Nclex Ch 23: Labor And Delivery And Associated Complications

Front 1

4 P's of Labor

Back 1

-Powers: uterine contractions, effacement, dilation
-Passageway: pelvis, soft tissue of pelvic floor, cervix and vagina
-Passenger: fetus, membranes, and placenta
-Psyche: perception of pain, fear, anxiety

Front 2

Leopold's Maneuver

Back 2

-A method of determining the presentation and position of the fetus, an aid for locating the FHR
-If head is in the fondus, a hard, round, movable object is felt; buttocks will feel soft, irregularly shaped, and difficult to move
-Fetal back should be felt on one side of abdomen (smooth, hard surface)
-On opposite side of abdomen, hands, feet, elbows and knees will be felt (irregular knobs and lumps)

Front 3

True Labor

Back 3

-Contractions occur regularly; become stronger, last longer, and occur closer together
-Cervical dilation and effacement are progressive
-Fetus usually becomes engaged in the pelvis and begins to descend
-Walking has no effect on contractions

Front 4

False Labor

Back 4

-No dilation or effacement or descent
-Contractions are irregular and w/o progression
-Walking often relieves the condition

Front 5

Fetal Monitoring

Back 5

-Displays FHR and uterine activity, frequency, and duration of contractions (only internal monitor can monitor the intensity of contractions
-FHR in relation to maternal contractions
-Baseline FHR is measured between contractions (normal 120-160 beats per minute)
-Internal monitoring is invasive and requires rupture of membranes and attaching an electrode to presenting part of fetus; mother must be dilated 2-3cm

Front 6

First Stage Breathing Techniques

Back 6

-Cleansing breath: each contraction begins and ends with a deep inspiration and expiration
-Slow-paced breathing: a slow deep breathing that promotes relaxation, used as long as possible during labor
-Modified-Paced Breathing: used when slow-paced breathing is no longer effective, shallow fast breathing
-Pattern-paced breathing: "pant-blow", after a certain number of breaths, the woman exhales with a slight emphasis or blow and then begins again
-Breathing to prevent pushing: short puffs when urge to push

Front 7

Second Stage Breathing Techniques

Back 7

-Several variations fo breathing can be used in the pushing stage of labor
-Woman may groan, grunt, moan, or sigh as she pushes
-Prolonged holding of breath while pushing may result in a decrease in cardiac output
-Limit holding breath to 6-8 seconds

Front 8

4 Phases of Labor

Back 8

-Stage 1: effacement and dilation of cervix
-Stage2: pushing stage
-Stage 3: separation of the placenta
-Stage 4: physical recovery

Front 9

First Stage of Labor

Back 9

-Latent: dilation 3cm; contractions every 5-30 seconds for 30-45 seconds; mother talkative, excited, happy and eager to be in labor; assist with comfort measures; void every 1-2 hours; rest or sleep if possible
-Active: dilation 4-7cm;contractions every 3-5 min for 40-70sec with moderate to severe intensity; mother feeling helpless, restless, and anxious; help with breathing pattern, comfort; void 1-2 hours
-Transition: dilation 8-10cm; contractions every 2-3 min for 45-90 seconds of strong intensity; mother tired irritable, may have nausea and vomiting; rest between contractions, help with breathing patterns (prompt panting respirations if she begins to push prematurely); encourage voiding 1-2hrs

Front 10

Interventions Through Stage 1 of Labor

Back 10

-Vitals; FHR before, during and after contractions (normal 120-160)
-Monitor contractions
-Prepare for Nitrazine or fern test to ***** for rupture of membranes
-Check the color of the amniotic fluid if the membranes have ruptured

Front 11

Second Stage of Labor

Back 11

-Begins with complete cervical effacement and full dilation and ends with birth of baby
-Contractions every 2-3 minutes for60-75 minutes
-Increase in the bloody show
-Mother feels urge to bear down; assist with pushing efforts
-Monitor for s/sx of approaching birth (i.e. perineal bulging, visualization of fetal head)
-Prepare for birth

Front 12

Third Stage of Labor

Back 12

-Lasts from birth of baby to expulsion of placenta
-Birth of placenta occurs 5-30 minutes later
-Schultze mechanism: the center of placenta separates first and the dill, red, rough maternal surface emerges from the vagina
-Examine placenta for cotyledons and membranes to verify that it is intact
-Examine umbilical cord for 2arteries and 1vein
-After, the uterine funds is firm and approximately 2 finger breadths below the umbilicus

Front 13

Fourth Stage of Labor

Back 13

-1-4 hours after delivery
-BP returns to pre labor level
-Pulse is slightly lower that during labor
-Lochia is moderate to heavy fro the first 2 hours and bright red and may contain small clots, should steadily decrease
-Maternal assessments are preformed every 15 minutes for 1 hour, every 30 minutes for 1 hour, then hourly for 2 hours
-Provide warm blankets
-Apply ice packs to perineum
-Massage the fondus if needed
-Breast feeding support
-

Front 14

Anesthesia For Labor

Back 14

-Local
-Pudendal block
-Lumbar epidural block
-Subarachnoid (spinal) block
-General anesthesia

Front 15

Local Anesthesia

Back 15

-Block pain during episiotomy
-Just before birth of baby
-No effect on fetus

Front 16

Pudendal block

Back 16

-Administered just before birth of baby to pudendal nerve through a transvaginal route
-Blocks perineal area for episiotomy
-Lasts about 30 minutes
-No effect on contractions or fetus

Front 17

Lumbar Epidural Block

Back 17

-Administered after labor is established or just before cesarean birth in epidural space at L3-L4
-Relieves pain from contractions and numbs the vagina and perineum
-May cause hypotension, bladder dissension and prolonged second stage
-Does not cause headache b/c dura matter is not penetrated
-Maintain mother in side lie posit or place rolled blanked beneath the right hip to displace the uterus from the vena cava
-Increase IV fluids if hypotension occurs

Front 18

Subarachnoid (Spinal) Block

Back 18

-Acts quickly, administered just before the birth in the subarachnoid space at L3-L5
-Relieves uterine and perineal pain and numbs vagina, perineum, and lower extremities
-Usually causes maternal hypotension (increase fluids if prescribed)
-May cause postpartum headache
-Mother must lie flat 8-12 hrs after injection

Front 19

Bishops Score

Back 19

-Used to determine the readiness for labor induction
-Evaluates fetal position and cervical status
-Score of 6 or more indicates readiness for labor induction

Front 20

Factors of the Bishop Score

Back 20

-Dilation of cervix: 0=0cm; 1=1-2cm; 2=3-4 cm; 3=>5cm
-Effacement of cervix: 0=0-30%; 1=40-50%; 2=60-70%; 3=>80%
-Consistency of cervix: 0=firm; 1=medium; 2=soft
-Position of cervix: 0=posterior; 1=mid position; 2=anterior
-Station of presenting part: 0=-3; 1=-2; 2=-1; 3=1,2

Front 21

Induction

Back 21

-The chemical or mechanical initiation of uterine contraction before their spontaneous onset for the purpose of bringing about the birth
-Elective induction accomplished by infusion of oxytocin (Pitocin) or amniotomy
-Obtain baseline uterine contractions and FHR
-Rate of infusion is not increased after desired contraction pattern is reached
-Discontinue immediately if uterine hyper stimulation or non reassuring FHR

Front 22

Amniotomy

Back 22

-Artificial rupture of membranes to stimulate labor
-Presenting part of fetus should be engaged before
-Increased desk of prolapsed cord and infection (monitor FHR before and after)
-Record characteristics of fluid
-Bloody may indicate abrupt placentae or fetal trauma
-Unpleasant odor associated with infection
-Polyhydramnios (increased amniotic fluid) is associated with maternal diabetes and certain congenital disorders
-Oligohydramnios (decreased amniotic fluid) is associated with intrauterine growth restriction and congenital disorders
-Limit activity after

Front 23

External Cephalic Version (ECV)

Back 23

-External manipulation of the fetus from a breech or shoulder position into vertex presentation
-Only in a labor or birth setting
-Women should receive RoGam
-Fetal nonstress test
-Ultrasound to rule out placenta previa, determine fetal position, locate cord, evaluate adequacy of maternal pelvis, assess amount of amniotic fluid, fetal age and presence of anomalies
-IV fluids and tocolytics may be administered to relax the uterus and permit easier manipulation of fetus
-Exert gental, consistant pressure on abdomen to direct fetus into cephalic presentation
-Monitor uterine activity, bleeding, ruptured membranes and decrease in fetal activity

Front 24

Episiotomy

Back 24

-Incision made into the perineum to enlarge the vaginal outlet and facilitate delivery
-Institute pain relief
-Provide icepack for first 24 hrs
-Sitz bath, blot not wipe, analgesic spray or ointment as prescribed, clean technique, shower rather than bathe
-Peri-pad w/o touching inside
-Report bleeding or discharge

Front 25

Vacuum Extraction

Back 25

-The suction device should not be kept in place any longer than 25 minutes
-Monitor FHR every 5 minutes
-Monitor newborn for signs of cerebral trauma, or cephalhematoma
-Caput saccedaneum (swelling of scalp) is normal and will resolve in 24 hours

Front 26

Dystocia

Back 26

-Difficult labor

Front 27

Prolapsed Cord

Back 27

-Umbilical cord is displaced between presenting part of the fetus and the amnion or protruding through the cervix, causing compression of the cord and compromising fetal circulation
-Mother feels something coming out of her vagina, palpable or visible cord, FHR slow and/or irregular
-If fetal hypoxia is sever, violent fetal activity may occur then stop
-Relieve cord pressure immediately, place in extreme trendelenburg's, modified sims, or knee to chest, administer O2, prepare for cesarean birth

Front 28

Precipitous Labor

Back 28

-Labor that lasts less than 3 hours

Front 29

Preterm Labor

Back 29

-Cervical changes and uterine contractions between 20-37 weeks
-Focus on stopping labor: identify and treat infection; restrict activity; ensure hydration; tocolytics may be prescribed to suppress labor

Front 30

Premature Rupture of the Membranes

Back 30

-Spontaneous rupture of amniotic membrane before onset of labor
-If before term, delivery will be delayed, and infection is a risk
-Evident by pooling in the vaginal vault; positive nitrazine test
-Record amount, color, consistency and odor of fluid
-may prescribe antibiotics

Front 31

Placenta Previa

Back 31

-Placenta is improperly implanted in the lower uterine segment near or over the internal cervical os
-Total, partial, marginal
-Data: sudden onset of PAINLESS, bright red, bleeding during last half of pregnancy; suspect whenever vaginal bleeding occurs after 24 weeks; soft nontender uterus; fundal height may be greater than expected for gestational age
-Prepare ultrasound, avoid vaginal exam or any other action that would stimulate uterine activity, maintain bed rest in left lateral, monitor amount of bleeding and s/sx shock; IV fluids, blood products and/or tocolytics may be prescribed; prepare to administer RoGram

Front 32

Abruptio Placentae

Back 32

-Premature separation of placenta after 20 weeks and before birth
-Dark red bleeding (however if bleeding is high in uterus there can be an absence of blood); uterine pain or tenderness, uterine rigidity, severe abdominal pain; fetal distress, shock if bleeding is excessive; increase in fundal height
-Maintain bedrest, administer O2, IV fluids and blood as prescribed; monitor any uterine activity, prepare for the delivery of the fetus; monitor for DIC postpartum

Front 33

Placental Abnormalities

Back 33

-Placenta accreta: abnormally adherent placenta
-Placenta increta: placenta penetrates the uterine muscle
-Placenta perceta: placenta all the way through the uterus
-May cause hemorrhage afterbirth because placenta does not completely separate
-Prepare for hysterectomy if large portion of placenta is abnormally adherent

Front 34

Uterine Inversion

Back 34

-May be partial or complete
-Occurs during delivery or after delivery of placenta
-Depression in the fundal area; Interior of uterus may be seen through cervix; severe pain; hemorrhage, shock
-Prep pt for return of uterus to correct position via the vagina; laparotomy with replacement if unsuccessful

Front 35

Amniotic Fluid Embolism

Back 35

-When amniotic fluid containg debris (vernis, hair, skin, cells, meconium) enter the maternal blood stream
-Causes resp distress, circulatory collapse and usually fatal to the mother; if mother survives she is likely to have hemorrhage and DIC
-Data: abrupt onset of resp distress and chest pain; cyanosis; seizures; heart failure; pulmonary edema; if delivery has not occurred, fetal distress
-CPR; administer O2 at 8-10L/min by face mask or 100% by resuscitation bag as prescribed
-Prepare client for intubation and mechanical ventilation; position on side; IV fluids, blood products, and medications may be administered to correct coagulation failure and maintain cardiac output; prep for emergency delivery once mother is stable

Front 36

Supine Hypotensive Syndrome

Back 36

-"Venal cava syndrome"
-Venous return to the heart is impaired by weight of uterus
-Faintness, lightheadedness, dizziness, breathlessness, pallor, clammy skin, sweating, hypotension, tachycardia, nausea, fetal distress
-Position on left side

Front 37

Fetal Distress

Back 37

-FHR of less than 120beats/ min or more than 160
-Meconium stained amniotic fluid; fetal hyperactivity, severe variable in baseline
-Place mother in lateral position and elevate legs; administer O2 8-10L/min via face mask as prescribed, discontinue oxytocin infusion, prep for emergency cesarean