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608 Cards in this Set
- Front
- Back
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what happens in the first stage of labor
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cervix dilates and effaces from 1-10 cm
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what happens in the second stage of labor
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completely dilated until birth of baby
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what happens in the third stage of labor
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From the birth of baby until placenta is delivered
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what happens in the fourth stage of labor
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1-4 hrs immediate postpartum recovery
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what are the 4 P's of labor
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power, pelvis, passenger, pysche
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what is power of labor
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The Power of the Uterine Contractions
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what is the duration of power
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Beginning of contraction until end of same contraction
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what is the frequency of power
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from start of one contraction until start of next contraction; eg. q 2-3 min
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what is must the power of the uterine contraction do
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Must dilate and efface the cervix
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what do braxton hicks contractions do
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do not dilate or efface cervix.
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what causes uterine contractions
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protaglandins and oxytocin
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what is cervical effacement
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Thinning and shortening of cervical canal from 2-3 cms to paper thin rim
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At the beginning of labor, there is no what
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cervical effacement or dilation.
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The fetal head is cushioned by
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amniotic fluid
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what happens as the cervix begins to efface at the beginning of cervical effacement
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more amniotic fluid collects below the fetal head
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what happens to the cervix at the beginning of cervical effacement
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Cervix is about one half (50%) effaced and slightly dilated
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what happens as the amniotic fluid below the fetal head increases
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events hydrostatic pressure on the cervix
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what happens at the end of effacement of the cervix
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Complete effacement and dilation
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what is cervical dilatation
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Enlargement of the cervical os from an orifice a few mm to an opening large enough to permit the passage of the fetus
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what is considered complete or totally dilated
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10cm
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what are the premonitory signs of labor
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Lightening, Cervical Ripening, bloody show, nesting
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what causes lightning
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Due to engagement of the fetal presenting part
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when does lightning occur
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occurs about 2 weeks before labor especially in primigravida
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what is cervical ripening
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softening of cervix
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what is the bloody show
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Within 24-48 hrs blood tinged secretion of mucus plug from cervix
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what is nesting
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Maternal home preparation activities
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what are signs of true labor
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Progressive effacement & dilation
Pain begins in back and sweeps around Contraction s intensify by walking Intervals shorten between contractions over time Contractions become stronger and longer duration over time |
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what are signs of false labor
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Negligible cervical change
Pain in lower abdomen or groin Pain goes away if change in position Contractions are irregular No change in intervals of contractions |
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what are the labor triggers theories
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prostaglandin theory and oxytocin theory
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what is the protoglandin theory of labor
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prostaglandin induces labor and is increased just prior to labor
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what are the types of PGE2
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Cervidil, Prepidil, Prostin E 2
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what are the types of PGE1
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Cytotec
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what is Indomethacin
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a prostaglandin inhibitor, acts by inhibiting the production of cytokines that may trigger labor
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what is Indocin therapy
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use only if ≤ 32 weeks
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what is the oxytocin theory of labor triggers
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IV pitocin infusion to induce labor
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when is pitocin used
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If cervix is “inducible”-- softened
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what happens to the length of labor the more times the cervix has been stretched
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the faster it will dilate each subsequent labor
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what kind of labors usually go the fastest
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Multipara labors usually go faster than primipara labors
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what do you do if pt has had several previous births and been in labor for hrs prior to admission
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do vaginal exam (VE) ASAP after admission to quickly evaluate how imminent birth will be.
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what does the friedman curve show
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multipravida labors are faster than primipravida
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what is the first stage of labor defined as
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The work of labor
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when is the first stage of labor
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0-10cm dilated
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what are the phases of the first stage of labor
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early active and transition phases
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what is the dilation during the early phase
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0-3cm
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what is the dilation of the active phase
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4-7cm
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what is the dilation of the transition phase
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8-10cms
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the woman may feel what during the early phase
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anticipation, excitement, animation, some fear and anxiety
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the woman can usually do what during the early stage of labor
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Can usually relax
Can usually stay at home during early labor |
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the woman in early phase of labor may have what
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ROM
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In the early stage of labor the woman may do what
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eat light snacks and drink fluids
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what is the active phase marked by
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Marked change in the pace and intensity of contractions.
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the woman becomes what during the active phase of labor
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serious, introspective, tense with ill defined fears. fear of being alone
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the woman must concentrate during what during the active phase
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contractions
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what is utilized during the active phase
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labor breathing and relaxation techniques
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what is PURR
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Position
Urination relaxation respiration |
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what marks the end of the first stage of labor
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the transition phase
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what is required for the mother during the transition phase
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skilled support
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what are common statements during the transition phase
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“Just get the baby out!”
“I wanna C/S!” |
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what is common during the the transition phase
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nausea and vomiting, rectal pressure, shaking, chills
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shaking and chills are what kind of behavior
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uninhibited
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what may be seen with shaking and chills
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amnesia, afraid of being left alone, little desire for interaction
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who is the passenger
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the fetus
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In primigravida, engagement usually occurs when with cephalic presentation
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2 weeks before labor
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“Floating” or “ballottable” is when it is freely moveable where
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above the inlet
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what is dipping
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The fetal head dips into the inlet but can be moved away by exerting pressure on the fetus
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Engagement of the presenting part occurs when in cephalic presentation
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when the largest diameter of the presenting part reaches or passes through the pelvic inlet.
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what is the largest diameter of the fetal head when the fetal head is flexed with cephalic presentation
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the Biparietal diameter (BPD) is the largest diameter of the fetal head
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usually the presenting part will be at what when the fetal head is flexed
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usually the presenting part (occiput) will then be at 0 station
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what is 0 station
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presenting part at the ischial spines
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what do negative values of station represent
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represent cms above the spines.
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what do positive values of station represent
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represent values in cms below the spines
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what is the attitude position of the baby
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the relationship of baby parts to each other
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what is the usual attitude position
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flexed
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what is the lie position of the baby
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relationship of the long axis of the fetus to the long axis of the mother
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what are the types of lie
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Longitudinal, transverse, oblique
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what is presentation
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Manner in which fetus enters the maternal pelvis.
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presenting part of fetus is most often what
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vertex
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what are the types of presentation
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Cephalic.
Breech. Shoulder |
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what are the types of cephalic presentation
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occiput, face, brow
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what is occiput presentation
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most common, flexed
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what is face presentation
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head all the way back
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what is brow presentation
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head straight chin elevated
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how big is the anterior fontanels
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2-3cms
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when does the anterior fontanels close
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18 months
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when does the posterior fontanel close
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8-12 weeks
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what causes a back ache during labor
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When fetal head
pushes against her back, it strains her muscles, causing a back ache--- |
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what relieves the back ache
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massage
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how big is the biparital diameter
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9.25 cm
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how long is the bitemporal diameter
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8cm
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what is a complete breech
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flexed hips and knees
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what is a frank breech
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hips flexed
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what is footling or incomplete breech
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one or both feet with extension at both hips and knees
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what is shoulder presentation
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Transverse Lie of baby.
Long axis of fetus is perpendicular to the long axis of mother. |
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what is not possible with shoulder presentation
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Vaginal delivery
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what is position
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The relationship of landmarks of the fetal presenting part to the
maternal pelvis |
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what are the 3 sets of position terms
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landmark, left or right, anterior posterior or transverse
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what are the types of landmark
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Occiput
Mentum Sacrum |
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what are the landmarks for presenting fetal parts
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Vertex Occiput (O)
Face Mentum (chin) (M) Breech Sacrum (S) |
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what are the pelvic classifications
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Gynecoid
Anthropoid Plateypoid Android |
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what is the mothers psyche
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Level of excitement, tension and fear experienced by mother and her family
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what causes the psych
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unfamiliar environment, loss of control
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what is the second stage of labor
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From 10 Cms Until the Baby Is Born
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what is descent
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Station--presenting part in relation to ischial spines
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what is flexion
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tucking the chin down (hyper flexion)
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what is engagement
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head enters true pelvis
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what is internal rotation
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LOA to ROA.
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what is extension
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back of head born 1st
then head extends and face born |
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what is Restitution
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head rotates 45
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what is external rotation
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Shoulders rotate 45
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what is expulsion
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After the head is born
Anterior shoulder born first. Then posterior shoulder and the rest of the baby quickly follows. |
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what is the 3rd stage of labor
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Expulsion of the Placenta
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when should you watch for emergence of the placenta
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Watch for emergence of placenta when see---
sudden gush of blood and ~8” of umbilical cord sliding out of the vagina |
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what is placental expulsion, how long does it lasts, what control the bleeding and what is routinly given after placenta and what should be done if unatteneded delivery by MD/CNM and no medication order
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~ 5 to 20 minutes
Retained placenta if ≥ 30 min Contractions of uterus controls the bleeding Pitocin infusion routinely given after placenta Put baby to breast if unattended delivery by MD/CNM and no medication order. |
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what is the Shiny” Schultz mechanism
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If placenta separates from the inside to the outer margins, it is expelled with the fetal (shiny) side presenting.
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what is the “Dirty” Duncan mechanism
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If the placenta separates from the outer margins inward, it will roll up and present sideways with the maternal surface delivering first, which is a rough surface.
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what is the fourth stage of labor and what changes occur
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Recovery Room- Immediate Post Partum
1-4 hours after birth in which physiologic readjustment of mother’s body begins. Hemodynamic changes occur with average blood loss at birth 250-500 cc |
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what is the primary focus in the fourth stage of labor
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uterine contractility
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what do you do during the 4th stage of labor
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Q 15 min uterine palpation for firmness
If boggy… massage to prevent uterine atony and hemorrhage |
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what is done in the initial labor assessment
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OB index, chief complaint, OB history, physical exam, birth plan
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what is the OB index
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Age___ G P EGA___
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what is done in the physical exam
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Fundal Height
Fetal Position Leopold’s maneuver VS: BP,T,P, R Lab work |
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when should ambulation be done in early labor
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if fetal presenting part engaged and membranes intact and FHR tracing reassuring
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what is the position of the mother in the 1st stage of labor
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Usually left lateral
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what are the fluids in the 1st stage of labor
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maintained @ 125cc/hr
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what is the elimination procedure in the 1st stage of labor
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Empty bladder q 2 hrs
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what are the maternal assessments in the 1st stage of labor
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Vital signs
Contraction frequency, intensity and duration Cervical changes Status of membranes |
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what are the fetal assessments in the 1st stage of labor
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Heart rate
Fetal position, station |
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what are the labor assessments for the low risk patients in the latent phase
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UC palpated q 30 min
FHR q 1 hr BP,P & R q 1 hr Temp q 4 hr |
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if there is a ROM, when is the temp assessed
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every 2 hours
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what are the labor assessments for the low risk patient in the active phase
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UC palpated q 30 min FHR q 30 min
BP, P, R q 1 hr |
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what is the baseline rate
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mean rate X 10 min
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what is fetal tachycardia
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≥ 160 bpm
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what is fetal bradycardia
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≤ 110 bpm
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what are the causes of fetal tachycardia
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Most commonly 2o maternal fever R/T prolonged ROM
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what should be done for fetal tachycardia
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take mothers temp
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fetal tachycardia May be compensatory mechanism for what
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transient hypoxia of the fetal system.
May be due to uterine hyperstimulation due to excessive pitocin stimulation and nurse needs to reduce pitocin drip |
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FHR of 220 may do what
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decrease O2 and the ventricles have little chance to fill
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FHR of 220 may lead to what
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severe fetal compromise
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what is uterine hyperstimulation
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> 5 UC / 10 min
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how long can a fetus tolerate severe bradycardia
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30 min severe bradycardia (≤ 60 bpm) before cerebral ischemia triggers cellular anaerobic metabolism and brain injury process.
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what does severe bradycardia cause
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metabolic acidosis
cord arterial pH ≤ 7.20; BE ≥ -8 |
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what are the causes of fetal bradycardia
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Prolapse or prolonged compression of umbilical cord, drugs, Fetal arrhythmias
Hypothermia inital response to maternal condition: seizure, excessive contractions, hypotension, abruptio placenta |
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Immediately after SROM what may happen
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cord may get compressed
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what should be done after the SROM
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listen to FHR to verify all is well
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what are the treatments for cord compression
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reposition pt to side that improves FHR
If not resolved: notify MD, IV fluid bolus, O2 by mask @ 8L and start Amnioinfusion |
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what are the treatments for cord prolapse
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Knee-chest position,
nurse keeps her exam fingers in woman’s vagina to use gravity and manipulation to relieve compression of the cord. |
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what drugs may cause fetal bradycardia
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anesthetics
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what are interventions for the second stage of labor
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Facilitate pushing
Intermittent pushing if needed for FHR tolerance May need to turn off Epidural to have more effective pushing Monitor fetal descent Normal duration < Primip 2 hrs < Multip 1 hr IV fluids |
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what are the types of birthing positions
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Left lateral Sims
Recumbant Squatting Semi-fowlers Sitting in birthing bed Hands & knees |
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what is the preparation for labor
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Cleansing the perineum
Assisting with the birth of the infant Assisting with clamping of the cord |
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what will the patient complain of if they are hyperventilating
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complain of tingling in her fingers & around her mouth
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how do you Promote parental attachment
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by positioning the healthy baby on the mother’s chest.
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what is the inital newborn care
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Apgar score to evaluate oxygenation
ID bands Temperature evaluation Hygiene |
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what is the First Priority in caring for the newborn immediately after birth
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maintenance of airway/breathing
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what can help clear the airway
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Suction with DeLee mucus trap can clear airway
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what do you do for the fourth stage of labor
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Assess for vaginal bleeding q 15 min
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If uterus is boggy (relaxed)
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Massage fundus to stimulate it to firm it up
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what do you do for the fourth stage of labor
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Assess for vaginal bleeding q 15 min
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If uterus is boggy (relaxed)
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Massage fundus to stimulate it to firm it up
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what is the pain signal
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action potential
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what controls the passage of the pain signal
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Voltage-gated sodium channels
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what do Anesthetic agents like Lidocaine & Marcaine do
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“sit in” sodium channels and BLOCK Action Potential from proceeding down axon.
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where is pain initially felt in labor
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Initially the pain is felt in the lower abdomen
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where is pain felt as labor progresses
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as labor progresses the distension of the birth canal by the descending fetal part causes back, perineal and thigh pain.
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what is a Dermatome
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an area of skin which is innervated by afferent nerve fiber coming to a single dorsal spinal root
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Labor pain is due to what
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cervical dilatation
primary source uterine contractions distension of the structures surrounding the vagina and pelvic outlet |
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afferent impulses are transmitted via what
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the A delta and C fibers
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the A delta and C fibers travel with what
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sympathetic nerves via the hypogastric plexus (L1) to enter the lumbar and lower thoracic parts of the sympathetic chain.
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Central connection to the spinal cord is via what
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the dorsal root ganglion and lateral division of the posterior roots of T10-L1.
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Labor pains are therefore referred to what
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the areas of skin supplied by these nerves
i.e. the lower abdomen, loins and lumbo-sacral region. |
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Afferent transmission is also via A delta and C fibers but with what
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the parasympathetic bundle in the pudendal nerves (S2,3,4).
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There is also a minor contribution from what
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from the ilio-inguinal, genito-femoral and the perforating branch of the posterior cutaneous nerve of thigh.
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It is important to appreciate that what is involved in labor pain
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pain sensitive structures in the pelvis are also involved
i.e. the adnexi, the pelvic parietal peritoneum, bladder, urethra, rectum and the roots of the lumbar plexus. |
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stage 1 labor pain is transmitted by what
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small-diameter nerve fibers
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stage 1 labor pain is blocked by what
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Blocked by stimulation of large-diameter nerve fibers
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Sensory impulses from the uterus & cervix synapse where in stage 1 labor pain
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at T-10 to L-1
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Sensory impulses from the perineum are carried where in stage 1 labor pains
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S-2 to S-4
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what causes stage 2 labor pain and where is pain felt
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Hypoxia of contracting uterus
Distention of vagina & perineum Pain felt from symphysis pubis to lower back |
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what causes stage 3 labor pain
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Pressure on adjacent structures
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what are the physiological Factors Affecting Response to Pain
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Intensity of labor
Fatigue Hunger sleep deprivation |
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what are facotrs that affect the intensity of labor
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cervical readiness
fetal position characteristics of pelvis |
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what phase should pain medicine be given in
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active phase to not slow progress of labor
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what are the psychological Factors Affecting Response to Pain
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Preparation for childbirth
Cultural norms & preferences Previous experience Anxiety |
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what are the effects of pain on labor
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Maternal discomfort
Negative childbirth experience |
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what causes maternal discomfort from pain
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exhaustion due to
Unable to relax Unable to push effectively in second stage Unable to participate effectively if asked to reposition as needed for fetal benefit |
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maternal pain and stress can have a more what than a small amount of analgesic
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adverse effect on the fetus
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what is the Lamaze Childbirth Preparation
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Gate -control Theory of Pain Relief
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what is the Gate -control Theory of Pain Relief
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If “gate” in spinal cord, that allows pain signal up to brain is blocked, pain signal can’t get through.
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what can the patient do so uterine pain signal won’t be perceived
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distraction:
Imagery Focal point Breathing pattern |
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how can you Relieve fear of childbirth
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childbirth through understanding process and thereby pt. able to relax during labor
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what are the natural opiates
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beta endorphins
& enkephalins |
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what do ergot derivatives do
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constrict cranial blood vessels
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what do triptans do
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bind serotonin receptors to cause cranial vasoconstriction
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what do narcotics do
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occupy opioid receptors to block pain response
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what are some non-pharmacological ways to control pain
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Cutaneous stimulation
Block signal by massage of skin Hydrotherapy Relaxation of warm water |
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how are Systemic Analgesia medications given
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These are medications are given either intravenously or intramuscularly to decrease the amount of labor pain.
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analgesia=?
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pain relief
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Systemic Analgesia may do what during labor
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They may alleviate, but not eliminate pain during labor.
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what do system drugs have effects on
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multiple systems
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what are the types of systemic drugs
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Opioids, Sedatives, Narcotic antagonists
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what are the types of opioids
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Demerol, Fentanyl, Stadol, Nubain
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what are the types of sedatives
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Phenergen, benadryl, atarax, vistaril
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what are the types of narcotic antagonists
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Narcan
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Effects of Pharmacologic Measures on the fetus
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They reduce FHR variability
Fetus cannot metabolize medications – immature liver |
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what do you do in fetal distress situations
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HOLD maternal systemic pain medications
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Narcotics are most effective medications for relief of labor pain because why
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site of action is in the brain
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what are the types of narcotics
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Butorphanol (Stadol), Nalbuphine (Nubain), Meperidine (Demerol)
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what does Butorphanol do
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30-40 times more potent than Demerol
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what is the dosage of Butorphanol
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IV 1-2 mg
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what is the pain relief and peak effect with the IV route
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less than 30 minutes
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what is the onset of pain relief for IM route
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30 minutes
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when is the peak pain relief for IM route
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less than 60 minutes
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Nalbuphine may cause what
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May cause dizziness & drowsiness so pt should NOT get up to BR but use bedpan
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what is the dose for Meperidine
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75 mg IM
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When should you withhold systemic analgesia
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Before active labor starts in primipara
If < 4 cm dilated, analgesia may prolong labor w/in 2-4 hrs prior to birth, IM analgesia May cause neonatal respiratory depression |
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what should you give if newborn is in respiratory depression
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narcan
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When pain relief is effective, patient may be able to relax enough to do what with additive sedatives
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doze between contractions
be able to maintain breathing pattern during contractions |
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what needs to be monitored with sedatives
|
fetal heart rate
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what are the Sedative/Antiemetic
|
Phenergen
Benadryl Atarax Vistaril |
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when is a local infiltration done
|
Instilled before episiotomy or suturing
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who does a local infiltration
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Done by MD or CNM responsible for delivery
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what does a local infiltration do
|
Provides anesthesia in immediate area of tissue
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Anesthesia =?
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temporary and reversible loss of sensation
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a local infiltration drug causes what
|
burning
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what is not required for a local infiltration
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No additional assessment of mother or fetus is required for this type of anesthesia
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what is Regional Anesthesia & Analgesia
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Injection of a local anesthetic to block specific nerve pathways
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Regional Anesthesia & Analgesia achieves what
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pain relief without loss of consciousness
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Regional Anesthesia & Analgesia may still do what
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still participate in birth process
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what are the fetal effects of Regional Anesthesia & Analgesia
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minimal
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who performs a pudenal block
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MD
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what does a pudenal block
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Anesthetizes vagina & part of perineum
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what does a pudenal block not do
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Does not block contraction pain or pressure
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a pudenal block has relief of what
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Relief of perineal pain
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what are some complications of a pudenal block
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Toxic reaction
Rectal puncture Hematoma Sciatic nerve block |
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what does a Paracervical Block do
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Labor pain can be effectively blocked by interrupting the transmission of pain sensation as it passes through or close to the cervix.
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what is used in a paracervical block
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Up to 20cc of 1% Lidocaine is used
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how is 20 CCs of lidocaine used in a paracervical block
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10 cc is injected on each side of the cervix, usually in divided doses
at 10 o'clock, 8 o'clock, 2 and 4 o'clock (5 cc in each site). |
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how long does it take for the patient to become pain free with a paracervical block
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Usually within 5 minutes, the patient becomes completely pain free.
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how long does a paracervical block last
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60-90 minutes
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what is the technique for a paracervical block
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Once the trumpet is in place, slide long needle through Iowa Trumpet until fully seated w/in trumpet.
The tip of the needle will be extending 5 mm beyond the Iowa Trumpet and just into the paracervical tissues. Aspirate to make sure you haven't perforated a blood vessel, then slowly inject 5 cc. Repeat the procedure at the 10 o'clock position. |
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paracervical blocks can have what adverse effects
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post-paracervical block fetal bradycardia.
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who are paracervical blocks reserved for
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patients without any significant abnormality in their fetal monitor tracing
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when does fetal bradycardia develop
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This usually develops 10 to 20 minutes following injection
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how long does fetal bradycardia last
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less than 10 minutes
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Fetuses who already have significant what will more likely concentrate lidocaine in their bloodstream
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variable decelerations or late decelerations will have a greater than average difference in acidity between the placenta and the mother
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who performs an epidural block
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Performed by Anesthesiologists or Certified Nurse Anesthetists (CRNA)
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what is the needle entry point for an epidural
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L3-L4
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when should an epidural block be given
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Should be given after labor established
Active labor cervical dilation ≥ 4 cm |
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Lumbar epidural used for what
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vaginal or cesarean births
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When the uterus contracts, pain impulses travel from where
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the uterus to the brain via nerves in the backbone
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Epidural and spinal anesthesia involve what
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placing local anesthetics within the backbone to block pain impulses originating from the uterus.
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The spinal cord is enclosed in what
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a sac (dura mater) containing fluid
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what fluid is in the dura mater
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Cerebrospinal Fluid (CSF) also surrounds the brain
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the dura mater is surrounded by what
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The sac is surrounded by vertebrae.
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The space surrounding the sac and inside the vertebrae is the what
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epidural space
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The epidural needle is inserted into the what
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epidural space for providing epidural anesthesia.
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The local anesthetic medication is injected where for an epidural
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outside of the dura
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The nerves are blocked in the what with an epidural
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epidural space
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there is a risk of what with an epidural
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dural puncture
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what happens to the catheter used with an epidural
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Catheter is left in epidural space
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what is a common local drug used in an epidural
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Bupivicaine
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Local anesthetic agent is usually combined with what in an epidural
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opioid:
Fentanyl Sufentanyl Morphine |
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what are the Contraindications for Epidural
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Coagulation problems
Thrombocytopenia < 100,000 platelets Uncorrected hypovolemia Infection in area Severe systemic infection Allergy |
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what are the adverse effects for an epidural
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Inadvertent Spinal, causing headache
Bladder distention Prolonged 2nd stage Catheter migration Maternal hypotension |
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what causes a headache in an epidural
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puncture into dura leaks CSF
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how do you prevent a headache
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To prevent HA, lay flat for several hrs after spinal
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what needs to be done for bladder distention seen with an epidural
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Pt unaware of full bladder sensation therefore needs to be reminded to void q 2 hrs
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what is done for a prolonged 2nd stage with an epidural
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Unable to sense need to push, so epidural turned off
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how is hypotension handled
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IV Fluid pre-load to prevent hypotension
Ephedrine |
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how are IV fluids given with an epidural
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500-1,000 cc bolus BEFORE Epidural started in labor
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what does ephedrine do
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Vasoconstricts maternal vasculature without constricting uterine arteries
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what are the Epidural Duramorph Side Effects
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Pruritus, Nausea
Respiratory Depression Urinary Retention, Reactivation of Herpes simplex I |
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when does pruritis occur
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Occurs ~ 3 hours after administration
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pruritis is related to what
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dose
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what is the treatment of pruitis
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Benadryl or Narcan may be used for treatment
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what happens if Vertebrae rotate forward, and if needle inserted in usual way with an epidural
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the apophyseal joints are encountered
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where is the needle in a lumbar epidural block
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Needle in the ligamentum flavum
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where is the tip of the needle in a lumbar epidural
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Tip of needle in the epidural space
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where does the spinal cord end
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Spinal cord ends @ L 1
Is NOT present at L 4 |
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when is spinal anesthesia used
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Used for delivery or C/S only
Not for labor anesthesia |
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who performs spinal anesthesia
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Performed by Anesthesiologists or Certified Nurse Anesthetists (CRNA)
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why is spinal anesthesia useful
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Simple & quicker than epidural
Used for emergency fetal distress Provides immediate anesthesia |
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what is needed with spinal anesthesia
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Smaller drug volume needed
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where is spinal anesthesia given
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At level of L3 or L4
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what may be a problem with spinal anesthesia
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Maternal hypotension may be a problem
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what does a spinal block do
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Relief of
uterine pain only |
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the spinal needle is inserted where in spinal anesthesia
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into the spinal space for providing spinal anesthesia
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the needle pierces what in spinal anesthesia
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The needle pierces the dura
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a local anesthesia is inserted where with spinal anesthesia
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The local anesthetic is injected into the CSF.
The spinal nerves are blocked in that region |
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The spinal needle is introduced into the what so the spinal cord is not injured with a spinal anesthesia
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spinal space below the level of the spinal cord
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who performs general anesthesia
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Performed by Anesthesiologists or Certified Nurse Anesthetists (CRNA)
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what is general anesthesia given for
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C-section
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when is general anesthesia used
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emergency situations
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when does general anesthesia reach the fetus and what does it cause
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Reaches fetus in about 2 minutes
Causes respiratory depression |
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what does general anesthesia do
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Systemic, loss of consciousness
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what are the adverse effects of general anesthesia
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Aspiration of gastric contents
Uterine relaxation |
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Position for fingers in applying cricoid pressure
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on cricoid cartilage
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what are the placental abnormalities
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Placenta Abruptio, Placenta Previa
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what are the symptoms of Placenta Abruptio
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Severe uterine tenderness
Persistent pain Dark red vaginal bleeding Board-like rigid abdomen decrease fetal movement |
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what is seen on the monitor for placenta abruptio
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uterus looks irritable between contractions
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what is seen with palpitation with placenta abruptio
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doesn’t feel soft between contractions
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what are the signs of placenta previa
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Painless
frank red vaginal bleeding Soft uterine resting tone Decreased fetal movement |
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what is placenta abruptio
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premature separation of normally implanted placenta
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what are the types of placenta abruptio
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Marginal abruption with
external hemorrhage Central abruption with concealed hemorrhage Complete separation |
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what is placental previa
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placenta is improperly implanted in lower uterine segment
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what are the types of placental previa
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Placenta previa
Low placental implantation Partial placenta previa Total placenta previa |
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what is Placenta percreta usually associated with
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Often associated w/ placenta previa
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what is Placenta percreta
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Life threatening retained placenta
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what is grown on the uterus with Placenta percreta
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Chorionic villi grown into uterus
total, partial, or focal |
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what can happen with placenta percreta
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maternal hemmorage
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placenta percreta requires what
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Requires emergency hysterectomy
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what is Battledore Placenta
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Umbilical cord inserted at or near the placental margin
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Insertion variations occur more frequently in what
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multiple gestations
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what is Circumvallate placenta
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These are placenta that are a form of placenta extrachorialis
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Circumvallate placenta are usually in what condition
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They are usually benign condition requiring no alteration of management and simply have to be differentiated from other type of bands and membranes in the uterine cavity
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what is Succenturiate placenta
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A morphological abnormality, in which there is one or multiple accessory lobes connected to the main part of the placenta by blood vessels
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what is the Average umbilical cord length
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~55 cm
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what rarely causes complications
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short cords
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short cords may be related to what
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May be R/T decreased fetal movement in utero
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short cords are associated with what
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Associated with abruptio placenta, umbilical hernias cord rupture
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what can long cords do
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Long cords may twist & tangle around the fetus and may cause variable decelerations, however they rarely pull tight until descent at the time of birth
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normal cords have what
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2 small firm arteries
1 large soft vein |
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what are some Umbilical cord abnormalities
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Congenital absence of 1 artery
and cord prolapse |
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what do you examine with Congenital absence of 1 artery
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Examine closely for other neonatal organ anomalies
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when does a prolapsed umbilical cord occur
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20x greater in breech (footling), shoulder, LBW, >5 previous births
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there is a prolapse on the VE if what
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palpate scrotal sac
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when do you assess cord
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when membranes rupture
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what happens in a cord prolapse
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blood vessels compress
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what happens in the blood vessels are compressed in the cord
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Stress, fetal bradycardia
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when do majority of cord prolapses occur
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50% in 2nd stage of labor
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when does the risk of cord prolapse increase
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47 times greater incidence after intervention / event
Amniotomy SROM external version application of fetal scalp electrode |
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how do you prevent cord prolapse
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Bedrest if vulnerable cord
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what is the treatment for a cord prolapse
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Keep fetal head off cord by leaving exam hand in vagina until C/S can be done
Emergency C/S |
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what may occur following SROM with cord prolapse
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Variable decelerations
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what should be done if variable decelerations occur after SROM
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Pt should have
VE to check for cord prolapse |
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what is Polyhydraminos
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greater than 2000cc of amniotic fluid
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Polyhydraminos frequently occurs with what
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often occurs with major congenital anomalies (anencephaly)
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what are the types of Polyhydraminos
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Acute (more severe) or chronic (most cases)
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what is Oligohydramnios
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less than 500cc of amniotic fluid
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what is the cause of Oligohydramnios
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unknown
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Oligohydramnios is found in what
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found in postmature pregnancies, IUGR
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Oligohydramnios can result in what
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Often results in cord compression
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what is an amniotic fluid embolism
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Bolus of amniotic fluid enters maternal circulation then carried to lungs
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78% of amnionic fluid embolism cases had what
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ruptured membranes
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what are the signs and symptoms of amniotic fluid embolism
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respiratory distress, heart failure, circulatory collapse
coagulopathy abnormalities |
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what is the management for amniotic fluid embolism
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CPR, O2 ventilation
IV fluid replacement inotropic agents, hemodynamic monitoring correct coagulapathy |
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multiple gestation is more likely to result in what
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More likely to result in dysfunctional labor, complications, potential for hypoxia
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what is the goal for multiple gestation
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Goal is to promote normal G&D, prevent maternal complications, PTL, fetal trauma during labor, maternal hemorrhage
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what is common for 3 or more fetuses
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c section
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what is seen with multiple gestations
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Many different presentations, FHR!!
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what is done in multiple gestations
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Leopold’s maneuver
Mom in lateral position |
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what is Nonreassuring Fetal Status and where is it shown
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When oxygen supply is insufficient to meet the physiologic demands of the fetus, a nonreassuring fetal status may result as shown on FHR tracing
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what commonly causes Nonreassuring Fetal Status
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Cord compression
Uteroplacental insufficiency |
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what is Uteroplacental insufficiency
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Effect compounded by presence of chorioamnionitis in terms of severity of hypoxic insult to fetal brain
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what causes Uteroplacental insufficiency
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due to effect of cytokines and prostaglandins
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what are the Abnormal Variations of Baseline FHR
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Tachycardia and bradycardia
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what is fetal tachycardia
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Baseline FHR >160 bpm for 10 min or more
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what are the possible causes of fetal tachycardia
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- maternal fever, fetal hypoxia, fetal anemia, drug effects, maternal hyperthyroidism, dehydration
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what do you do for fetal tachycardia
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Ensure optimal blood flow, treat symptoms
check maternal temp. |
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what is fetal bradycardia
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Baseline FHR <110 bpm for 10 min or more
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what happens in a bradycardia less than 60
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< 60 severe decrease to cerebral and coronary circulation
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what are the possible causes of fetal bradycardia
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fetal asphyxia, maternal hypotension, cord compression, fetal arrhythmias
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what is a key indicator of danger in fetal bradycardia
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Variability is key indicator of danger
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what is the baseline rate
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mean rate X 10 min (rounded to 5 bpm
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minimum baseline duration must be how long
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greater than 2 minutes
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what is baseline variability
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Measure of the interplay (push-pull effect) between the
sympathetic nervous system (acts to increase heart rate) & the parasympathetic nervous system (acts to decrease heart rate |
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what are the two types of fetal heart rate variability
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Long term
Short term |
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what is Nl long-term variability
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5-15 bpm
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what is Minimal Long Term Variability
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less than 5 bpm
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late deceleration indicate what
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Indicate fetal hypoxia, due to uteroplacental insufficiency
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late deceleration appear similar to what
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Appear similar to early decels except for time in relation to the contractions
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when do decelerations start
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starts at or after the contraction peak
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decelerations are what
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smooth
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when do you do a In-utero resuscitation
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Upon diagnosis of a nonreassuring FHR tracing such as persistent late decelerations, bradycardia, and/or decreased variability
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what is done for In-utero resuscitation
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Reposition to left lateral side
IV bolus hydration Oxygen via mask @ 8-10 L DC pitocin drip |
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what is not given with nonreassuring FHR tracing
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give any analgesia pain medication to patient
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what is Dystocia
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Abnormal progress of dilatation & effacement & or fetal descent
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dystocia may result from problems with what
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Powers
Passageway Passenger Pscyhe |
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what are the occurrences in the 1st stage of labor
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Onset of regular contractions to full (10cm) dilitation and effacement of the cervix
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what are the occurrences in the 2nd stage of labor
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Full dilitation and effacement of the cervix to delivery of the fetus
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what are the occurrences in the 3rd stage of labor
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Delivery of the fetus to delivery of the placenta
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how long does the 1st stage of labor last in primigravida
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16-18 hr
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how long does the 2nd stage of labor last in primigravida
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1 hr (can last 2 hr)
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how long does the 3rd stage of labor last in primigravida
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3-4 min (can last up to 45 min)
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how long does the 1st stage of labor last in multigravida
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7-12 hr
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how long does the 2nd stage of labor last in multigravida
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20 min
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how long does the 3rd stage of labor last in multigravida
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4-5 min
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During active labor (≥ 4 cm), the cervix should dilate at a rate of at least what for 1st babies
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1.2 cm/hr for first babies
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During active labor (≥ 4 cm), the cervix should dilate at a rate of at least what for subsequent babies
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1.5 cm/hr for subsequent babies
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Ineffective contractions can be what
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Hypertonic or Hypotonic
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what must contractions be do be effective
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Contractions must be coordinated, frequent & sufficient number to be effective
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what are the causes of ineffective contractions
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fatigue
maternal inactivity Fluids & electrolyte imbalances hypoglycemia excess analgesia/anesthesia maternal catecholamines CPD uterine over- distention |
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Hypertonic Contractions occur when
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Less common, occurs mostly in latent phase
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what are Hypertonic Contraction
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Ineffective, erratic contractions of poor quality, More frequent, painful, no dilatation or effacement, prolonged latent phase
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what are the risks of Hypertonic Contraction
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Risks similar to abruption
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what are the maternal risks to hypertonic contractions
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pain, fatigue, stress
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what are fetal risks to hypertonic contractions
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fetal distress molding, caput s., cephalhematoma
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what do you need to rule of if hypertonic contractions occur
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CPD
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what is the treatment of hypertonic contractions
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bedrest, systemic analgesia, low dose oxytocin infusion, tocolytics, amniotomy
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what is the nursing management of hypertonic contractions
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positioning, touch, breathing, etc.
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when do hypotonic contractions usually occur
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Usually occurs during active phase
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what are hypotonic contractions
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Coordinated, weak, infrequent uterine contractions &/or soft tissue relaxation
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what is the cause of hypotonic contractions
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unknown, genetic factors
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hypotonic contractions are not what
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dangerous
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what is the hypotonic labor pattern
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Protracted labor
Arrest of Progress |
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what is protracted labor
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≤1 cm/hr cervical dilatation
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protracted labor is due to what
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contractions are irregular
of low amplitude |
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what is arrest of progress
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No cervical change for 2 hrs
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what is dystocia
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dysfunctional labor pattern that results in prolongation of labor
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what is the treatment for hypotonic contractions
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Pitocin augmentation or amniotomy
IV fluids Electronic Fetal Monitoring assess fetal presentation Reposition Rule out CPD |
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what are the fetal signs of compromise
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Non-reassuring FHR pattern
Fetal acidosis Meconium |
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what are the maternal signs of compromise
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Maternal exhaustion
Maternal infection |
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what is ineffective pushing
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Reflex urge when presenting part reaches pelvic floor
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what are the causes of ineffective pushing
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Incorrect technique or positioning,
Fear of injury, pain, decrease or absent urge, Maternal exhaustion, analgesia or anesthesia, Psychological issues |
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what is a prolonged 2nd stage
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2 hrs multipara
1 hr primipara |
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prolonged 2nd stage has risks for what
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Risk of head compression and brain trauma with prolonged 2nd stage
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what is the management for ineffective pushing
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Try squatting
Use Mc Roberts Manuver to increase angle of pelvic outlet Intermittent pushing Increased fluids |
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what is the McRoberts maneuver
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Thighs are flexed up onto abdomen to increase the angle of the pelvis
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what are some problems with the passenger
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Presentation or position
fetal size |
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what are some presentation or position problems
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Persistent OP/OT (occiput posterior or transverse)
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what is a fetal size problem
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Macrosomia
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what are the effects of malpresentation
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Prolonged labor, increase risk of infection, increase fetal injury & mortality
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what does malpresentation do
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Prevents normal flow - cardinal movements
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how do most fetus' rotate
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spontaneously
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what are Deflexion abnormalities
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military, brow, face
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breech presentation causes what
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slow effacement & dilatation
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what are the potential effects of breech presentation
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Head may not fit, fetal injury, prolapsed cord, hydrocephalus, previa, LBW, C/S
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what is External cephalic version
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breech (38 wk)
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external cephalic version is never seen when
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primigravida
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what is done with external cephalic version
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c-section
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what is macrosomia
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fetal weight > 4500 gm. (9.9 lb
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Fetal size risk is relative to what
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pelvic size…
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what are the complications of marcosomia
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shoulder has difficulty passing under symphysis pubis
Shoulder dystocia Uterine distension |
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what is shoulder dystocia
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urgent situation
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what does uterine distention cause
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reduces contraction strength
Dysfunctional labor postpartum hemorrhage from uterine atony infection Forceps, vacuum or C/S delivery may be necessary |
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Difficult shoulder dystocia delivery may cause what
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fetal shoulder injury-Brachial plexus injury
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Brachial plexus injury can cause what
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Erb’s palsy
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what is erbs palsy
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Paralysis of arm caused by injury to 5th & 6th cranial nerves
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what is brachial plexus
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The Brachial Plexus is a network of nerves that run from the spine through the shoulder and to the tips of the fingers
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Brachial means what
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arm
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Plexus means what
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network of nerves
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The Brachial Plexus conducts signals from where
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the spine to the arm and hand.
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signals from the brachial plexus cause what
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These signals cause the arm and hand muscles to move.
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what are some Problems with Passageway
|
Contracted pelvis (CPD)-Cephalopelvic Disproportion (CPD)
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what are some implications of contractures
|
Implications of contractures:Prolonged labor, difficult delivery, necrosis, fistulas
No amniotomy unless r/o CPD increase risk of cord prolapse Oxytocin augmentation of labor Failure of dilatation or descent leads to C/S |
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what should be evaluated with CPD
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Evaluate size of maternal pelvis
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what are adequate types of maternal pelvis for CDP
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Gynecoid, anthropoid types are adequate
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contractions occur where in CPD
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Inlet, midpelvis, or outlet
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what can cause contractions in CPD
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Abnormal fetal positions & presentations
Large Fetal size |
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what is assessed with CPD
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Assess engagement
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when should a nurse suspect CPD
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Unengaged fetal head in early labor in primigravida
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what should the nurse assess in CPD
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station
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what happens in stage 1:active phase of labor with CPD
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Arrest of descent with adequate contractions after
1 hour in nullipara 0.5 hrs in multipara |
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what happens in stage 2 with CPD
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Failure of descent after
2 hrs in primipara 1 hr in multipara |
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what is Precipitous Birth
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Entire process of labor and birth occurs w/in 3 hrs
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what are the maternal reasons for facilitation of labor
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Maternal risks of a. placenta, lacerations, hemorrhage
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what are the fetal reasons for facilitation of labor
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Fetal risks of intracranial trauma, apgar, meconium
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what is post-term pregnancy
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Extends more than 294 days, 42 weeks
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who is post term pregnancy more common in
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More frequent in primigrav & >35 yrs.
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what is the Most frequent cause of post term pregnancy
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error in EDC
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what are the fetal risks of post term pregnancy
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Decreased amniotic fluid volume: < 5cm AFI
poor placenta function O2 Meconium stained fluid trauma, shoulder dystocia |
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what are the maternal risks of post term
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LGA or macrosomia,
forceps, vacuum, C/S maternal hemorrhage |
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what is the therapy for post term
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assess BPP, NST, & Doppler
Induction C/S |
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what accounts for ½ perinatal mortality >20 wks
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Intrauterine Fetal Demise
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what is Intrauterine Fetal Demise associated with
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increase in maternal age
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Intrauterine Fetal Demise can lead to what
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DIC
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Intrauterine Fetal Demise patients usually have what
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Usually have spontaneous labor in 2 wks
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what are the causes of Intrauterine Fetal Demise
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Unknown cause or maladaptations
Postmaturity cord accident Preeclampsia abruptio placenta, placenta previa Diabetes Mellitus infection Rh neg congenital anomalies |
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what is a uterine rupture
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Tear in uterine wall, unable to withstand pressure of contractions
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who is at risk for a uterine rupture
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previous uterine surgery, grand parity, thin uterine wall, uterine overdistension abdominal trauma, CPD, excessive pitocin
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what are the types of uterine rupture
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Complete, Incomplete, dehiscence (partial separation of incision)
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what are the signs and symptoms of uterine rupture
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sudden fetal bradycardia (impaired fetal O2,)
ascent of fetal presenting part (decreasing station) slow or stopped labor/contractions abdominal pain or tenderness, verbalize tearing sensation chest or respiratory pain (scapular area), shock |
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what are some 3rd Stage Complications
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Retained placenta
Uterine Inversion Perineal & Vaginal Lacerations |
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what is a retained placenta
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30 min beyond birth
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what can a retained placenta result in
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in excessive bleeding
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what is a retained placenta associated with
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placenta accreta
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what do you do if a manual removal fails
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D/C
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what are the types of uterine inversion
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Complete or partial
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when does uterine inversion occur
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3rd stage
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what are the causes of a uterine inversion
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fundal pressure during birth or non-contracted uterus
abnormally adherent placenta congenitial weakness fundal placenta implantation |
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how do you prevent a uterine inversion
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Wait until placental spontaneously separates before pulling on umbilical cord
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what are the signs and symptoms of uterine inversion
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depression in fundal area,
absence of uterus in abdomen, interior of uterus visible, massive hemorrhage, shock, pain |
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what is the management of uterine inversion
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tocolyticl, laparotomy, hysterectomy
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what is a 1st degree laceration
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Limited to the fourcehtte, perineal skin and vaginal mucosa
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what is a 2nd degree laceration
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Involves perineal skin, vaginal mucous membrane, underlying fascia and muscles of the perineal body
May extend upward on one or both side of the vagina |
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what is a 3rd degree laceration
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Extends through the perineal skin, vaginal mucous membranes and perineal body and involves the anal sphincter
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what is a 4th degree laceration
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Same as 3rd degree but extends through the rectal mucosa to the lumen of the rectum
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a fourth degree laceration may be due to what
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may be due to an extension of a midline episiotomy following the delivery of a very large fetus
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what are the parts to forceps
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blade (open or solid)
the shank the handle |
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what does the lock on the handle do
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the baby’s head is not compressed
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what is the purpose of the forceps
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To provide traction in a difficult delivery and facilitate the birth of the fetal head by augmenting the mechanisms of descent or internal rotation
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what are the advantages of forceps
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The shortening of a difficult expulsion stage
Prevention of maternal exhaustion Protection of the fetus Avoidance of a c-section |
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what are the 3 types of forceps operations
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outlet, Low forceps, midforceps
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when is outlet forceps used
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head on pelvic floor
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when is low forceps used
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skull be at station of +2 or more
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when is mid forceps used
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fetal head is engaged, but skull above +2 station
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what are the types of outlet forceps
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Simpsons
Tucker-McLean |
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what is used For the aftercoming head in breech.
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Piper forceps
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what are some contraindications to forceps use
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CPD
fetal position or station is uncertain cervix not fully dilated inadequate anesthesia inexperienced operator |
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what are the risks of forceps delivery
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Trauma to the baby
Trauma to the mother |
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what are the risks of trauma to the baby with forceps delivery
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Forceps marks, small areas of ecchymosis on sides of face
Caput succedaneum or cephalhematoma |
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Trauma to the mother with forceps delivery
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Lacerations
Extension of the episiotomy into the rectum Uterine rupture and atony Infection |
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what is the initial postpartum care for forceps delivery
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Ice pack to treat swollen perineum
Applied for 30 min then removed for at least 20 min before reapplied |
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what is vacuum delivery
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Instrument utilized to assist in delivering the fetus
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the instrument in vacuum delivery consists of what
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Consists of a metal or plastic cup connected by a flexible Silastic or rubber tubing to a vacuum pump
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what is done during vacuum delivery
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Negative Pressure is exerted with the suction pump ~ 50-60 mm Hg and traction applied to fetal head
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what is the most common indicator for vacuum delivery
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a prolonged second stage of labor
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Vacuum extractor cup is applied to what when
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the occiput when head is on the pelvic floor.
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what is applied during a contraction for a vacuum delivery
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traction
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Time of application should not exceed what for vacuum delivery
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30 minutes
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vacuum delivery Can NOT be used before what
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complete dilatation
Membranes must be ruptured |
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what do you reassure parents with a vacuum delivery
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that trauma to baby’s head is transient and will resolve in ~ 48-72 hrs hours
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how is vacuum extraction done
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The cup is placed on the fetal occiput creating suction
Traction is applied in a downward and outward direction Traction continues in a downward direction as the fetal head begins to emerge from the vagina Then pulling with slight upward motion to get head past symphysis pubis. |
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what are contraindications to vacuum extraction
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Non-vertex presentation
CPD < 35 wks gestation |
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what are the fetal risks with a vacuum extraction
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trauma to fetal head
cephalhematoma, caput, scalp lacerations |
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what are the maternal risks with a vacuum extraction
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cervical, vaginal and perineal lacerations
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what are some advantages of a vacuum extraction
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less damage to maternal tissues
less trauma to bladder no absolute need for anesthesia more traction on the fetal head with less pressure exerted on it. Needs less room in vagina, so fewer lacerations |
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what is an episiotomy
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Surgical incision of perineal body to prevent damage to the peri-urethra, perineum, anal sphincter & anus
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when is an episiotomy done
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Performed just before birth
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where is an episiotomy done
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Midline or mediol-ateral
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research suggests what for an episiotomy
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Suggests use during fetal maternal stress, dystocia
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what are some factors that predispose women to an episiotomy
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excessive perineal stretching:
Lithotomy or recumbent position Sustained breath holding during pushing Primigravida Macrosomia Occiput posterior presentation Use of forceps or vacuum extraction |
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repair of an episiotomy may be what
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Repair maybe painful when only a few remaining stitches are required and local is no longer effective
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how can nurse help patient with pain from episiotomy
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Nurse can help pt tolerate pain by placing her hand on patient’s shoulder and distracting patient by talking to her
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what is a cesarean delivery
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Delivery of an intrauterine fetus or fetuses through an abdominal and uterine incision.
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when is a cesarean delivery the method of choice
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when maternal or fetal complication exists that prevents a vaginal birth
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what are some indications of a cesarean delivery
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PIH
diabetes active genital herpes CPD placental complications prolapsed cord breech or transverse lie fetal distress failure to progress repeat C/S |
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what has increase the rate of c/s
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life-style choices
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what are some life-style choices that increased the c/s rates
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women having 1st babies later in life are at higher risk of having C/S
increase in dx of fetal distress by Electronic Fetal Monitor genital herpes repeat c/s increased use of induction and regional anesthesia. |
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what are some psychosocial implications of a c/s
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To some, a C/S may mean failure.
A traumatic delivery such as an emergency c/s may predispose the mother to postpartum depression. |
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what is the management for a c/s
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Prepped as for any other major surgery
Consented by physician, nurse assure it is on the chart Shave, IV, Foley, non-particulate antacid Anticipatory guidance for procedure, recovery phase and role of the partner Lab work on chart and reviewed for abnormalities Lateral tilt—place wedge under a hip, scrub mother’s abdomen Notify nursery personnel Last assessment the nurse should make just prior to the patient being draped for the cesarean is to listen to the fetal heart tones |
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what are the types of c/s incisions
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Low Transverse incision
Vertical incision Classical incision |
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what is a vertical incision
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Midline incision done in lower uterine segment.
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what is a classical incision
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made in the body or corpus of the uterus. Prone to rupture with labor.
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what happens to the fetal lungs with a c/s
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Since newborn’s chest is not “squeezed”, as in vaginal delivery,
lungs are still fluid filled and need more suctioning |
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fluid in fetal lungs with delivery may cause what
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Trainsient Tachypnea of the Newborn “TTN”
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what are some contraindications to Vaginal Birth after Cesarean
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previous T-incision or classic incision, CPD
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what are the guidelines for Vaginal Birth after Cesarean
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One previous C/S with transverse incision
Physician must be immediately available |
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what are the risks of a Vaginal Birth after Cesarean
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hemorrhage, uterine rupture
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what is external cephalic version
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Fetus is changed from breech, transverse, or oblique to cephalic presentation by external manipulation of the maternal abdomen
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when is external cephalic version done
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Done after 36-37 wks
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why is version done after 36-37 weeks
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assure that baby is not born prematurely if version triggers labor
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what is done with an external cephalic version
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Reactive nonstress test
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what are predictors of success for an external cephalic version
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Higher parity
Posterior placenta type of breech or presentation, position of fetal spine |
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what must exist for an external cephalic version to be successful
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Adequate amniotic fluid volume must exist
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Adequate amniotic fluid volume does what
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Eases movement of fetus
provides adequate room for umbilical cord to float without being compressed and preserves cord function and integrity |
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what are some contraindications to an external cephalic version
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Suspected IUGR
Fetal anomalies Abnormal FHR ROM Any condition where C/S is already indicated previa Maternal problems DM uncontrolled HTN amniotic fluid abnormalities |
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what is the nursing management for external cephalic version
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NPO 8 hrs pre-procedure
Explain procedure may be painful Terbutaline sq injection prior to manipulation for uterine relaxation greatly enhances pt comfort Pt may tell Dr to stop if she can’t tolerate the pain Maternal & fetal assessments IV line in case of difficulties Lab work Education & Emotional support |
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what is induction of labor
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Stimulation of uterine contractions before the spontaneous onset of labor, with or without ruptured fetal membranes, for the purpose of accomplishing birth.
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It is ESSENTIAL to determine what prior to any type of elective induction of labor
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Fetal Gestational Age
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how do you determine Fetal Gestational Age
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Ultrasound for fetal measurements
Lung maturity L/S ratio & phosphatidylglyceral (PG) |
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what is the Fetal fibronectin assay
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predicts impending term labor & successful induction
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where is the Fetal fibronectin assay present
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cervicovaginal secretions
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the Fetal fibronectin assay is not typically used when
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Not typically used in term labor due to high cost
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what shows cervical readiness
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Bishop score
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what is the bishop score
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Vaginal exam for cervical & fetal characteristics (0-13
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what are the criteria for the bishop score
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dilation, effacement, consistency and position and fetal station
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what is a 0 dilation score
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closed
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what is a 0 Effacement score
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0-30%
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what is a 0 consistency score
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firm
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what is a 0 position score
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posterior
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what is a 3 point dilation score
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≥ 5 cms
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what is a 3 point effacement score
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≥ 80 %
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what is a 2 point consistency score
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Soft
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what is a 2 point position score
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Anterior
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what is a 0 fetal station score
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-3
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what is a 3 point fetal station score
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+1
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a higher bishop score is what
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more “inducible
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what is a bishop score greater than 9
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Score of ≥ 9 is considered favorable for successful induction
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lower bishop scores correlate with what
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prolonged labor
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what are indications to facilitate labor
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DM, renal disease, preeclampsia Isoimmunization, mild abruptio placenta
PROM, chorioamnionitis fetal demise postterm gestation, macrosomia nonreassuring antepartal testing IUGR, severe oligohydramnios |
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what are maternal contraindications to facilitate labor
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severe HTN,
maternal CVD, genital herpes, cervical cancer, pelvic structure abnormality, previous classic uterine incision, previous myomectomy, |
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what are obstetric complications that contraindicate the facilitation of labor
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Complete placenta previa, vasa previa, abruptio placenta
Vaginal bleeding Polyhydramnios Prolapsed umbilical cord Abnormal FHR: fetal bradycardia Breech, unknown fetal presentation Unengaged presenting part |
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when is the stripping of the membranes done
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Done in office by health care provider @ 38-42 wks
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how is the stripping of the membranes done
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Gloved finger in cervical os rotated 360°x2
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what does stripping of the membranes do
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Separates amniotic membranes from uterus
believed to release PGF2α |
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what is used near or at term when induction is indicated for cervical ripening
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Prostaglandin E2 gel
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what does the Prostaglandin E2 gel do
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Gel softens & effaces cervix
Cervidil, placed in posterior vagina, left in place |
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what are the advantages of cervical ripening
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birth within 24 hours
Easily removed if uterine hyperstimulation Causes ripening shorter labor decrease oxytocic need |
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what are the disadvantages of cervical ripening
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Uterine hyperstimulation
Non-reassuring fetal status increase risk of hemorrhage |
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what is the goal of a pitocin infusion
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Adequate labor pattern
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what is an adequate labor pattern
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UCs q 2-3 minutes lasting 45-90 seconds
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why is an IV piggyback of fluids used with pitocin infusion
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prevents overdose
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what does pitocin do
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Stimulates smooth muscle of uterus and blood vessels causing rhythmic contractions
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what is the half life of pitocin
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Half life is 3-5 minutes
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pitocin is always given how
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Always given IV piggyback, so can be removed quickly while mainline IV continues
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Steady-state plasma concentrations occur after how long with pitocin
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40 minutes doses of ≥20 mu/min
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Steady-state plasma concentrations can cause what
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water intoxication
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what should you do with pitocin infusion
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Mix IV solution : Add 10 u of pitocin to 1000cc LR
1mU/min = 6mL/hr on infusion pump |
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what kind of regimen is a pitocin infusion
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low-dose
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how should you start a pitocin infusion
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: 1 to 2 mU/minute
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how do you increase a pitocin infusion
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increasing by 1 –2 mU/minute every 15-40 min depending on which interval protocol (q 15 min) or (30-40 min) ordered
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what are the dosage limits for pitocin
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20 mU/minute low dose protocol.
40 mu/min for high dose protocol |
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when do you discontinue pitocin
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Fetal distress
Hyperstimulation > 5 UCs/10 min uterus does NOT properly relax between contractions |
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what is the Goal of Active Management of Labor
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Prevent protracted labor and arrest of progress
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a pitocin augmentation is used during labor if what
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several hours have past
contractions are not irregular & not very strong cervical dilation is not progressing and CPD had been ruled out |
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pitocin can be used to do what
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pitocin can be used to strengthen or “augment” labor contractions
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what is the nursing management to facilitating labor
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Client education
Comfort measures EFM, continuous monitoring Labor progress assessments Multigravida w/ UCs q 3 min X 50 sec, mod intensity, with controlled breathing needs to be evaluated BEFORE a primip w/ q 2-4 min UCs talking on phone |
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what is D. Amniotomy
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Artificial Rupture of Amniotic Membranes (AROM)
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a D. Amniotomy is performed as a what
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method of induction
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what is a D. Amniotomy used for
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to accelerate labor any time during 1st stage
to allow placement of EFM scalp electrode to allow fetal scalp blood sampling |
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what are the advantages of an amniotomy
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elicits contractions without the risk of uterine hyperstimulation or rupture as with pitocin infusion
opportunity to evaluate amniotic fluid |
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what are the disadvantages of an amniotomy
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birth needs to occur within 24 hrs due to risk of infection
danger of cord prolapse risk of cord compression increased head molding |
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Prior to performing an
Amniotomy for a labor induction, the following 3 Fetal assessments MUST be made: |
Presentation
Fetal Position Fetal Station |
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what is an amnioinfusion
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Volume of warmed NS or Ringer’s Lactate infused via sterile catheter into uterus to fluid (oligohydramnios)
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what are the indications for an amnioinfusion
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Prevents variable decelerations
Relieves pressure on umbilical cord Decrease meconium aspiration dilutes thick meconium for PTL with PROM |
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what are the contraindications to an amnioinfusion
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hydraminos
fetal or uterine anomalies amnionitis hypertonus multiple gestation placental previa or abruptio placenta |
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Intrapartum amnioinfusion appears to improve outcomes in gravidas with what
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variable decelerations
thick meconium during labor |
