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96 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Ominous Warning Signs
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• Ensure patient knows warning signs:
• Rupture of membranes (ROM), • Vaginal bleeding, • Decreased fetal movement, change from baseline • Abdominal pain abdominal muscles ripping, placenta ripping, headache, visual changes – preklasia, backpain = preterm labour, foul discharge or flu like symptoms = infection, feeling of impending doom = usually right |
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Five factors affect the process of labour and birth (five P's) |
• Passenger (fetus and placenta)
• Passageway (birth canal) • Powers (contractions & urge to push) • Position of mother- relationship presenting part to pelvis, maternal position during labour • Psychological response anxiety, fear, tension |
PA PA PO PO PY |
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Passenger
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• Size of fetal head
• Fetal presentation (Fetal lie & attitude) • Fetal position • Engagement • Cardinal moves • Placenta If placenta attached over birth canal baby can’t pass |
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Fetal Lie
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• Longitudinal
• Transverse • Oblique |
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Passenger: Fetal Head
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• Palpation reveals fetal presentation, position, & attitude
• Cranium vault: 2 frontal, 2 parietal, 2 temporal & occiptal • United by membranous or suture lines (sagiittal, coronal, and frontal) • Fontanelles: so head can compress and bones overlap |
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Fontanelles parts
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• Anterior: diamond shape closes at 18 months
• Posterior: triangle shape closes 8 to 12 weeks if baby in right, ideal, position, should be able to feel during vaginal exam • Shape adapts in labour; called moulding |
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The posterior fontanel is what shape at birth and closes approximately at ____months:
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b) 2 months and triangular shaped
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Passenger: Attitude & Presentation
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• Attitude: relation of fetal parts to one another (flexion or extension) think dance!
• Presentation: determined by lie, attitude & by body part entering pelvic passage (what part if coming out first? face, brow, breech or shoulder) |
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Passenger: Fetal Positions in relation to the Occiput
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LOP LOT LOA ROR ROT ROP |
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Engagement
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largest part of presenting part reaches or passes through pelvic inlet
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Occiput
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the back of the head or skull.
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Passenger: Fetal Position
(when) |
• Primigravida- 2 weeks before term
• Multigravida- several weeks to labor |
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Station
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-relationship of the presenting part to ischial spines (0) of pelvis
-good test question, mostly useless in real life, basically once you see head = point 0, after the + range. |
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Passenger: Cardinal Movements
(DFIEREE) |
• After Engagement mechanism of labor:
• Descent- progress of fetus through pelvis • Flexion- fetal chin in contact with chest • Internal rotation- occipitotransverse position • Extension- fetal head reaches perineum • Restitution- after head is born • External rotation- shoulders rotate to midline • Expulsion-birth of fetus • If first time delivery, fetus move into position earlier |
"Don't Forget I Enjoy Really Expensive Equipment”
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Place the cardinal movements (position changes) that occur after engagement and descent of the fetus in the correct sequence.
1. Expulsion 2. External rotation 3. Flexion 4. Internal rotation 5. Restitution |
c) 3, 4, 5, 2, 1
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Passageway (birth canal) is composed of what parts?
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Bony pelvis: • Inlet or brim • Midpelvis or cavity • outlet Soft tissue: • Lower uterine segment • Cervix • Pelvic floor muscles • Vagina & external opening • Perineum |
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Bony Pelvis
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• True pelvis ‘bony canal’ 3 planes: inlet, pelvic cavity, outlet
• Pelvis widens & stretches • Progesterone & relaxation facilitate softening & increase elasticity of muscles, ligaments, & pelvic joints • Whether diameter at plane of pelvic inlet, mid-pelvis, outlet, & axis of birth canal can accommodate presenting part of fetus determines whether vaginal birth is possible |
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Pelvis shapes: how many and what are the classic shapes? |
1: Gynecoid 2:Anthropoid 3:Android 4:Platypetoid |
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Factors Affecting Labour: Powers
what are the 2 types of power? |
Primary secondary |
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Primaryforces |
uterine muscular contractions cause effacement & dilations of cervix; signal beginning of labour.
• Involuntary, rhythmic, intermittent to allow rest & restore uteroplacental circulation • Described by frequency, duration, intensity compare admission contractions to labour |
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Secondary forces
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• use of abdominal muscles to push 2nd stage of labour. Pushing adds to primary force after full dilation of cervix.
• Bearing-down efforts (triggered by endogenous oxytocin release); increased intra-abdominal pressure compresses uterus leading to expulsion. |
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Primary Powers: Effacement & Dilation
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• Amniotic fluid & fetus exerts downwards pressure on cervix.
• Effacemen • Dilation • Nurse can give exam by inserting finger to see how much room left in cervix – gauge, not 100% accurate |
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Effacement
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drawing up of internal os & cervical walls into side walls of uterus
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Dilation
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Opening of cervix; think of a ‘lifesaver’ candy
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The most conclusive sign that uterine contractions are effective is?
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b) Descent of the fetus
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Effects of Position of labouring woman
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• affects woman's anatomical & physiological adaptations to labour
• Frequent changes in position: • Relieve fatigue • Increase comfort • Improve circulation • Laboring woman should be encouraged to find positions most comfortable to her. • Gravity is your friend |
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Factors Affecting Labour: Psychosocial Considerations
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• Assess usual coping mechanisms in response to stressful events
• Support systems in place • Preparation for child birth • Cultural & individual values influence how coping with childbirth • Prepare through meaningful actions & imaginary rehearsal• If bad previous labour, more stress hormones released which impedes labour |
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Process of Labour
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• Labour is the process of moving the fetus, placenta, and membranes out of the uterus and through the birth canal.
• Various changes take place in the woman's reproductive system in the days and weeks before labor begins |
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Signs of labour
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• Lightening or “dropping”- presenting part of fetus (usually head) drops downward in to the true pelvis; usually occurs 2-4 weeks before term in first-time pregnancies & during true labor in the multiparous.
• Braxton Hicks contractions |
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Braxton Hicks contractions |
strong, frequent and irregular uterine contractions.
"false labor contractions" |
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Onset of Labour
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• Distension of uterine muscles causing > prostaglandin. Connective tissue loosens to permit softening, thinning & opening of cervix
• Changes in biochemistry of fetal membrane leads: < Progesterone > prostaglandin > estrogen stimulating > contractile response of uterus • Factors result in occurrence of strong, regular, rhythmic uterine contractions • Muscles of upper uterine segment shorten & exert an upwards pull on cervix |
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Signs of Impending Labour
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• Possible rupture of membranes (ROM)
• Increased vaginal discharge; bloody show • Weight loss • GI upset • Sudden burst of energy • Low backache • Braxton Hicks contractions • Lightening |
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Lightening |
fetus moves into pelvic outlet
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As a normal uncomplicated labour progresses, contractions develop which of the following characteristics?
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b) More intense, more frequent, and of longer duration
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Signsof maternal Infection |
• Maternal Fever
• Fetal Tachycardia • Foul-smelling Vaginal Discharge |
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Possible rupture of membranes (ROM) |
or amniorrhexis is a term used during pregnancy to describe a rupture of the amniotic sac.
-Normally, it occurs spontaneously at full term either during or at the beginning of labor. -Rupture of the membranes is known colloquially as "breaking the water" |
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Premature rupture of membranes (PROM) |
is a rupture of the amnion that occurs prior to the onset of labor.
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Preterm Premature Rupture of Membranes (PPROM) |
? |
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FalseLabour |
• Contractions irregular
• Walking relieves contractions • Bloody show usually not present • No cervical change in effacement & dilation |
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True Labour
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• Contractions regular & increase in frequency, duration, intensity
• Contractions stimulated with walking • Discomfort in lower back/abdomen • Bloody show often present • Progressive effacement & dilation of cervix |
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Induction/Augmentation of Labour
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• Stimulation of uterine contractions to start labour prior to the onset of spontaneous labor (post-term, PROM, fetal demise, pregnancy complications)
• Or augmentation as labour progressing slowly & to enhance contractions after labor has begun • Simulated hormone naturally produced by posterior pituitary gland (oxytocin) that stimulates uterine contractions |
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Oxytocin (Pitocin)
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• Administered by infusion pump piggybacked into main line at closest port to insertion site
• Once induction starts, gradually increased until contraction pattern (every 2-3 min lasting for 40 to 60 sec). • Continuous fetal monitor to evaluate contraction pattern & FHR. Goal: contractions lasting 40 to 90 seconds, 2 to 3 minutes apart. • Hyper-stimulation: uterine contractions lasting >90 seconds & occurring <2 minutes in frequency; If occurs turn infusion off to rest uterus notify physician • Ruptured membrane (Water breaking) doesn’t usually occur before labour – huh, TV lied to me |
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Signs of preceding labour |
• Lightening or dropping • Braxton Hicks • Bloody show |
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Onset of labor
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Many factors including: changes in the maternal uterus, cervix, and pituitary gland
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1st Stage labour
(stages that occur) |
• Onset of labour to cervix completely dilated:
• Latent phase: mild regular contractions with increasing in freq, duration, & intensity, ROM (Primi 8.6 (<20) hours, Multip 5.3 (<14 hours) • Active phase: >anxiety, > intensity, 4 to 5 cm dilation (P:1.2/ M:1.5 cm per hour), fetal descent • Transition phase: >anxiety, restless, dilation 8-10cm, >rectal pressure, urge to bear down (P: 3 hours/ M: 1hour). Discomfort from dilation of cervix, stretching of lower segment, pressure, hypoxia of uterine muscles -Perineum Thins & Anus Stretches |
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Episiotomy
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baby in abnormal position, expedite delivery, or if extensive vaginal tearing is likely
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Degree of stretching |
• 1st degree =small nick in the perineum, not involving muscle
• 2nd degree = a tear through part or all of perineal muscles • 3rd degree = Laceration through part or all of anal sphincter muscle • 4th degree = Laceration that goes through anal sphincter & rectal wall |
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2nd Stage of Labour
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• Begins with completed cervical dilation & ends with birth of infant.
• Descent of fetal presenting part • Bulging of perineum, uncontrollable urge to bear down, increased bloody show, > intra-abdominal pressure • Feeling scared, loss of control • Crowning: fetal head is encircled by the external opening on the vagina • Spontaneous birth • Discomfort: contracting uterine muscle cells, distension of vagina & perineum, & pressure of fetus |
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Maternal Adaptions
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• Increased levels of estrogen, prostaglandins, oxytocin increase
• Endogenous endorphins raises pain threshold & produces sedation. • Increased cardiac output • Heart rate, WBC, BP systolic (1st stage), systolic & diastolic (2nd stage) all increase. • Temp slightly elevated & oxygen consumption doubles. • Metabolism increases with decreased blood glucose, GI motility & absorption. |
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Fetal Adaptations to Labour
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• Changes occur in fetal heart rate (FHR), circulation & respiratory movements.
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Fetal Health surveillance
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provides information about fetal health (oxygenation); wellbeing gauged by response of FHR to uterine activity.
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Fetal Circulation
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can be affected by maternal position, uterine contractions, BP and umbilical cord blood flow. Fetal & placental reserves usually adequate during anoxic periods.
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Fetal Respiration
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changes prepare fetus for initiating respirations immediately after birth.
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What is the most critical physiologic change that occurs in the newborn at the time of birth?
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d) Initiation and maintenance of respirations
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FHR Variability
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• Average FHR 110 to 160 beats per minute
• Fluctuations in baseline FHR are normal & expected: • temporary accelerations & slight early decelerations of FHR occur in response to fetal movement, vag exams, fundal pressure, uterine contractions, fetal head compression • Decreased variability: hypoxemia, drugs, prematurity, tachycardia, fetal sleep cycle |
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Fetal Heart Rate (FHR) Patterns
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• Assess baseline FHR, variability, accelerations, & decelerations
• Baseline FHR is average rate during a 10 min period excluding periods of accelerations, decelerations, marked variability |
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Tachycardia
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• Tachycardia > than 160 beats/min in 10 minutes:
• Early sign of fetal hypoxemia • Infection from PROM, effect of drugs, • Prolonged activity of fetus |
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Bradycardia
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< than 110 beats/min for 10 mins or longer: fetal cardiac problems, viral infections, drugs, maternal: position, hypoglycemia, hypotension, hypothermia
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Fetal Monitoring
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• Electronic fetal monitoring (EFM), intermittent auscultation (IA) always in context with overall clinical picture.
Goal: improve fetal oxygenation • Fetal heart rate & uterine activity assess together relative to likelihood & timing of vaginal birth |
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Variability in fetal monitoring
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• Normal/ increased variability or irregularity of a cardiac rhythm.
• Absence or decreased variability, or a smooth flat baseline, is a sign of fetal compromise. • AFJFJQ0 |
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types of Variability |
-Accelerations -normal -Deceleration- early=head -Late Deceleration- uteral placental -Prolonged Deceleration- -variable- cord compression (see notes for more information) |
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Variable decelerations in FHR during labor are severe dips occurring at the peak of contraction. This FHR problem is associated with which one of the following conditions?
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b) Fetal head compression
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Fetal Distress: contributing factors |
• Cord compression
• Utero-Placental Insufficiency • Pre-existing maternal or fetal disease |
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Fetal Distress: warning signs |
• Meconium stained amniotic fluid
• Bad because can breathe in! • Intubate baby and suction out |
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Ominous FHR Patterns |
• Persistent late decelerations
• Persistent severe variable decelerations • Prolonged decelerations • Decreased variability |
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Cord Prolapse: Contributing factors |
• Long cord (longer than 100 cm)
• ROM • Unengaged presenting part • Malpresentation (breech) • Transverse lie |
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Management of cord prolapse |
• Hold presenting part off umbilical cord until delivery
• Change patients position to relieve cord pressure • Keep protruding cord moist; warm sterile saline compresses • Monitor fetal heart rate • Emotional support • Prepare for assisted delivery (instrumentation or C/S) |
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Reasons for Caesar Section |
• Elective & Urgent
Urgent indications: • Abnormal FHR Malpresentation: breech, shoulder • Cord Prolapse |
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Caesar Section: SOGC guidelines
ELECTIVE |
• Determined prior to start of labour
• Placental: previa, abruption • Previous C/S • Malpresentation • Cephalopelvic disproportion (CPD) • Maternal request |
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Cephalopelvic disproportion (CPD) |
occurs when a baby’s head or body is too large to fit through the mother’s pelvis
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Caesar Section: SOGC guidelines
EMERGENT |
Complications detected during labour:
• Abnormal FHR • Malpresentation • Cord Prolapse • Dysfunctional labour pattern • Failure to progress (CPD) • Abruption • Hypertension • Uterine rupture |
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3rd Stage of Labour |
Birth of placenta: After infant born, uterus contracts firmly, placenta begins to separate from wall of uterus.
Signs of separation: • globular shaped uterus, • rise in the fundus, • sudden gush or trickle of blood • > cord protrusion• expulsion <30 minutes |
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4th Stage of Labour |
• 1 to 4 hours after birth
• Physiologic readjustment of the mother’s body; homeostasis re-established • Mother may feel energized • Optimal time for infant/mother bonding and breastfeeding as ‘period of reactivity’ |
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Stages of birth summary |
1st: onset of labour: Latent- mild regular contractions; Active- 4-5cm dilated, fetal descent; Transitional- 8-10cm, perineum thins and cervix opens, time to push 2nd: descent of fetus; birth 3rd: birth of placenta 4th: 1-4 hrs after birth, physiological readjustment |
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Admission for labor: Nursing role |
• Immediate assessments:
Maternal status: interview • Fetal status • Risk factors • Palpation to evaluate contractions • Determine if membranes ruptured If birth is not imminent: • Review antenatal data (EDB, lab findings, allergies, infections) • Complete maternal health history & physical assessment Birth plan: explore labour & birth preferences • Prepare & orient to unit |
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What does Leopold’s Manoeuvres help identify?
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1. Number of fetuses
2. Presenting part, fetal lie, fetal attitude 3. Degree of descent of presenting part 4. Expected location fetal heart ‘loudest‘ point |
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Rupture of Membranes: what does it look like? What Tests are used?
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• Tests to assess status of membranes: nitrazine (ph test acidic/alkaline) & ferning (crystallization test)
• Intact: yellow, • Ruptured: blue/green (7 -7.5)• Ferning: Place a smear of fluid on a slide & allow to dry. Check results. If fluid takes on a fernlike pattern, it is amniotic fluid. |
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Ferning |
- in relation to membranes -after a smear, if the pattern appears to be fernlike then it is amniotic fluid |
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what is Leopold's Manoeuvers |
The maneuvers consist of four distinct actions, each helping to determine the position of the fetus
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Tocodynamometer ("toco")
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a part of the electrical fetal monitor that is placed over the uterine fundus -used to monitor unterine contractions |
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Contraction Cycle |
At peak of contraction:
• Mild: fundus feels like the tip of your nose • Moderate: fundus feels like touching your chin • Strong: feels like you are pushing on your forehead |
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vaginal cervical exam |
• Exam stressful, uncomfortable with infection risk Explanation, support, & privacy
• Performed only when indicated: admission, significant change in uterine activity (UA), maternal perception of perineal pressure, ROM, prior to pain medication, variable deceleration in FHR. • Hand hygiene & sterile gloves • Exam never done by RN if vaginal bleeding is present |
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What do Cervical Examinations Reveal?
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• Dilation in centimeters see above
• Effacement in % • Station + or – ischial spine • Position • Consistency • Presenting part • Status of membranes |
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Nursing role for 1st stage of labor |
- primary goal: ensure safety of mom and baby - focus is on assessment (FHR, contractions, maternal status, fetal membranes, and psychosocial) - communication of labor progress to team |
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Nursing roles to mother |
-emotional support -pain management (both relief and pharmacological) - |
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Pain management: non-pharmacological |
Imagery, visualization, relaxation, touch, conscious breathing, hydrotherapy, counter pressure, & position changes
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Pain management: Pharmacological- 1st stage |
• Systemic analgesia (fentanyl)
• Epidural, spinal • Nitrous oxide safe and effective, deliver with oxygen mask |
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Pain management: Pharmacological- 2st and 3rd stage |
• Above without systemic analgesia as cross placental barrier with profound effect on infant (Narcan-opioid antagonist on hand)
• Second & Third stage: pudendal block (local anesthetic) • Pain meds given IV because can control more effectively |
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Epidural: Nursing Care
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Hypotension possible side effect due to vasodilation; interferes with adequate placental perfusion.
• Keep well hydrated before & during epidural anesthesia. If hypotension: • change to lateral position. • Increase intravenous (IV) fluids. • Administer ephedrine per anesthetist order • Notify anesthetist & physician • Incidence of after birth headache is higher with spinal blocks than epidurals. |
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2nd Stage: Nursing Interventions
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• Monitor vital signs every 15 to 30 minutes (q15-30 min)
• Check FHR every 15 minutes for the low-risk woman & every 5 minutes for the woman who is at risk for labor complications • Assess woman’s report of an uncontrollable urge to push • Ongoing support & encouragement • Change of positions & breathing to support effective pushing. • Prepare for delivery of newborn |
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3rd Stage of Labor: Nursing Role
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• After birth of the baby until the placenta is expelled.
• Assess cord for two umbilical arteries and one vein; • Assess placenta for completeness & anomalies; • Maternal care: Assess for signs of postpartum hemorrhage; provide comfort measures • Infant assessment & care |
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4th Stage of Labour: Nursing Role
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• Infant Assessment: checking airway, assigning APGAR score, prevent cold stress; vitamin K & eye prophylaxis; • First Period of Reactivity: Promote skin-to-skin contact & breastfeeding • Provide comfort measures: pain control, warm blankets & reassurance • Post-anaesthesia recovery: q15 assessments • Promote family relationships: skin-to-skin contact; siblings |
1 to 4 hours after birth; physiologic readjustment of the mother’s body.
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APGAR scale picture |
• Goal: assist new mother and her partner through initial transition to parenting
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Parts of APGAR (BUBBLESS) |
• Postpartum Assessment: Physical assessment :
• B = Breasts (firmness) and nipples (intact) • U = Uterine fundus (location; consistency) • B = Bladder function (amount & frequency) • B = Bowel (passing gas or bowel movement) • L = Lochia (amount; colour) • E = Episiotomy (perineum: discomfort; condition of repair) • S = Swelling (legs, edema) • S= (Ps)ychological status |
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Fourth Trimester: Nursing Care |
Nursing Interventions: Provide direct care;
• Rubella vaccine & Rh Isoimmunization (RH immune globulin) • Teach mother-baby care & self-care • Provide anticipatory guidance; encouragement & support; • Demonstrate breast/ bottle feeding care • Integrate newborn in to family • Discharge teaching |
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Postpartum Blues
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• The “pink” period the first day or two after birth;
• 50%-80% of new moms; • Emotionally labile and tearful; • Symptoms include: fatigue, restlessness, insomnia, anxiety, sadness & anger; • Lasts 5-10 days postpartum • Multiple contributing factors: hormones, social, cultural • EPDS (PPD screening) |
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