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29 Cards in this Set
- Front
- Back
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first stage of labor |
-begins with the onset of regular uterine contractions and ends with compete cervical effacement and dilation - consists of three phases: latent phase (through 3cm of dilation), active phase (4-7 cm of dilation), and the transition phase (8-10 cm of dilation) |
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true labor |
-contractions: occur regularly, becoming stronger, lasting longer and occurring closer together; become more intense with walking; are usually felt in lower back, radiating to lower portion of abdomen, and continue despite use of comfort measures - cervix: shows progressive change (softening, effacement, and dilation signaled by appearance of bloody show); moves to an increasingly anterior position - fetus: presenting part usually becomes engaged in pelvis, which results in increased was of breathing; at same time, presenting part presses downward and compresses bladder, resulting in urinary frequency |
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false labor |
-contractions: occur irregularly or become regular only temporarily; often stop with walking or position change; can be felt in back or admen above navel; can often be stopped through use of comfort measures - cervix: may be soft but with no significant changes in effacement or dilation or evidence of bloody show; is often in posterior position - fetus: presenting part is usually not engaged in pelvis. |
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Nitrazine test for Ph ( test for ruptured membranes) |
- membranes probably in intact: identifies vaginal and most body fluids that are acidic: - yellow pH 5.0 - olive yellow pH 5.5 - olive green pH 6.0 - membranes probably ruptured: identifies amniotic fluid that is alkaline - blue green pH 6.5 - blue gray pH 7.0 - deep blue pH 7.5 - false tests are possible because of presence of bloody show, insufficient amniotic fluid or semen |
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fern test |
- a microscopic slide test to determine the presence of amniotic fluid leakage - positive test means that water broke - using sterile technique, a specimen is obtained from the external os of the cervix and vaginal pool and is examined on a slide under as microscope - fern like pattern produced by the effects of salts of the amniotic fluid indicates the presence of amniotic fluid - interventions: position client in the dorsal lithotomy position; instruct client to cough, which causes the amniotic fluid to leak from the uterus if the membranes are ruptured. |
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stage one of labor: latent phase |
- stage one is the longest - a labor curve, often called a friedman curve, may be used to identify whether a woman's cervical dilation is progressing at the expected rate. -Assessment: cervical dilation is 1-4 cm; uterine contractions occur every 15-30 minutes and are 15-30 seconds in duration and are of mild intensity - interventions: encourage mother and partner to participate in care; assist with comfort measures, changes of position and ambulation; keep mother and partner informed of progress; offer fluids and ice chips; encourage voiding every 1-2 hours |
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stage 1: active phase |
- Assessment: cervical dilation is 4-7 cm; uterine contractions occur every 3-5 minutes and are 30-60 seconds in duration and are of moderate intensity - Interventions: encourage maintenance of effective breathing patterns; provide a quiet environment; keep mother and partner informed of progress; promote comfort with back rubs, sacral pressure, pillow support and position changes; instruct partner in effleurage (light stroking of abdomen); offer fluids and ice chips and ointment for dry lips; encourage voiding every 1-2 hours |
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stage 1: transition phase |
- assessment: cervical dilation is 8-10 cm; uterine contractions occur every 2-3 minutes and are 45-90 seconds in duration and are of strong intensity - Interventions: encourage rest between contractions; wake mother at beginning of contractions so she can begin breathing pattern; keep mother and partner informed of progress; provide privacy; offer fluids and ice chips and ointment for dry lips; encourage voiding every 1-2 hours |
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interventions through out stage 1 |
- monitor maternal vital signs - monitor FHR via ultrasound doppler, fetoscope or electronic fetal monitor - asses FHR before, during and after a contraction, noting that the normal FHR is 110-160 bpm - Monitor uterine contractions by palpation or tocodynamometer, determining frequency, duration and intensity - asses status of cervical dilation and effacement - assess fetal station presentation and potion by leopold's maneuvers - assist with pelvic examination and prepare for a fern test - if membranes have ruptured, assess the FHR because of risk of collapsed umbilical cord and assess color of amniotic fluid because meconium stained fluid can indicate fetal distress. |
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stage 2 assessment |
- cervical dilation is complete - progress of labor is neared by descent of fetal head through the birth canal (change in fetal station) - uterine contractions occur every 2-3 minutes, lasting 60-75 seconds and are of strong intensity - increase in bloody show occurs - mother feels urge to bear down; assist mother in pushing efforts |
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stage 2 interventions |
- perform assessments every 5 minutes - monitor maternal vital signs - monitor FHR via ultrasound doppler, fetoscope, or electronic fetal monitor - assess FHR before, during and after a contraction, noting that the normal FHR is 110-160 - Monitor uterince contractions by palpation or tocodynamometer, determining frequency, duration and intensity - provide mother with encouragement and praise and provide for rest between contractions -keep mother and partner informed of progress -maintain privacy - provide ice chips and ointment for dry lips -assist mother into a position that promotes comfort and facilitates pushing efforts, such as lithotomy, semi sitting, kneeling, side lying or squatting -monitor for signs of approaching birth, such as perineal bulging or visualization of fetal head - prepare for birth (expulsion of fetus) |
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stage 3 assessment |
- contractions occur until the placenta is expelled - placental separation and expulsion occur - expulsion of the placents occurs 5-30 minutes after the birth of the infant - schultze mechanism: center portion of the placenta separates first and its shiny fetal surface emerges from the vagina - Duncan mechanism: margin of the placenta separates and the dull, red, rough maternal surface emerges from the vagina first |
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stage 3 interventions |
- assess maternal vital signs - assess uterine status -provide parents with an explanation regardless expulsion of placenta - after expulsion, uterine funds remains firm and located 2 fingers below umbilicus -examine placenta for cotyledons and membranes to verify that it is intact - assess mother from shivering and provide warmth -promote parental-neonatal attachment |
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stage 4 assessment |
- period 1-4 hours after delivery - BP returns to pre labor level - pulse is slightly lower than during labor -fundus remains constructed in the midline, 1-2 finger breadths below umbilicus - monitor lochia discharge. lochia may be moderate in amount and red in color.
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stage 4 interventions |
- perform maternal assessments every 15 minutes for 1 hour and every 30 minutes for 1 hour and hourly for 2 hours (or per policy) - provide warm blankets -apply ice packs to perineum - massage uterus if needed and teach mother to massage the uterus - provide breast feeding support as needed |
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leopold's maneuvers |
- methods of palpation to determine presentation and position of the fetus and aid in location of fetal heart sounds - if the head is in the funds, a hard, round, movable object is felt. -the buttocks feels soft and have an irregular shape and are more difficult to move. - the fetus' back, which is smooth, hard surface, should be felt on one side of the abdomen - irregular knobs and lumps, which may be the hands, feet, elbows and knees and are felt on the opposite side of the abdomen. - helps determine number of fetuses; presenting part, fetal lie, and fetal attitude; degree of descent into pelvis of presenting part; expected location of the point of maximal intensity of the FHR on the woman's abdomen. |
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McRobert's Maneuver- difficult labor because baby's shoulder is stuck |
- the woman's legs are flexed apart with her knees on her abdomen - causes the sacrum to straighten and the symphysis pubis to rotate toward the mother's head - angle of the pelvic inclination is decreased, which free's the shoulder -suprapubic pressure can be applied at this time - this is the preferred method when a woman is receiving epidural anesthesia. |
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amniotomy |
- artifical rupture of the membranes is performed by the HCP to stimulate labor - is performed if the fetus is at 0 or a plus station - increases the risk of proposed cord or infection - monitor FHR before and after - record time, FHR and characteristics of fluid - meconium stained amniotic fluid may be associated with fetal distress - bloody amniotic fluid may indicate abrupt placentae or fetal trauma - an unpleasant odor to amniotic fluid is associated with infection - polyhydramnios is associated with maternal diabetes and certain congenital disorders - oligohydramnios is associated with intrauterine growth restriction and congenital disorders. |
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chorioamionitis |
- bacterial infection of the amniotic cavity; can result from premature or prolonged rupture of membranes, vaginitis, amniocentesis or intrauterine procedures, and may be result in the development of postpartum endometritis and neonatal sepsis. |
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chorioamionitis |
-Assessment: uterine tenderness and contractions; elevated temperature; maternal or fetal tachycardia; foul odor to amniotic fluid; leukocytosis -Interventions: monitor maternal vitals and FHR; monitor for uterine tenderness, contractions and fetal activity; monitor results of blood cultures; prepare for amniocentesis to obtain amniotic fluid for gram stain and leukocyte count; admin abx as prescribed to increase uterine tone; prepare to obtain neonatal cultures after delivery. |
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Von Willebrand's disease |
- a hereditary bleeding disorder that occurs in males and females and is characterized by a deficiency of or a defect in a protein termed van willebrand factor - causes platelets to adhere to damaged endothelium; van willebrand factor protein also serves as a carrier protein for factor VIII - it is characterized by increases tendency to bleed from mucous membranes - Assessment: epistaxis, gum bleeding, easy bruising and excessive menstrual bleeding -Interventions: treatment and care are similar to measures implemented for hemophilia, including admin of clotting factors; provide emotional support to child and parents; child with a bleeding disorder needs to wear a medic alert bracelet. |
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uterine contraction characteristics |
- frequency: how often utterance contractions occur; the time that elapses from the beginning of one contraction to the beginning of the next - intensity: the strength of a contraction at its peak - duration: the time that elapses between the onset and end of a contraction - resting tone: the tension in the uterine muscle between contractions; relaxation of the uterus |
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palpating the uterus and what is felt |
- mild: slightly tense fundus that is easy to indent finger tips (feels like touching finger to tip of nose) - moderate: firm fundus that is difficult to indent with finger tips ( feels like touching finger to chin) - strong: rigid boardlike fundus that is almost impossible to indent with fingertips (feels like touching finger to forehead) |
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benefits of upright positions may be related to |
- straightening of the longitudinal axis of the birth canal and improvement in the alignment of the fetus for passage through the pelvis - application of gravity to direct the fetalhead toward the pelvic inlet, thereby facilitating descent - enlargement of pelvic dimensions and restriction of the encroachment of the scrum and coccyx into pelvic outlet - increased utrtplacental circulation, resulting in more intense, efficient uterine contractions - enhancement of the woman's ability to bear down effectively thereby minimizing maternal exhaustion |
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three phases of spontaneous birth of a fetus in a vertex presentation |
- birth of the head -birth of the shoulders -birth of the body and extremities |
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crowning |
- occurs when the widest part of the head (the biparietal diameter) distends the vulva just before birth |
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episiotomy |
- incision into the perineum to enlarge the vaginal outlet is necessary, it is done at this time to minimize soft tissue damage. - a local anesthetic may be administered if necessary before performing an episiotomy |
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hands on approach to control the birth of the head/baby |
- applying pressure against the rectum, drawing it downward to aid in flexing the head as the back of the neck catches under the symphysis pubis - applying upward pressure from the coccygeal region to extend the head during the actual birth, thereby protecting the musculature of the perineum - assisting the mother with voluntary control of the bearing down by coaching her to pant while letting uterine forces expel the fetus |
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perineal lacerations |
- first degree: laceration that extends through the skin and structures superficial to muscles - second degree: laceration that extends through muscles of the perineal body - third degree: laceration that continues through the anal sphincter muscle - fourth degree: laceration that also involves the anterior rectal wall. |
