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76 Cards in this Set

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Fetal Position
1st letter- location of the presenting part in the [R]ight or [L]eft side of pelvis.
2nd letter - the specific presenting part of the fetus; [O]cciput, [S]acrum, [M]entum (chin), [Sc]apula (shoulder)
3rd letter - location in relation to anterior. [A]nterior, [P]osterior, [T]ransverse
Ex. LOA, ROA, LOP, ROP, RMT
Factors affecting labor
Five P's
Passenger - (fetus and placenta)
Passageway - birth canal
Powers - (contractions)
Position of the mother
Physiologic response
Presentation
Part of the fetus that enters the pelvis inlet first and leads thru the birth canal during labor at term.
3 main presentations are
cephalic - head first (occiput=vertex)
breech - butt or feet first
shoulder
attitude
the relation of fetal body parts to one another
General flexion - chin flexed on chest; thighs are flexed on abdomen; legs are flexed at knees
Types of pelvis
gynecoid - classic female type (50% of women have this type)
android - resembling the male pelvis (23%)
anthropoid - resemble the pelvis of anthropoid apes (24%)
platypelloid - flat pelvis (3%)
Fetal position - Station
Measures the degree of descent of the presenting part of the fetus through the birth canal in relation to the ischial spines.
0 - is at ischial spines
+4-+5 birth is eminent
engagement
Largest transverse diameter of the presenting part has passed through the maternal pelvic brim or inlet into the true pelvis.

Remember it is the widest diameter of the fetal presenting part to at least a zero station---ischial spines
The way the fetus moves through the birth canal is determined by
Size of the fetal head
Fetal presentation
Fetal lie
Fetal attitude
Fetal position
fetal lie
the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother.
The two primary lies are longitudinal (vertical) and transverse (horizontal or oblique).
dilation
• Opening of the cervix
• Contractions and pressure exerted by the presenting part
• Increases from Long/Thick/Closed to 10 cm
• When the cervix is 10 cm, it can no longer be palpated
• Scarring of the cervix from surgery or infection can slow or inhibit cervical dilation
Effacement
Shortening and thinning of the cervix
• Generally speaking a primigravida’s effacement advances before dilation
• Subsequent pregnancies—effacement and dilation occur together although I have seen
multigravidas dilate first before effacement.
lightening
when the fetus's presenting part descends into the true pelvis. Primigravidas the uterus sinks downward and forward about 2 weeks before term
bloody show
brownish or blood tinged cervical mucous
braxton hicks contractions
strong, frequent, but irregular uterine contractions
-may be a sign preceding labor
back labor
a result of an occiput posterior or transverse position.
-the "all fours" position may be used to relieve the backache and may assist in the anterior rotation of the fetus.
true labor contractions
-occur regularly, becoming stringer, lasting longer and occurring closer together.
-become more intense with walking
-usually felt in lower back, radiating to lower portion of abdomen
-continue despite comfort measures
preterm labor contractions
uterine contractions more frequent than every 10 minutes, persisting for 1 hour or more.
-can either be painful or painless.
-occur between 20-37 weeks gestation
The 3 Stages of labor
First stage- Latent phase (1cm-3cm); Active phase (4cm-7cm); Transition phase (8-10cm)
Second stage - pushing phase (10cm to birth of baby)
Third stage- birth of placenta
Stage One
Latent Phase
• Onset of regular contractions
–Frequency 5-15 minutes apart
–Duration 30-40 seconds long
–Intensity mild to moderate
• Mom’s Behavior
–Excited anticipation
–Mild fear/anxiety
–Relief-It is almost over
Stage One
Active Phase
• Cervix: 4-7 CM (Descent of baby can be rapid)
• Contractions
–Frequency 2-5 minutes apart
–Duration 60 seconds long
–Intensity Moderate to Strong
• Mom’s Behavior
–Increasing apprehension/tension
–Fear of being alone
First Stage
Transition Phase
• Cervix: 8-10 CMs (Stretching Pelvic Sensation)
• Contractions:
–Frequency 2-3 minutes apart
–Duration 60-90 seconds
–Intensity --Strong to Very Strong
• Mom’s Behavior
–Little desire for interaction
–May vomit/shake/shiver/perspire
–Difficulty controlling behavior
Second Stage
• Lasts from the time the cervix is fully dilated to birth of the baby.
• Lasts an average of 1-2 hours for primigravidas
• Lasts an average of 10-60 minutes in multiparous
• If she has an epidural and the mom-baby unit is stable may last 4-5 hours
• Laboring down is GREAT!!!!
mechanisms of labor
cardinal movements that occur in a vertex presentation are:
engagement
descent - the degree is measured by station
flexion
internal rotation
extension
restitution and external rotation
expulsion of the infant
Mechanism of Labor -
1. engagement
–Presenting part is reaches the level of the ischial spines and is encircled by the bony pelvic inlet
Mechanism of Labor -
2. Descent
–Progress of the presenting part through the pelvis
• Measured by station
Mechanism of Labor -
3. Flexion
–Chin is brought into closer contact with the chest
Mechanism of Labor -
4. Internal rotation
–Turns to fit through the ischialspines
Mechanism of Labor -
5. Extension
–Head and neck ease under the pubic bone and emerge
Mechanism of Labor -
6. Restitution/External Rotation
–Once outside the introitusthe head will rotate to realign to his/her original position
Mechanism of Labor -
7. Birth/Expulsion
–The rest of the body is birthed
–Birth is complete
–Time of birth is recorded
–Second stage ends
Nursing care during First stage of labor
• Monitor maternal vital signs
• Monitor uterine activity
• Monitor fetal heart rate
• Vaginal show
• Monitor behavior, mood and energy level of mother and partner
• Vaginal examinations to assess labor progression if per hospital protocol
Nursing care during Second stage of labor
• Monitor BP more frequently
• Promote comfort level of mom
• Position changes
• Monitor fetal well-being
• Prepare for birth—delivery set up
• Update/Call Midwife/Physician
• Update Staff for Baby Nurse and/or NICU
Positions used in Labor -
Back Labor
-Hands and knees position
-All fours; allows for pelvic rocking.
-relieves backache
-facilitates internal rotation of the fetus by increase mobility of the coccyx, increasing the pelvic diameters and using gravity to turn the fetal back and rotate the head.
-can also use the trendelenburg position or squatting position to help rotate head
Positions used in Labor -
Cord prolapsed
place woman in extreme trendelendburg position or knee-chest position (Sim's)
-to take pressure off the cord and get more oxygen to the fetus
positions used in Labor -
speed up labor
Upright position (walking, sitting, kneeling, or squatting) is useful. Gravity can promote the descent of the fetus and the uterine contractions are generally stronger and more efficient in effacing and dilating the cervix resulting in shorter labor.
positions used in Labor -
Cord prolapse
Modified Sim's, trendelenburg or knee-chest position, in which gravity keeps the persenting part off the cord.
positions used in Labor -
epidural
for placement- sitting or in a modified Sim's position
after placement - woman is preferably positioned onher side that the uterus does not compress the ascending vena cava and descending aorta, which can impair venous return, reduce cardiac output and decrease placental perfusion.
during 2nd stage- usually lithotomy
positions used in Labor -
late deceleration
change to a lateral position to allow for placental perfusion.
PROM
-premature rupture of membranes
• Rupture of the amniotic sac and/or leakage of amniotic fluid at
least 1 hours before the onset of labor at any gestational age
PROM treatments
– Goal is to prevent infection
– Hospitalization
– Bedrest
– Hospitalization
– Bedrest (depends on many factors)
– Frequent FHR and UC monitoring
– Maternal vital signs every 4 hrs.
– Track Amniotic Fluid via a pad count
– Prophylactic antibiotics
PROM assessments
• Nitrazine
– pH strip turn blue (6.0-6.5)
– False positives if woman has infection or has had sex in the
last 12 hours
• Fern Test
– Must have a microscope
– Must use a slide without the cover
– Must be dry, looks like a fern (salt H2O)
PROM complications
Infection is most serious side effect; Can precipitate cord prolapse
Preterm Labor
-Uterine contractions 5 or more per hour
-Lower abdominal cramping
-Dull intermittent lower back pain
-Bloody show or leaking of fluid
Preterm Labor Risk Factors
-Regular uterine contractions causing cervical changes between 20 & 37 weeks
-Infections
-Age < 17 or > 35 years
-History of previous preterm labor or birth
-Cervical incompetence
-Multifetal pregnancy
-Hydramnios
-PIH
-Poor nutrition
-substance abuse
-PPROM
Preterm Labor Prevention
- Bedrest
- No sexual activity
- Tocolytic medications
Preterm Management (drug therapy)
- Procardia
- Magnesium sulfate
- Terbutaline
- Prostaglandin Inhibitors
Betamethasone: Given when preterm birth is threatened; stimulates fetal lung maturity
24 to 34 weeks: Monitor maternal hyperglycemia and Pulmonary Edema.
Epidural
Nerve block that can be a single injection or continuous pump
Advantages:
• Excellent pain relief
• Partial but not full leg paralysis
• Flexibility in dosing
Epidural complications
• Marked hypotension
• Impaired placenta perfusion
• Ineffective breathing pattern
• Bladder Atony
• Uterine Atony
Epidural Interventions
• Bolus of IV Fluids
• Lateral positioning
• Frequent vital signs, including monitoring labor
• Continuation of fetal monitoring
• O2 available
• IV Vasopressor available (Ephedrine)
• O2 available
• IV Vasopressor available (Ephedrine)
• Mom must void in bedpan or with indwelling Foley or straight
catheter (red robin)
• Bedrest until sensation returns.
pudendal block
“Saddle Block”; Relieves pain in lower vagina, vulva and perineum
- Must be administered 5 - 10 minutes prior to be effective
-does not change maternal hemodynamic or resp functions, VS or FHR; but the bearing down reflex is lessened or lost completely
Cesarean - Indications
-consistent abnormal FHR and pattern
-CPD
-malpresentations (breech, shoulder)
-placental abnormalities (previa, abruptio)
-umbilical cord prolapse
-dysfunctional labor pattern
-multiple gestation
-medical factors -HTN disorders, active genital herpes, positive HIV status, diabetes
Cesarean complications - maternal
aspiration, pulmonary embolism, wound infection, wound dehiscence, thrombophlebitis, hemorrhage; UTI, injuries to bladder, ureters or bowel and complications to anesthesia
Cesarean complications - infant
Fetus may be born prematurely if gestational age has not been accurately determined
Placenta Previa
Bright Red Blood
Painless
Uterine tone WNL
No clotting defects
Fetus often stable
High risk of PPH
Placenta Abruptio
Dark Red Blood
Uterus/Abdomen very painful, tender
Signs of shock
Fetal Distress
Clotting defect possible
PIH associated
Substance Abuse
Episiotomy
-1st degree - through the skin only
-2nd degree - through the muscles (need to repair)
-3rd degree - through the anal sphincter
-4th degree - through the rectal mucosa into lumen of the rectum
Purpose of episiotomy
made to enlarge the vaginal outlet.
-good nutrition, and appropriate hygienic measures help to maintain the integrity and suppleness of the perinal tissue, enhance healing and prevent infection.
Fetal monitoring - normal HR for fetus
110 - 160 bpm
baseline FHR
-the average rate during a 10 minute segment that excludes accelerations, decelerations and periods of marked variability.
-there must be at least 2 minutes of baseline segments in a 10 min segment.
Variability
– Absent—undetectable
– Minimal—>undetectable to <5 beats/minute
– Moderate—6 to 25 beats/minute
– Marked-->25 beats/minute
Early decelerations
a visually apparent gradual decrease and return to baseline FHR associated with UCs.
-Head compressions caused by UCs, vag exam, fundal pressure, placement if IUPC
-sometimes referred to as the "mirror image" of a contractions.
Early decel interventions
benign so therefore interventions are not necessary.
Variable decelerations
• Variable
– Visual abrupt decrease in FHR
– Umbilical cord compression
– Looks like “V’s”, “U’s” or “W’s”.
-repetitive variable decels indicate a recurrent disruption in the O2 supply of the fetus.
-occasional var. decels have little clinical significance.
Variable deceleration interventions
-change positions (side to side, knee chest)
-d/c pitocin
-administer O2
-assess for cord prolapse
Late decelerations
-gradual decrease in and return to baseline FHR.
-caused Uteroplacental insufficiency caused by:
maternal supine hypotension
epidural or spinal
placenta previa or abruptio
HTN disorders
postmaturity
IUGR
Diabetes
Intraamniotic infection
Late decel interventions
-change position (lateral)
-correct maternal hypotension by elevating legs
-increase IV fluids
-d/c pit
-assess for tachysystole
-consider internal monitoring
-prepare for deliver (svd or c/s)
periodic
occurs with a contraction
episodic
occurs independent of a contraction
pitocin and FHR pattern
if pit produces tachysystole it may reduce the blood flow thru the placenta and result in FHR changes such as bradycardia, tachycardia, decreased or absent baseline variability, late decelerations.
accelerations
can be caused by occiput posterior and breech positions
PPH risk and causes
uterine atony
laceration in birth canal
retained placental fragments
ruptured uterus
inversion of uterus
placenta previa or abruptio
mag sulfate during labor or PP
uterine atony causes
overdistended uterus
anestheisa and analgesia
previous Hx
high parity
prolonged labor, oxytocin induced labor
trauma during labor and birth - forceps, vac, c/s
meds used for PPH
oxytocin
Methergine
prostaglandin
cytotec
-all used for contraction of uterus
-monitor bleeding and uterine tone
Nursing care for PPH
-massage fundus
-empty bladder and monitor output
-IV access
-admin meds
-notify primary
-fluid/blood replacement
-provide discharge instructions
-observe for delayed/insufficient lactation and PPD
Emotional responses to PPH
- promote maternal/infant bonding
- promote breastfeeding
- monitor return of sensory perception (from epidural)
- monitor for thrombophlebitis
- provide food and fluids