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260 Cards in this Set
- Front
- Back
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when is rhogam given and to whom
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rhogam given at 24-28 wks to all Rh- moms having an Rh+ baby to protect future pregnancies against Rh incompatibility
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How often do we want to see moms?
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every month until 28 wks, then every 2 wks until 36 wks, and then every wk until delivery
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signs of HTN in moms
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unrelenting headaches/visual disturbances
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how many fetal movements per 12/hrs do we want
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10-12
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what is the most common cause of preterm labor?
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UTI - pain, burning, urgency
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what is it called when dads get pregnancy symptoms too such as cravings?
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couvade
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maternal response psychologically in first trimester
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1. primary focus is on herself (maybe because vomiting from HcG), 2. mom may also present uncertainity and ambivalence
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maternal response psychologically in 2nd trimester
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pregnancy begins to feel real, mom accepts pregnancy, WIDE mood swings of joy anticipatiomn and fear, ULTRASENSITIVE MOM, quickening occurs (mom feels baby kicking) and now focus becomes the BABY. mom may be introverted abt ability to care for herslef and her baby. issues with body image and sexuality. fantasizes about what baby will be like, encourage childbirth ed classes
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3rd trimester maternal responses psychologically
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mom is vulnerable and dependant. getting nervous abt labor and really preparing for the birth - nesting occurs - mom goes to childbirth ed classes. nurse should talk to mom and dad about good positive communication with spouse, mom is introverted and self absorbed
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Nursing interventions at 8 wks gestation
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Prepare client and husband for pregnancy, discussing attitudes toward pregnancy, talk abt value of early pregnancy classes and give info, include dad
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12 wks gestation nursing interventions
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teach prevention of common discomforts and prevention of UTI, start to discuss effects of pregnancy on sexual relationship, recognize fathers role,
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ways to prevent UTI
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adequate fluids, void every 2 hrs while awake, void before and after intercourse, wipe front to back (hygiene)
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20 wks nursing interventions
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encourage to remain active, teach common discomforts, many maternal changes ocurring, teach about supine hypotension and turning to left later or knee chest
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maternal changes during 20 wks gestation
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quickening is occuring, pregnancy becomes real to mom, postural hypotension so teach mom to lay in lateral position, fundus at umbilicus, breasts secrete colostrum, brest changes, amniotic sac holds 400 mL or .4 L
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32 wks nursing interventions
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teach comfort measures like wearing supportive bra and proper posture, teach to decrease edema by keeping feet elevated or using natural diuretics, semi fowelers position to decrease dyspnea
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when is fundus at the xiphoid process?
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36 wks
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38 wks nursing interventions
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safety measures such as low healed shoes, no heavy lifted, sleep on side, labor prep exercises. Now talk about after delivery like choosing a pediatrician, touring L&D, circumcision, feeding infant, PP blues
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interventions during 3rd trimester
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birth plan, signs of labor, transportation, plans for other kids
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ultrasound is usually a screening T or F
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true
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Types of prenatal testing that classifies as screening: will require future tests
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1. ultrasound screening. 2. alpha fetoprotein screening AFP, 3. multiple marker screening, 4. antepartum surveillance
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types of prenantal tests that classify as diagnostic
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1. ultrasound diagnostic. 2.CVS diagnostic (chorionic villi sampling. 3.AMniocentesis. 4. PUBS.
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maternal risk factors to recommend prenatal testing
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1. maternal age <17 or >34.
2. multiple gestations 3. high parity >5 4. HTN or preclampsia 5. Rh incompatibility 6. dystocia or C section previously 7. maternal medical disease during pregnancy 8. malnutrition (over or underweight) 9. infection during pregnancy |
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dystocia
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abnormal or difficult childbirth
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multiple gestations
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multiple babies per pregnancy like twins or triplets
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malnutrition as a maternal risk factor
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underweight 15% under ideal weight, or overweight 20% over ideal weight
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Description of ultrasound
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high freqeuncy sound waves on abdomen, echoes returned recording location and size of fetus
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reasons for ultrasound in first trimester
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1. to confirm EDC., 2. to confirm number of fetuses. 3. to detect presense of fetal heart beat. 4. to detect uterine abnormalities
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reason for ultrasound in 2nd and 3rd trimesters
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to locate the placenta, growth scans to assess IUGR vs wrong dates, determine amnitoic fluid volume, confirm viability, Biopysical profile
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Why is a biophysical profile conducted BPP
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to assess fetal wellbeing
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IUGR
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intrauterine growth restriction
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Nursing care/interventions for ultrasound
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1. need full bladder during 1st and 2nd trimesters because fetus is small. 2. instruct to drink 3-4 glasses of H20. 3. position pillows under knee and neck to keep pressure off bladder. 5. position display so woman canwatch. 6. have bathroom immediately available
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BPP facts
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1. ascertains fetal wellbeing, 2. assesses 5 variables. 3. each variable worth 2 points for total of 10. anything under 8 is cause of concern. 8-10 is reasuring. 6 points is equivocal. under 6 DELIVER NOW
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5 variables assessed in BPP for fetal well being
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1. fetal breathing movements (we want 1 or more lasting 30 seconds).
2. gross body movements. 3. fetal tone (flex/extend) 4. reactivity of fetal HR 5. amniotic fluid volume ( we want 1 or more pockets measuring 2 cms) |
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A BPP is done to assess fetal wellbeing and achieves a score of 6. what can the nurse anticipate?
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This number is equivocal, open to interpretation of the physician. 8-10 is a reasuring number. under 6 is immediate delivery
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Doppler flow studies
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less commonly used- purpose to see 4 chambers of the heart/cardiac structure and umbilical vessel flow to check for placental insufficiency mainly in woman who are HTN or fetal growth restriction IUGR
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A pregnant woman comes in with HTN and intra-uterine growth, what kind of test will most likely be done and why
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Doppler flow study to asses 4 chambers of heart and determine umbilical vessel flow to see if there is placental insufficiency
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What is the main component in fetal plasma?
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Alhpa fetoprotein AFP
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WHat happens in an AFP test
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draw blood from mom because some AFP crosses placenta from babys plasma and can be detected in maternal blood. When we look at markers of MSAFP (maternal serum AFP) we can see elevated levels or lower levels may indicate abnormalities and then they will go for further diagnositc testing.
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Low levels of AFP in maternal blood is most likely
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Down Syndrome
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Elevated levels of AFP in maternal blood is most likely
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Open nerual tube defect NTD
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Multiple marker screening
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like an AFP test but looks for much more - still a screening test, can be a triple screen or quad screen - done at 16-18 weeks
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Benefits and Limitations of CVS and amnio
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CVS Can be done between 8 and 12 (book) and 10-12 (teacher) weeks' gestation, with results returned in 2 days 28 hrs, which allows for decision about termination while still in first trimester. Amnio is done later on like 14-16 wks or after 35 weeks.... BUT CVS cannot replace an amniocentesis, detect AFP, or Rh Disease while an amnio can look at AFP to show risk for down syndrome or NTD and can also treat rH disease and asses L:S ration for fetal lung immaturity
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two types of CVS
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transcervical or transabdominal
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WHen is a CVS performed and WHY?
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performed at 8-12 or 10-12 wks under ultrasound guidance to detect chromosomal disorders, enzyme deficiencies, fetal gender, sex linked disorders and autosomal recessive disorders.
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WHen is an Amnio done and WHy?
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amnio can be done earlier in pregnancy at 14-16 wks or later in pregnancy after 35 wks. why? early its to detect chromosomal disorders, trisomies, sex linked, metabolic disorders AND AFP. Later in pregnancy it is to assess lung-surfactant ratio and rH isoimmunization.
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what is the L:S ration demonstrating fetal lung maturity
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2:1
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Risks/Benefits of amnio
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painless from local anestesia and relatively safe and simple procedure. risks are SAB .5% or less and risk for infection or fetal injury. Also RH - moms always need RHOGAM for an amnio to prevent sensitization
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PUBS: percutaneous umbilical blood sampling
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done after 16 wks, collect blood directly from umbilical cord vessel. fine needle is inserted intra-abdominally.
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why is PUBS most commonly used?
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management of RH disease, intrauterine fetal blood transfusions, also to get CBC bloodtype, risk of fetal infection, chromosomes etc.
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important nursing interventiomn after diagnostic prenatal testing like CVS, amnio and PUBS
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monitor FHT and for contractions 1 hr after procedure to assess for uterine contractions, vaginal bleeding, and fetal wellbeing
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RH neg moms must get rhogam before amnio, PUBS or CVS true or false
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TRUE
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Risks of PUBS
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fetal loss, fetal bradycardia, infection, cord laceration/cord hematoma, preterm labor, premature ROM
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Types of antepartum surveillance which just involves putting moms on monitors
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1. NST (non stress test)
2. Vibroacustic stimulation 3. CST contraction stress test 4. BPP 5. Kick count |
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WHat is the easiest and most cost effective method of antepartum surveillance?
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Kick count - mom can do this at home - record how many times baby kicks throughout day. we want 10-12/12 hr period or more than 3 kicks in 1 hr.
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WHen and why is an NST done
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NST done after 28 wks for high risk pregnancies such as HTN, diabetes, IUGR, twins and post date testing or with concerns abt fetal movement. All we assess with NST is fetal heart rate and contractions and it is just an external monitor like in L&D
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A mom has a reactive NST, is this good or bad?
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GOOD. reactive is good. nonreactive is bad.
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Reactive NST
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1) 2 FHR accelerations above baseline.
2) HR up 15 pbm for 15 secs 3) within 20 minute time frame 4. vibroacustic stimulation buzz for 3 secs wakes baby. A non reactive non stress test means this criteria is not met after 40 mins |
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Contraction stress test CST is also called a
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OCT - oxytocin challenge test
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when do you do a CST or OCT and what is it?
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if a 20 min NST is non reactive we actually want to induce contractions without causing labor - 3 contractions lasting 40 seconds in 10 mins. We induce contractions by nipple stimulation or oxytocin via IV piggy back.
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T or F ; maternal reporting of fetal kicks is as valid as formal counting and documentation of fetal movement
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TRUE
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baseline fetal HR should be
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110-160.. anything less than 100 is bradycardia. >160 is tachy
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variability
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irregularity of cardiac rhythym. this is a good thing! absent irregularity is a problem. We WANT 6-25 bpm irregularity which is MODERTATE variability.
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a nonreassuring variability
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absent is nonreassuring and so is minimal variability less than 5 bpm.
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external monitor of FHR
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ultrasound device strapped ontp abdomen -
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internal monitor of FHR
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scalp electrode placed on fetal head - required ROM and physician procedure - gives more accurate reading
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uterine activity is measured by
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1. frequency
2. duration 3. intensity |
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Interpreting monitor strips: Periodic FHR changes
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VEAL CHOP
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V - C
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Variable decelerations caused by Cord Compression (reduced blood flow thru umbilical cord) --- nursing intervention is to get pressure off cord so change maternal position, increase fluid IV to get blood flow to fetus and possibly think about amnioinfusion
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E - H
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Early Decelerations = Head Compression (requires NO nursing intervention) = mirror images of contraciton - occur in active labor between 4-7 cm and in second stage of labor (during pushing)
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A - O
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Accelerations = OK
temporary increase in FHR is reassuring associated with fetal movement = 15 bpm for 15 secs |
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L = P
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Late decelerations = PROBLEM
- reflects possible impaired placental exchange - utero placental insufficiency - requires nursing intervention to improve blood flow and fetal oxygen supply = turn PITOCIN OFF, give O2, IV open, notify provider, position change |
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what kind of variability would require nurse to give O2 and change position
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Late decelerations which indicate a problem, baby not getting enough blood and oxygen from placenta
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Premonitory signs of labor - giving a forewarning
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1) braxton hicks, 2) bloody show 3) small weight loss 4) energy spurt 5) lightening, 6)increase in clear and nonirritating vaginal secretions
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Effacement
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thinning of cervix in percentage. pushing begins when 100% effaced and 10 cm dilated
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bloody show
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mucous plug
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no one knows what mediates labor - t or f
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TRUE
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True vs False labor
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true labor is pain that begins in lower back and radiates to abdomen. false labor is discomfort localized to abdomen. true labor pain is accompanied by regular rhythmic contractiosn while false labor has no contractions. true labor contractions get worse when ambulating when false labor improves when walking.with true labor there is cervical dilation and effacement.
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Components of the birthing process - 4 Ps
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1. powers
2. passage 3. passanger 4. psyche |
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Power or labor
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uterine contractions and maternal pushing effort - strength/intensity, duration and freqeuncy
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true labor = cervical change TorF
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True
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Passage/Passageway
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- maternal pelvis and soft tissues. the bony pelvis is false while the true pelvis is the portion thru which the baby must travel.
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3 planes to the true pelvis
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1. pelvic inlet
2. mid pelvis (ischial spines) 3. pelvis outlet |
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ideal pelvic shape for birth
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Gynecoid (50% of women, rare in men)
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which pelvic shape is least common and will most likely require c section
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platypelloid (less than 5% of population
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which pelvic shape will require difficult birth
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Android heart shaped- 20% of women also common men
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Which pelvic shape is most common in men, 20-30% of women, vaginal birth but usually back labor with posterior presentation?
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Anthropoid aka oval shaped
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Passanger
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molding, attitude, presentation, position/fetal lie, station, engagement
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Molding
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Shaping of the fetal head during movement through the birth canal. molding is allowed by the fontanels that allow the babys head to shape to the birth canal. Molding refers to changes in the shape of the head from overriding of cranial bones at the sutures. It occurs most often in infants born vaginally and allows the head to pass through the birth canal more easily. The condition usually resolves within a few days to a week after birth.
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Attitude
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flexion of babys neck - Relationship of fetal body parts to one another, such as flexion or extension. flexion of neck is normal while extension is abnormal
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Presentation
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Whats presenting to outlet first. The fetal part that enters the pelvis first is the presenting part. Presentation falls into three categories: (1) cephalic, (2) breech, and (3) shoulder. The cephalic presentation with the fetal head flexed is the most common
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Position/fetal lie
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landmark on the babys body - baby's spine related to mom's spine- Fetal position describes the location of a fixed reference point on the presenting part in relation to the four quadrants of the maternal pelvis ----Right (R) or left (L).
The first letter of the abbreviation describes whether the fetal reference point is in the right or the left of the mother's pelvis. If the fetal point is neither to the right nor to the left of the pelvis, this letter is omitted. Occiput (O), mentum (M), or sacrum (S). The second letter of the abbreviation refers to the fixed fetal reference point, which varies with the presentation. The occiput is used in a vertex presentation. The chin, or mentum, is the reference point in a face presentation. The sacrum is used for breech presentations. Letters may also designate the less common brow (F for fronto) and shoulder (Sc for scapula) presentations. Anterior (A), posterior (P), or transverse (T). The third letter describes whether the fetal reference point is in the anteri |
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station
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relationship of presenting part to the ischial spines - Measurement of fetal descent in relation to the ischial spines of the maternal pelvis.-- Ballotable = -4 (babys head hasnt entered pelvis)... 0 station is engagement. +4 is baby is crowning
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Engagement
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Descent of the widest diameter of the fetal presenting part to at least a zero station (level of the ischial spines in the maternal pelvis).
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Anterior fontanelle
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diamond shaped - closes 12-18 mos
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posterior fontanele
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triangular shaped - closes 8-12 wks
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what is the purpose of suture lines/ fontanelles
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importance of a well flexed head to decrease biparietal diameter
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military attitude
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neither flexed nor extended - difficult delivery
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Leopold's maneuvers
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used to determine fetal position and lie
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cephalic/ head/ occiput is also termed
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vertex = 95% of births
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breech accounts for what percentage of births
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3%
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different kinds of breech presentation
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1) frank (diver
2) full breech (knees tucked up) 3) single footling/double footlinjg |
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2 % of births presentation is
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shoulder presentation
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Ballotable
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babys head has not entered the pelvis - station is Neg 4 -4...
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Crowning
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+4
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0 station
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engagement babys head enters pelvis- largest part of the baby has engaged or passed thru most narrow part of moms pelvis.
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engagement for primigravidas
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38 wks
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engagement for multiparas
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engage in labor
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Cardinal movements of labor
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engagement, descent, flexion, internal rotation, extension, external rotation, expulsion
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Psyche
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birth affects the whole way mom thinks of herself - lasting effects - RN has a role to provide a positive birthing experience by giving clear information, positive support, encourage self confidence, trustworthiness, breathing exercises, anticipitory guidance
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#1 most important aspect of RN role in promoting a positive birth experience to facilitate psyche of mom
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TRUSTWORTHINESS
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Anticipatory guidance
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Providing the family with information on what to expect regarding a future event, a potential problem or issue, or a child's next developmental phase.
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Stages of labor
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Stage 1: dilating can be 12 hrs phase 1) latent = beginning of true labor to 4 cm , phase 2 active = 5 to 7 cm, phase 3)transition = 8 to 10 cm
Stage 2: pushing after dilated 10 cm. 10 cm to deliver can be 2/12 hrs max 3 stage 3: delivering placenta: organ must separate from uterine wall so no hemmorhage stage 4: 1-4 hrs post partum aka recovery period |
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when do mom get pain meds in labor?
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4-5 cm so end of latent phase beginning of active phase of stage 1.
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what is a factor that will slow down stage 2
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epidural because mom doesnt know where to push and doesnt feel the involuntary urge
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when is pitocin turned on and off?
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pitocin on. turned off once crowning in stage 2. no pitocin during placenta delivery. pitocin turned back on stage 4 post partum
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Nurses often perform vaginal exams throughout labor with sterile gloves to assess cervical dilation, effacement, consistency (soft or firm), fetal station and fetal presentation. Why are vaginal exams limited once there has been a rupture of membranes?
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once ROM, no longer sterile so we want to prevent infection.
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Bishops score
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scoring tool used to measure cervical readiness (favorable for induction/labor)
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categories of bishops score
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1. cervical dilation
2. cervical effacement 3. cervical position 4. cervical consistency 5. fetal station. score >8 = readiness for labor/ 0-3 points per category |
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Nursing care in stage 1 latent phase
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obtain baseline NST 20 mins
FHR and contraction every hour maternal vitals every hour BP between contractions temperature every 4 hrs if membrane in tact temperature every 2 hrs if ruptured mom doesnt have to be on monitor bc we cant determine veal chop so mom can ambulate |
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nursing care stage 1 active phase 5-7 cm
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FHT and cx every 30 mins
assess bladder fullness ever 1-2 hrs straight cath if needed epidural usually given in active phase N&V breathing techniaue, effleurage |
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hyperventilation during active phase of stage 2 of labor
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hyperventilation results in respiratory alkalosis, sx include dizziness,and tingling of fingers - have woman breathe into cupped hands or paper bag
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nursing care stage 1 transition phase 8-10 cm
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vaginal exam to assess cervical dilation
ass vitals every 15 mins, and FHR and cx every 15 mins. |
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when do we call provider?
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during stage 1 transition stage at 8 cm
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Stage 2 pushing nursing care
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only push if cervix dilated fully. assess FHR 15 mins and vitals. set up delivery table, turn on infant warmer, observe for crowning, help position mom for pushing
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laboring down
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if pt. epiduralized she may not feel urge to push. mom can go sleep for 1 hr to rest and allow descent to ocurr naturally
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stage 3 nursing care
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make sure pitocin is D/C during placental delivery and start pitocin IV or IM after placental delivers. take maternal BP. observe for EBL
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EBL
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estimated blood loss
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nursing care stage 4
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cleanse perineal area. ice or cold pack. give pitocin or methergine or hemabate to stimulate uterine contractions and prevent hemmorhage-- encourage attachment, breastfeeding, assess bladder distention, PP assessments, fundus, lochia, bed rest
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When to never give methergine or hemabate
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methergine contraindicated w HTN
hemabate contraindicated w asthma |
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why bed rest 1-2 hrs after delivery?
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to prevent orthostatic hypotension
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nursing priority post partum
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prevent post partum hemmorage 24 hours during recovery
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2 benefits of breast feeding after delivery
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1. encourage bonding and attachment. 2. contraction of uterus to prevent hemmorhage 3) baby is most awake
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how often in stage 4 do we do post partum assessment / bubblhep
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every 15 mins X1 hr... every hr for 4 hrs. then q shift
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most common reason for uterine atony or hemmorhage in first 24 hrs after delivery
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full bladder - therefore rn must always assess bladder
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physiological effects ocurring with pain
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increase demand for oxygen and altered placental exchange of O2 and CO2, increase production of catecholamines like epi and norepi, cortisol and glucagon. less oxygen/waste exchange for fetus...
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types of pain
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visceral pain: from uterine contractions - deep slow pain poorly localized - first stage of labor with uterine contractions (tissue ischemia) and cervical dilation.
somatic pain: faster sharp pain precisely located - knife stabbing - transition phase stage 1 and stage 2 - stretching of vaginal canal (fetus putting direct pressure on maternal tissues/distention of vagina and perineum) |
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psychological effects of excessive pain
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no interaction with infant, unpleasant memories, inadequate feelings of partner
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Nonpharmacologic Pain management techniques
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effleurage, CAM(contemporary alternative medicine) like accupressure on back, breathing and relaxation techniques like imagery, whirpool or warm bath not above 98 degrees) environment (soft music, soft lights, birthing ball, presense of doula), general comfort like cleaning up mom to keep warm and dry, education to reduce fear and give anticipitory guidance, presence of other for support.
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Breathing techniques
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stage 1:
laten phase is slow paced breathing and modified shallower faster at peak of contraction. active phase is patterned paced breathing like hee hee hoo. transition phase breathing short puffs when urge to push is strong bc cervix not fully dilated. stage 2: deep cleansing breath and then at peak of contraction open glottis grunting and bearing down for full count of 1 to 10 repeating 2 to 3 times a contraction |
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ways that pharmacologic meds affect the fetus
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1. decreased fetal heart rate variability
2. depressed respiratory if given too late in stage 2 |
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if pain meds given too late in stage 2 what do you do?
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have narcan/naloxone or naltrexone/trexan ready (narcotic antagonist) to reverse respiratory depression in newborn
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When is anestesia/analgesia given in labor
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5-6 cm in active phase of stage 1 to reduce risk of slowing labor progress.
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Opiod analgesics given in labor
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1. Demerol (meperidine) 12.5-50 mg q 2-4 hrs IV
2. Sublimaze (Fentanyl) 50-100 mcg commonly used with epidural 3. Stadol *Butorphanol) 1 mf every 3-4 hrs 4. Nubain (nalbuphine) 10 mg every 3-6 hrs |
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adjunctive potentiator drugs given in labor
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Phenergan (promethazine) 12.5-25 mg every 2-4 hrs iv slow push
Vistaril (hydroxyzine) - 25-100 mg IM z track |
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narcotic antagonists ready to give if in 35 mins baby comes out after narcotic and is respiratory depressed.
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1. Narcan (Naloxone)
2. Trexan (Naltrexone) |
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standing order narcotics
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Stadol, Demerol
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Analgesia nursing care
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1. document baseline maternal VS and FHR prior to adminstering narcotics.
2. assess phase of labor (vaginal exam) 3. determine clients desire for analgesia and support informed choice 4. obtain MD or CNM order for meds that are not standing order 5. administer med IV first choice (IM second choice) no PO meds. 6. recond maternal response and pain relief after administration 7. monitor maternal VS, FHR and cx every 15 mins for 1st hr following narcotic administration. 8. decrease environmental stimuli 9. monitor bladder for distention 10. assess for labor progress and possibility of precipitous delivery, need for narcan at warmer bed. |
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why dont we give po meds to mom in labor?
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decreased GI absorption and motility
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How should we give IV meds during labor?
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IV push slowly at beginning of contraction to decrease amt of medication to placenta
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IM vs IV narcotic administration during labor
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IV: quicker onset, shorter duration. onset 5 mins, peak 30 mins duration 1 hr.
IM slower onset, longer duration. onset within 30 mins, peak 1-3 hrs, duration 4-6 hrs. |
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types of regional pain management during labor
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1. epidural block
2. intrathecal opiod analgesics 3. subarachnoid (spinal) block |
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Epidural (regional) block
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local anastesia into epidural space between dura matter and spinal cord - great relief.
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Risks of epidural block
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1. maternal hypotension (low BP)
2. vasodilation from sympathetic nerve block 3. prolonged 2nd stage of labor 4. migration of the epidural catheter |
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spinal (subarachnoid) regional anestesia
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for c sections, spinal headache is most common risk, blood patch (10-15 mls of womans blood into epidural space)
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why does spinal headache occur during c section subarachnoid regional anestesia
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leakage from CSF
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epidural blocks nerve impulses from
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T10-S5
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reason for epidural block
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relief of perineal and uterine pain.
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maternal hypotension with epidural block
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may cause maternal and fetal distress. before epideral administration, must give at least 1 L isotonic IV fluid. monitor maternal BP every 1-2 mins for first 15 mins after inserting meds. monitor fetal heart tones closely for decelerations due to maternal hypotension.
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when can we not offer epidural?
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maternal BP <100/70
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why is epidural associated with prolonged second stage
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decreased effectiveness of pushing because mom loses sensation for urge to push
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complications of epidural
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1. maternal hypotension
2. common persistent OP (occiput posterior position) 3. stopping continuous infusion in second stage beginning to increase effectiveness of pushing. 4. allow mom to labor down until fetus decends further into vaginal canal at +2 or 3 station before having mom push. 5. regional blocks commonly associated with forceps or vacuum extraction secondaryu to inability to push effectively |
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nursing implications with epidural insetion
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1. empty bladder before insertion
2. witness informed consent 3. prehydrate with at least 500 cc isotonic fluid, usually 1 L. 4. assist with positions, dont want flat on back because maternal hypotension risk 5. rotate patient every 1 hr from side to side to ensure even block and prevent pooling 6. continuously monitor FHT 7. matrernal vital signed evbery 15 mins after initial dose. 1-2 mins first 15 mins 8. assess bladder distension every 2 hrs, catheterize 9. assess level of pain with dull object every 1 hr |
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how often do we monitor FHT with eidural block
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continuously
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what is first sign that epidural is working
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warmth and tingling in ball of foot or big toe
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what stages of labor can epidural be used?
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all stages
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when is epidural contraindicated
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maternal hypertension <100 /><95000, bleeding disorder, allergies to caine drugs, CNS disorders like MS or parkinsons, spinal disorders like scoliosis
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spinal disorders will have to receive general anestesia. t or f
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true
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nursing actions if hypotension occurs with epidural
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1. turn client to left side
2. increase IV solution 3. begin oxygen 8-10 L/min via mask 4. notify health care provider 5. assess FHT 6. ephedrine at bedside |
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what are first signs of hypotension with epidural block
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nausea and vomiting
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what is the antidote for epidural is blood pressure drops too mcuh
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ephedrine
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intrathecal opiods
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subarachnoid space, no motor block allowing woman to ambulate during labor
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spinal block (subarachnoid space)
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C section
insert opiod into subarachnoid space. single dose. woman loses both motor and sensory function below level of block. adverse effects are maternal hypotension, bladder distension, spinal headache. |
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similarities between epidural and spinal
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maternal hypotension, bladder distension are risks
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differences with epidural and spinal
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epidural is not used for C section. Epidural can have single blous dose or continuous IV pump. straight cath with epidural, foley with spinal. epidural goes into epidural space between dura mater and spine. spinal goes into subarachnoid space. epidural, only sensory function is lost. spinal both sensory and motor function lost. with spinal you must lay flat 6-8 hrs post delivery and pust have compression device on lower extreemties
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opiods injected into subarachnoid for spinal block
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duramorph (morphine) or fentanyl (sublimize)
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local anesthesia
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vaginal births: either local infiltration or pudendal block ( forceps delivery )
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general anestesia:
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raely used. only for c sections. only if ER situation, or spinal problem. maternal aspiration and respiratory depression of baby can occur
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worst complication with general anestesia
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maternal aspiration and baby respiratory depression
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local anestesia: local infiltration
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infiltration of perineum with lidocaine before performing episotomy or suturing laceration. very rare adverse effects - it is safe and doesnt affecdt infant
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pudendal block
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only used in second stage of labor pushing to deaden nerve plexus (deadens pain in perineum). provides analgesia for perineal repair or vaginal birth. has no effect on uterine contraction pain
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pudendal block has no affect on uterine contraction pain - treu or false
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true, it only helps with perineum repair
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what kinds of drugs do you give with general anestesia and why
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give Tagamat to reduce gfastric secretions or clear antacids like bicitra to neutralize gastric acid because maternal aspiration of gastric content into lungs is most common cause of maternal death. pt must be assessed closely for uterine atony post partum because general depression to muscle puts mom at risk for PP hemmorhage
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3 tests to determine rupture of membranes
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1. amniotest
2. nitrazine paper 3.fern test |
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with the amnio test and nitrazine paper, how do we know if ROM
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turns blue if + ROM
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how is the fern test done and how do you know if ROM
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fern test: speculum exam
Swab posterior aspect of vagina near cervix. Swab onto slide Under microscope, + ROM looks like “fern” as it dries |
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amniotomy
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artificial rupture of the membrane sac (fetal membranes) AROM- is usually done in conjunction with induction or stimulation of labor or to permit internal electronic fetal monitoring (see Chapter 18). Although it is a common procedure, amniotomy implies a commitment to delivery
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3 risks with amniotomy
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1. infection
2. prolapse of the umbilical cord 3. abruptio placentae |
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nursing implications for AROM
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1. monitor FHT at least 20 min before AROM
2. monitor FHT immediately after procedure because risk of prolapsed corse or cord compression. 3. document time, amt of fluid (scant, moderate, large), color (clear, light, meconium, particulate meconium), and odor. 4. Plase clean dry chux under patient and change often. 5. avoid frequent vaginal exams to reduce risk of infection 6. record maternal temp every 2 hrs after ROM |
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how often does the nurse have to take maternal temperature after AROM
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every 2 hrs
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what kind of meconium are we worried about
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particulate thick meconium
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why would we use internal monitors
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more accurate fetal heart tones than external monitors
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in order to use internal monitor we must have AROM or SROM true or false
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true
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2 kinds of internal monitors (done by provider)
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1. scalp clip (scalp electrode)
2. intrauterine pressure catheter IUPC |
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how is uterine intensity counted with IUPC and why would you do a IUPC
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montevideo units MVU = true uterine pressure. 1) trying to go vaginal after cesarian
2) pts with pitocin |
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difference between fetal scalp electrode (scalp clip) and IUPC
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fetal scalp electrode (FSE) monitors fetal heart tones. IUPC monitors contractions
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Induction and Augmentation of labor is indicated when?
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1. IUGR: intrauterine growth restritction- small for gestational age- uteroplacental insufficiency)
2. SROM without onset of labor and at term. (ruptured but not contracting) 3. Post dates: after 42 weeks 4. Chorioamnionitis: inflammation of amniotic sac (fetal membranes) usually caused by bacteria or virus. 5. HTN with pregnancy (uteroplacental insufficiency) 6. IUFD: intrauterine fetal demise (stillborn) |
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induction
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giving pitocin to start contractions from scratch.
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augmentation
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to make contractions better- already in labor, maybe slowing down or having trouble
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true or false, the longer ROM before delivery the greater chance of PP infection
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TRUE
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Induction of labor using Bishops score
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bishops score: system used to evaluate cervical ripeness: dilation, effacement, station, cervix consistency, cervix position.
scored 0-3. *only induce labor if cervix is ripe* |
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successful induction with bishops score
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multiparas: score >5
primigravida: score >7 |
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if cervix is not ripe, we can give medications. induction of labor with pitocin will begin the following morning after meds if not a score of 5-7 on bishops score. what transvaginal meds are given for cervical ripening
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PG gel (prostaglandin gel)
cervidil Miso (cytotec) |
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Pitocin, what is it
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pitocin is synthetic vergion of oxytocin given to stimulate uterine contractions. pitocin has a very short half life
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what happens if we give too much pitocin and uterus contracts too much?
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baby hypoxia
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true or false
during labor pitocin is always IV piggy bag. post partum we can give it IM |
TRUE
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pitocin rate to start IV piggy back using port closest/proximal to venipuncture site
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start pitocin at 1 mU/min, increase by 1-2 mU/min every 15 mins
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how long prior to giving pitocin infusion do we monitor FHT and uterin cxn and maternal vitals
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20-30 mins
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which each increase in pitocin dose we must assess
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FHT and uterine contractions and maternal vitals
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how often to we increase pit
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every 15 mins (1-2 mU)
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true or false, pitocin is not on a pump
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FALSE pitocin is always on a pump
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what effects does pitocin have on the body
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ADH effect, decreasing urine output - can lead to pulmonary edema and water intoxication so listen to lungs, look at feet and edema. assess for signs of hypertonic uterine contraction, now called tachysystole by ACOG
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how do you know how to increase pit
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gradually increase titrating in relation to uterine and fetal responses
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hypertonic uterine activity is a bad side effect of what? what impact does this have on baby
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increasing pitocin can cause hypertonic uterine activity causing baby to not get enough time to recover between contractions
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signs of hypertonic uterine activity
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1. contraction longer than 90-120 seconds
2. contractions ocurring less than 2 minutes apart or relaxation less than 30 seconds between contractions 3.uterine resting tone about 20 mm HG 4. peak pressure higher than 80 mmHG during first stage labor 5. montevideo units MVU greater than 400. 6. fetal heart rate pattern of late decelerations |
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if hypertonic uterine activity occurs what should the nurse do
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reduce or discontinue pitocin.
increase IV rate of primary nonadditive infusion keep laboring woman in left lateral position or change to right side give oxygen by snug face mask 8-10 L/min notify physician or nurse midwife |
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order for nursing actions with hypertonic uterine activity
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1. turn pit off
2. left side 3. give O2 4. call doc |
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what is an amnioinfusion
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(replacement of fluid that came out) NSS infused via gravity drip using IUPC into uterus for indications of 1) thick meconium stained fluid (thin out meconium)
2) if deep variable decelerations noted (get fluid to cushion cord) |
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when would we not use an amnioinfusion
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late decelerations because late decelerations are placental insufficieny which would not benefit from amnioinfusion
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circumstances for amnioinfusion
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IUPC in already, ROM already, now add more fluid to cushion inside cord or baby with thick meconium, variable deceleration
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when to never give amnioinfusion
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never give for late decelerations, never use if increased intra uterine resting tone. only give if thick meconium to thin it out (reasurring FHT), or if deep variable decelerations noted to cushion cord.
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External version, what is it and when is it done
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Its a 30 min quick procedure to try to flip baby at 37 weeks if baby is breech, shoulder or oblique presentation on ultrasound (while monitoring FHT and guide manipulations)
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what is administered during an external version?
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tocolytics: terbutaline, to break contractions and relax uterus.
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what must you do 1 hr after external version
|
monitor FHT and maternal vitals
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what is a negative aspect of the external version
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baby may revert back to the original position
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internal version: what is and when would you do it
|
internal means to move baby if malpresentation like transverse lie or used for vaginal birth with second twin. this is an urgent procedure
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true or false: if external ECV is successful, mom may be able to have vaginal birth instead of c section
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TRUE
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vacuum and forceps indication
|
shorten labor with maternal exhaustion when we are worried about babys heart rate, such as +3 station and severe deceleration.
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what are contraindications to vaccuum and forceps
|
babys too big
not enough time. |
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what are the risks to mom and baby with vaccuum and forceps
|
1. mom may get a painful hematoma laceration in vagina.
2. baby may get a cephalohematoma, facial or scalp laceration. |
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define cephalohematoma
|
pull of fluid in head
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nursing role with vacuum or forceps
|
1. empty bladder
2. explain procedure 3. pain management: either pudendal or local block. 4. emotional support |
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true or false, we vacuum in place of mom pushing
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FALSE: we vacuum as mom pushes to help her
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true or false: an episiotomy will need to be done with vacuum or forceps
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TRUE
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Episiotomy; what is it and when would you use it and what would you do afterwards.
|
episiotomy is an incision into muscle tissue to enlarge perineum. it can be midline or mediolateral. give ice pack afterwards to decrease inflammation, sitz bath and high fiber diet.
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what is done to reduce need of episiotomy or risk of laceration
|
perineal massage 36 weeks onward for 10 mins/day. = strecth
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what is key to reducing risk of laceration or episiotomy
|
gradual strethcing of perineum
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true or false. episiotomys do not increase healing time.
|
TRUE
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if baby gets cephalahematoma from vacuum forceps, what are they set up for and what do you evaluate?
|
set up for jaundice: evaluate neorlogic function
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what is the statistic for c sections
|
33.5% of births.
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contraindication for c section
|
risk for mother must not outweigh risk for fetus. for example:we dont give c section for IUFD (stillborn), preterm before viability, or maternal coagulopathies.
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Indications for C section
|
1. dystocia; difficult labor
2. CPD (cephalopelvic disproportion) - baby wont fit thru pelvis shape. 3. severe HTN - emergent delivery 4. active genital herpes lesions at time of delivery 5. placenta previa (placenta lies over cervical os in lower uterus) 6. previous classical c section incision 7. prolapsed cord (came out) 8. fetal malpresentations (breech transverse lie etc( 9. abruptio placenta: placenta tears away from uterine wall. |
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|
what is usually the circumstance with abruptio placenta
|
baby is sick from crack cocaine
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true or false: prior c/s is not an indicator for another c/s
|
TRUE mom may go vbac
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|
C section risks to mom
|
infection
UTI thrombophlebitis DVT paralytic ileus anestesia complications like resp depression and PPT hemmorhage from uterine atony hemmorhage trauma to bladder thromboembolism to brain atelectasis in lungs. |
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|
c section risks to infant
|
TTN: transient tachypnea of newborn
inadvertent preterm birth injury ((laceration bruisings fractures) respiratory distress |
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nursing implications for c section
|
labs: CBC with diff, type and screen, PT and PTT platelets.
EFM 20 mins at least anestesia itnerview/consents IV hydration 1 or 2 L bag fluidwith prophylactic antibiotic X 1 dose emotional support/teaching pre op checklist like history last intake gown/hat skin prep betadine foley insertion after spinal block inform neo team |
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|
3 types of c section incisions
|
1. low transverse = best
2. low vertical 3. classic (ER) |
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post op nursing care
|
1. maternal VS with oulse ox (check for resp depression)
2. Bubblep BUBBLE EP 3. pain relief: duramorph or toradol. 4.incision/dressing assessments 5. iv site, fluid foleys I & O 6. intemrittent compression device 7. clear fluids po 8. OOB within 8 hrs 9. assess edema 10 encourage early frequent ambulation 11. add IV pitocin drip post c section |
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|
side effect of duramorph morphine
|
pruiritus so give benadryl
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|
iv ibuprofen
|
toradol
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discharge instructions
|
no driving 2 weeks, no tampon douching tub baths for 6 weeks, follow up at OB office c/s 2 weeks after and 6 weeks after vag delivery, assess incision for infection, no heavy lifting 2 weeks, listen to body
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what are you assess for signs of infection after c section
|
redness,swelling, purulent drainage, approximation of incisional edge
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|
vbac
|
vaginal birth after cesarian - only given if woman is at low risk for uterine rupture
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who would be at high risk for uterine rupture and not able to have vbac
|
multiple gestation moms - overdistending the uterus
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if vbac, induction may be attempted in which circumstances
|
induction may be attempted as long as you use IUPC to monitor contractions internally. IUPC makes sure intensity of contraction is not too high using the MVU (montevideo units). pitocin is titrated conservatively.
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|
when does anterior fontanel close and what shape is it?
|
anterior fontanele closes at 12-18 mos. it is diamond shaped.
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|
when does the posterior fontanele close?
|
the posterior fontanele closes at 8-12 weeks and is triangle shaped.
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nursing actions after placental delivery
|
start pitocin again.
take maternal BP fundal massage calculate EBL maintain patency and site integrity of infusing IV |
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|
true or false: never give uterine stimulants before delivery of placenta
|
TRUE
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pitocin, hemabate and methergine all do what?
|
uterine stimulates to prevent post partum hemmorhage after delivery of placenta.
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