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increased anxiety, writhing, crying, groaning, hand-clenching, and excessive muscular excitability
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Factors influencing pain
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Physiologic: prostaglandins( released through changes in placenta to increase contraction of uterus), body positioning, endorphins (endogenous opioids) – higher when a woman has a spontaneous, natural childbirth. Culture – values, beliefs, expectations and cultural practices . Anxiety- increases pain perception. Previous experience. Childbirth preparation – learning based on gate-control theory (block pain receptors by doing something else like breathing), and cognitive work (visualization, giving women control over how they respond to pain). Comfort. Support (dula, partner, etc). Environment
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Cutaneous stimulation strategies
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Counterpressure, Effleurage (light massage in rhythm with breathing) (Stroking the skin in rthymic with the breathing) Therapeutic touch and massage, Walking, Rocking, Changing positions, Application of heat or cold, Transcutaneous electrical nerve stimulation (TENS unit), Acupressure, Water therapy
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Sensory stimulation strategies
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"Aromatherapy, Breathing techniques, Music, Imagery, Use of focal points
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Cognitive strategies
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"Childbirth education, Hypnosis, Biofeedback
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Sedatives
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may be used in prodroma labor, but not in active labor b/c they can cause respiratory depression in fetus – drug of choice is morphine (use with caution in patients with asthma)
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Analgesia
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relieving perception of pain or raising pain threshold without loss of consciousness
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Systemic
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"the major method in labor, when regional anesthesia not available. Effects on fetus and newborn can be profound (respiratory depression, decreased alertness, delayed sucking). IV preferred to IM because onset faster and more predictable
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Opioid (narcotic):
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meperidine (Demerol) and fentanyl – can decrease gastric emptying, promoting N/V, inhibit bowel/bladder emptying, affect HR, BP and respiratory rate – need safety precautions (sedation/dizziness)
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Opioid agonist-antagonist:
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"butorphanol (Stadol) and nalbuphine (Nubain) – less likely to cause N/V, but sedation may be greater – not for use in women with opioid dependence (precipitates withdrawal sx)
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Co-drugs:
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"promethazine (Phenergan) hydroxyzine (Vistaril) metoclopromide (Reglan)Benzodiazapines: diazepam (Valium), lorazepam (Ativan)
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Opioid (narcotic) antagonists
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naloxone (Narcan)
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Nerve block- Local perineal infiltration
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(1% lidocaine or 2% chloroprocaine, with or without epinephrine) – for episiotomies
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Pudendal nerve block (transvaginal)
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provided sufficient pain relief for spontaneous vaginal birth, or forceps- or vacuum-assisted birth (but does not provide pain relief for uterine exploration or manual removal of placenta)
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Spinal nerve block
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local anesthetic injected in third, fourth or fifth lumbar space into the subarachnoid space, where it mixes with CSF
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Epidural anesthesia/analgesia
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"Injection of an opioid (e.g., fentanyl) or suitable local anesthetic into the epidural space between fourth and fifth lumbar vertebrae Most effective pharmacologic pain relief for labor currently available. More than half of women in U.S. choose this method
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Advantages of epideral
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"woman remains alert; good relaxation; airway reflexes intact, normal gastric emptying, blood loss not excessive
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Disadvantages of epideral
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impairs ability to move freely; orthostatic hypotension and dizziness; sedation, weakness of the legs; higher rate of fever(effect around spinal cord); longer second stage of labor possible
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Contraindications for epideral:
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antepartum hemorrhage; anticoagulant therapy or bleeding disorder; infection at injection site(example: shingles); allergy to anesthetic drug
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General anesthesia
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"Rarely used for uncomplicated birth or cesarean section. Nursing interventions: NPO, wedge under one hip; IV infusion in place; recovery: maintain open airway and cardiopulmonary function; prevent postpartum hemorrhage; assess maternal readiness to see the baby, and to deal with the events that necessitated general anesthesia
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Physical examination:
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Hydration status (I&O, mucous membranes, skin turgor, urine concentration, bladder distention). Skin status near needle insertion sites. If in labor, status of vital signs, FHR and pattern, uterine contractions, amniotic membrane status; cervical effacement/dilation, fetal descent. Labs: CBC and PT. Once anesthetic agent is administered, observe for any sign of allergic response, and be ready for emergency interventions
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Nursing Diagnoses
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"1. USCR in maintaining sufficient intake of air: risk of ineffective tissue perfusion related to effects of analgesia and maternal position 2. USCR in prevention of hazards to life, functioning and well-being: 3. hypothermia, related to effects of analgesia 4.Risk of maternal injury, related to changes in sensation and motor control secondary to analgesia 5. Acute pain, related to processes of labor and birth. 6. DSCR in provision of care associated with the birthing process
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Assessment info in labor for pain
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"Use a pain assessment tool to document the woman’s pain levels. Review patient history for allergies, obstetric history, prenatal history, history of smoking, drug dependency, neurologic and spinal disorders. Interview patient re type and time of last meal and fluid intake; current respiratory conditions; childbirth preparation classes; labor preferences/birth plan; if substance abuse, time and type of last use
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Outcomes for women in labor pain
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"Woman will promptly report characteristics of pain/discomfort. Verbalize understanding of needs and rights with regard to pain relief management (nonpharmacologic and pharmacologic) that reflect her preference. Report adequate pain relief, without increased maternal risk. Fetus will maintain well-being, and the newborn will adjust to extrauterine life
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Fetal well being during labor is measured by….
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the response of the fetal heart rate (FHR) to uterine contractions. Nurses are responsible for the assessment of FHR patterns, and for the interventions in the event of the fetal compromise.
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How does labor effect the fetus?
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Labor is a time of physiologic stress to the fetus, and fetal oxygen supply must be maintained, to prevent fetal compromise and promote newborn health after birth.
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Factors that compromise fetal oxygen supply
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1.Reduction of maternal blood flow from maternal hypertension, hypotension from maternal positioning or analgesia 2. Hypovolemia from hemorrhage. 3. Reduction of oxygen content in maternal blood from hemorrhage or severe anemia 4. Compression of umbliical cord. 5. placental separation or abruption 6. Vagal nerve stimulation from head compression 7. reduction in blood flow to placenta because eof excessive oxytocin or deteration of blood vessels from HTN or diabetes.
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Baseline FHR in normal range
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110 to 160 bpm with no periodic changes a moderate baseline variability
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reassuring FHR patterns
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FHR 110-160 bpm, FHR accelerations with fetal movement, contractions every 2-5 minutes lasting less than 90 sec., moderate to strong in intensity (100mg or less IUPC), 30 sec or more btwn end of contractions and start of the next- unterine relaxation of 15mmHg or less
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Nonreassuring FHR patterns (assoc. with fetal hypoxemia)
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"8 ways: 1. Progressive increase or decrease in baseline rate 2. Tachycardia of 160 bpm or more 3. Progressive decrease in baseline variability 4. Severe variable decelerations (FHR less than 60 bpm, lasting longer than 30-60 sec, with rising baseline, decreasing variability or slow return to baseline 5. Late decelerations of any magnitude, especially those that are repetitive or uncorrectable 6. Absence of FHR variability 7.Prolonged deceleration (greater than 60-90 sec) 8. Severe bradycardia (less than 70 bpm) calls for a c-section ASAP!
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Nurses role of nonreassuring FHR
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Nursing role is to continually assess for reassuring patterns, and to discriminate between patterns that indicate mild hypoxemia or severe hypoxia.
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Intermittent asscultation..what does it involve?
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"Using ultrasound or manual fetoscope, Listen over the area of maximal intensity of sound, Palpate the fundus to count FHR between contractions, Count maternal radial pulse at the same time, differentiate from fetal rate, Count FHR for 30-60 sec between contractions, to identify baseline rate, Auscultate during contraction and for 30 sec after, to identify any increase or decrease in response to contraction
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Institutional policy dictates frequency of intermittent assessment – should assess before and after:
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"Ambulation, Rupture of membranes, Administration of medications or analgesia, more frequently when nonreassuring FHR patterns
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External Fetal Monitoring is done how?
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Ultrasound transducer for FHR, Tocotransducer for UC, Prints findings on formatted monitor paper (standard speed 3 cm/min), Easily applied by the nurse, easy to put on, Requires re-positioning of the transducers as mother changes position, Woman must remain in bed unless portable telemetry monitors are available
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Internal Fetal Monitors
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"Small spiral electrode is attached to the presenting part for continuous FHR monitoring. Separate IUPC is introduced into the uterine cavity (average pressure during a contraction is 50-85 mm Hg)
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Monitor paper
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"Each small square represents 10 sec, Each larger box of 6 squares represents 1 minute (when paper moves at 3 cm/min)
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Variability
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Irregular fluctuations in the baseline FHR of two cycles per minute or greater
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Short-term variability:
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beat to beat (jagged line is better rather than a straight line)
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Long-term variability:
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rhythmic waves or cycles from baseline
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Visualization of amplitude of FHR in peak-to-trough segment
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"Absent, Minimal (not more than 5 bmp), Moderate (6 to 25 bpm), Marked (> 25 bpm)
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Tachycardia in fetus
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baseline FHR > 160 bpm, for 10 minutes or longer
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Tachycardia – baseline FHR > 160 bpm, for 10 minutes or longer..what causes it?
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"Early sign of hypoxemia, Associated with maternal/or fetal infection, maternal hyperthyroidism, fetal anemia, or drugs (atropine, Vistaril, terbutaline, cocaine, methamphetamines
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Bradycardia of fetus
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baseline FHR < 110 bpm for 10 minutes or longer
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Bradycardia – baseline FHR < 110 bpm for 10 minutes or longer..what causes it?
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"Later sign of hypoxia; known to occur before fetal death, Associated with prolonged umbilical cord compression, anesthesia, maternal hypotension or hypothermia
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Periodic (decelerations)
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occur with direct association with uterine contractions
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Episodic (decelerations)
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not assoc. with uterine contractions, can be caused by many things like environment, vaginal exam, or medications
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Acceleration
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a visually apparent abrupt increase in FHR above the baseline – 15 bmp or more, lasting for 15 seconds or more, with return to baseline in less than 2 minutes
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Periodic accelerations are often associated with
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breech presentation
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Episodic accelerations occur during...and imply...
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fetal movement, and are indications of fetal well-being (good signs)
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Decelerations
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may be benign or nonreassuring – four types: early, late, variable, prolonged
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Early decelerations
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a visually apparent decrease and gradual return to baseline in response to fetal head compression (normal and benign finding), starts before peak of UC, returns to baseline at same time UC returns to baseline
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Late decelerations
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"caused by uteroplacental insufficiency – a visually apparent gradual decrease in and return to baseline associated with UC’s – begins after UC starts, and lowest point of decel occurs after peak of UC – does not return to baseline until after the contraction is over. May be caused by maternal supine hypotensive syndrome, which can be corrected by turning the mother onto her side Other causes: hyperstimulation by oxytocin; PIH (pregnancy induced hypertension), postdates, amnionitis, SGA fetus, maternal diabetes, placenta previa, abruption, anesthesia-caused hypotension, maternal cardiac disease or anemia
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Variable decelerations
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"a visual abrupt decrease in FHR below the baseline, by 15 bpm or more, lasting at least 15 sec, and returning to baseline in less than 2 minutes. Occur at any time during uterine contraction phase, and represent compression of the umbilical cord. Often have a “U” or “V” shape, characterized by rapid descent and ascent to and from nadir of the deceleration. May be a partial, brief compression, that can be corrected by changing the mother’s position; oxygen administration by mask may be helpful
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prolonged decelerations
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"a visually apparent decrease in FHR below the baseline 15 bpm or more, lasting more than 2 min, but less than 10 min. If lasts more than 10 min, it is considered a change in baseline......Benign causes: pelvic exam, application of scalp electrode, rapid descent, sustained maternal Valsalva maneuver. Other causes: progressively severe variable decels; sudden umbilical cord prolapse(cord falls out before baby causing the cord to be compressed as the baby head comes out); hypotension from spinal or epidural; tetanic contraction, maternal hypoxia (from seizure)......Usually isolated events, but if seen in a prolonged series of variable or late decels, may occur just before fetal death
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Nursing Interventions for …?reassuring EFM
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"Position mother on either side, not supine (don’t keep her on her back for a long period of time). Encourage pushing with the mouth open and glottis open with vocalizing (avoiding Valsalva). Until amnioinfusion (put sertile saline into uterus to “refloat’ the baby) can relieve pressure on a non-prolapsed cord, and elevate the mother’s legs first. Infuse oxytocin in the piggyback port closest to the indwelling needle?.
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First priority Nursing Interventions for Nonreassuring FHR Pattern
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"open the maternal and fetal vascular systems. Position mother side-lying, if not already (left side because it opens vascular most quickly)
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Second priority Nursing Interventions for Nonreassuring FHR Pattern
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"increase blood volume. Elevate mother’s legs or increase rate primary IV infusion
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Third priority Nursing Interventions for Nonreassuring FHR Pattern
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"optimize oxygenation of the circulating blood volume. Provide oxygen by face mask
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Nursing Interventions in Third Stage
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"Placental separation is may be managed expectantly or actively. The immediate physiological changes for the mother are profound, with rapid increase in cardiac output, slower pulse rate, potential hyper- or hypotension.....Observe carefully for potential problems:..Excessive blood loss, Vital signs, pallor, restlessness, decreased urinary output, change in LOC (may indicate hemorrhage), Risk of rupture of preexisting cerebral aneurysm, Pulmonary embolus, Amniotic fluid embolus............After placental delivery: Gently clean vulvar area with warm water or NS (some agency policies require sterile technique), Reposition the birth bed, lower the woman’s legs and remove drapes, replacing wet linens with dry ones; provide clean gown and warm blanket
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Parents often respond to praise of the baby, although some women may seem indifferent or turn away …b/c?
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possibly related to cultural expected behaviors
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Indications for c-sections
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"Complete placenta previa, Cephalo-pelvic disproportion (CPD), Placental abruption, Active genital herpes, Umbilical cord prolapse, Failure to progress in labor, Non-reassuring fetal status ???, Breech presentation
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Maternal mortality with c-section
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In the U.S., women undergoing cesarean delivery have a 4-times greater risk of death, compared to those who deliver vaginally.
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Common postoperative complications:
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"Infection, Reaction to anesthesia agents, Blood clots, Bleeding, Ureteral injury, bladder laceration
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Incisions of c-section
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"Both a skin and a uterine incision, may not be the same type. Primary low transverse uterine incision is preferred. May allow for future VBAC. “Classic” incision is a vertical incision into the upper uterine segment, now generally reserved for emergent birth situations. (can not have VBAC with ""classic"")
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Pre-op preparations for c-section
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"IV, Foley catheter, abdominal skin prep, patient positioning on the operating table, Patient NPO, Continue FHR monitoring until immediately before the surgery.
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postpartal care for c-section
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Same as for vaginal delivery, with the addition of post-op assessment of pain and positioning post anesthesia.
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Family as Context
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"Family is background or secondary focus, with main emphasis still on the individual client. This is the most common perspective of the nurse caring for a patient in the hospital. Many nursing theories use this approach (family is primary social support)
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Family as Sum of its Members
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"Care is given to all family members. Seen in family primary care and community health nursing.An “accumulation” of individual members
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Family Subsystem as Client
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"Assessment and intervention on inter-personal relations between family members. Examples would be assessing/intervening with: parent-child relationship; marital relationship; caregiving issues; bonding/attachment
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Family as Client
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"Entire family is the primary focus of assessment and care. Family is “foreground” and individuals are “background” or context. An interactional system, with focus on family dynamics, structure-function, relation of subsystems to the whole family and the community. This is the unique arena of family nursing. Assess connections between illness, family members and the family in an interactional perspective (“family systems nursing”). Uses advanced clinical assessment and intervention skills which combine nursing, family therapy and systems theory
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Family as Component of Society
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"Here the family is viewed as a subsystem of the larger community system. Family is a basic societal institution (like education or religion)
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