Nur 125 OB Test 2: Intrapartal Period Flashcards

Terms Definitions
What are the 4 factors affecting the process of labor and birth? (4 "P's")
1. Passenger (fetus/placenta)
2. Passageway (birth canal)
3. Powers (contractions; primary & secondary)
4. Psyche
The way the fetus moves through the birth canal is determined by several interacting factors. What are they?
size of fetal head
fetal presentation
fetal lie
fetal attitude
fetal position
The placenta also must pass through the birth canal. Is it considered a passenger?
Name the fetal head bones.
Parietal (2) (sides of skull)
Temporal (2)(by ears)
Frontal (1) (forehead)
Occipital (1) (base of skull)
Name the fetal sutures.
Lambdoid (separates occipital)
Sagittal (down middle separating parietal bones)
Coronal (separates frontal)
Name the fetal sutures.
Coronal = crown
Sagittal = sides
What purpose does the fontanels serve in the fetal skull?
Makes skull flexible to accommodate the infant brain
Allows skull to adapt to various diameters of the pelvis
Anterior and Posterior fontanels help determine the fetal presentation, position & attitude after ROM
Rupture of Membranes
Name the diameters/measurements of the fetal head
What is the suboccipitobregmatic diameter/measurement?
Visualize a line from anterior fontanel to base of occiput
It is the smallest diameter of fetal head (9.5cm) when chin is to chest.
Head in complete flexion allows head to pass through the true pelvis.
What is the biparietal diameter/measurement?
Visualize top of head: line from 1 parietal bone to the other.
It is the largest transverse diameter.(9.25cm)
In a well flexed cephalic presentation, the B.D. will be the widest part of the head entering the pelvic inlet
What is Fetal Lie?
the relationship of the long axis(spine) of the fetus to the long axis(spine) of the mother.
What are the 2 primary lies?
1. Longitudinal/vertical (spine of fetus is parallel with spine of mom)
2.Transverse/horizontal/oblique (spine of fetus is at a right angle to spine of mom)
(Can’t have a vaginal birth)
Fetal attitude is the relationship of the fetal body parts to each other. What is the normal characteristic posture? (attitude)
back rounded
chin flexed on chest
thighs flexed on abd.
legs flexed at knees
Arms crossed over throax
umbil. cord lies b/w arms & legs
This is called general flexion
What is fetal presentation?
The part of the fetus that enters the pelvic inlet first & leads through the birth canal during labor at term.
e.g. cephalic, breech, shoulder
What are the main fetal presentations?
Cephalic-head first
Breech-buttock(sacrum) or feet
What is the presenting part?
the part of the fetal body first felt by the examining finger during a vaginal examination.
What are the common presenting parts?
Cephalic presentation: it is usually the occiput (O)-noted as vertex
Breech presentation: it is usually the sacrum(S)
Shoulder presentation: it is usually the scapula (SC)
*note: the "parts" are the occiput, sacrum, & scapula
The relationship of the presenting part to the four quadrants of the mother’s pelvis is called what?
Postition is denoted by a three letter abbreviation.
The postition is denoted by a three letter abbreviation. What does the 1st letter represent?
First letter: location of the presenting part in the right or left side of the mother’s pelvis. R or L (p 318)
The postition is denoted by a three letter abbreviation. What does the 2nd letter represent?
The middle letter: stands for the specific presenting part of the fetus (Reference Points) (p 318) e.g follows->
O = occiput
S = sacrum
M = mentum (chin)
SC = scapula (shoulder)
The postition is denoted by a three letter abbreviation. What does the 3rd letter represent?
The third letter: stands for the location of the presenting part in relation to the anterior(A), posterior(P) or transverse(T) portion of the pelvis (p 318)
When determining postition, which of the three letters should you determine first?
The 2nd letter: the presenting part
How do you determine station and fetal presentation?
Sterile Vaginal Exam (SVE)
A measure of the degree of descent of the presenting part of the fetus through the birth canal is called what?
How is station determined?
It is the relationship of the presenting part of the fetus to an imaginary line drawn b/w the maternal ischial spines. (numbers are - before ischial spines, and + as the fetus passes past ischial spines)
If the lower most portion of the presenting part is 1 cm above the spines then the station is said to be ___.
If the presenting part is at the level of the spines, the station is said to be ___.
When the presenting part is 1cm below the spines the station is said to be ___.
Why do you need to determine the station when labor begins?
So that the rate of descent of the fetus can be accurately determined.
What is sinciput presentation?
Straight on head presentation
What should you do if you see a prolapsed cord?
Manually hold/push up presenting part to keep it from compressing cord/blocking blood supply.
What is the term used to indicate that the largest transverse diameter of the presenting part(usually the biparietal diameter) has passed through the maternal pelvic brim or inlet into the true pelvis and usually corresponds to station 0?
How is engagement determined?
abdominal or vaginal exam
The passageway/birth canal involves the pelvis. Name the parts that make up the pelvis.
Bones: 2 innominate bones (2 ilium, 2 ischium), 1 pubis, 1 sacrum, 1 coccyx
Joints: 2 sacroiliac joints, 1 sacrococcygeal, and 1 symphysis pubis
False Pelvis: greater than the inlet (area above the brim or the linea terminalis; Plays no part in childbearing)
True Pelvis: less than the inlet (lower tunnel area; Part involved in birth; divided into three planes). Page 322
Areas of focus involving the passageway/birth canal
Pelvis and its Measurements
What measurements do we take of mom in labor and why do we take them?
Measurements are diameters of the planes of the pelvis to determine whether vaginal birth is possible
List the measurements necessary to determine whether vaginal birth is possible.
Inlet A-P measurements
Inlet A-P measurements include what?
true conjugate: 11cm- upper margin of the pubis to the sacrum promitory
Diagonal Conjugate: 12.5-13cm from the upper posterior margin of the pubis to the sacrum promitory
What is the midpelvis measurement?
the transverse measurement->
10.5cm distance b/w the ischial spines
Parts of the outlet measurements
Ishcial tuberosities: greater than 8 cm
Wide pubic arch: greater than 90
Classification/pelvic types involved in determining passageway measurements.
Gynecoid - Round (classic female pelvis)
Android - Heart (resembles male pelvis)
Anthropoid - Oval
Platypelloid - Flat
(p 324 for more info)
What powers are involved in labor/birth?
Primary powers
Secondary powers
(Review Specific Parts of contractions)
What is the primary "power" of labor & delivery?
Involuntary uterine contractions
Involuntary uterine contractions signal what?
Beginning of labor
Primary powers (involuntary uterine contractions) are responsible for what?
descent of fetus
How do contractions work?
They move over the uterus in a downward motion from the fundus to the cervix making the uterine cavity smaller
What is the range of cervical dilation?
What marks the end of the 1st stage of labor?
Full cervical dilation (10 cm)
What is effacement?
Shortening and thinning of the cervix during the 1st stage of labor. (0-100%)
What is effacement?
"C" in effaCement = cervix
Does dilation and effacement always correspond?
No, the cervix may be full dilated while not having fully effaced (lip remains)
What are the Secondary Powers?
Voluntary bearing down effort
The pregnant woman bears down during the force of the contraction once the cervix is fully dilated.
Contracting of the abdominal muscles occurs and they are used to push the contents out of the birth canal.
(should only push when fully dilated)
How is gravity a "power" of labor & delivery?
-Moves uterus forward to straighten long axis of birth canal so head can descend through vagina
-Pressure of head stretches the receptors of pelvic floor = urge to push (Ferguson Reflex)
-Stimulates increase in oxytocin from pituitary
-Leads to increase in intensity of contractions
-Upright position good for increasing pelvic outlet & C.O. /second stage of labor sitting or squatting is good
-Relieves backache for a fetus in occipitoposterior: all fours/hands and knees
What are the parts of a contraction?
Frequency (timing)
Resting tone
Duration (length)
What are the parts of a contraction?
Think of a picture of contractions & lable
The time that elapses between the onset and the end of a contraction. Increment-acme-decrement
Duration (length)
The beginning of the contraction to the beginning of the next contraction is called _____?
Frequency (timing)
The time interval between the end and the beginning of a contraction is called _____.
Resting tone
The strength of the contraction at its peak. Mild, Moderate and Firm
The peak of contraction
The Psyche affects the process of labor & birth. What areas should you focus on that involve the psyche?
Accomplishments of the Tasks of Pregnancy (Safe Passage)
Coping Mechanisms
Support Systems
Preparation for Childbirth
Cultural Influences
What are some signs of preceding labor?
Strong Braxton Hicks Contractions
Bloody Show
Cervical Ripening
Increased Urinary Frequency
SOB Decreases
Spontaneous ROM (rupture of membranes)
Weight Loss
Burst of Energy
The onset of labor has no single cause. Name some factors that may contribute to the start of labor.
Fetal Hormones
Progressive Uterine Distention
Increasing Intrauterine Pressure
Aging of the Placenta: increased levels of estrogen & prostaglandins, with decreased levels of progesterone
When is the mother most likely to hemorrhage?
During the 4th stage of labor (1st hr after delivery of placenta)
Describe the first stage of labor.
1st stage: Onset of regular uterine contractions to full dilatation of cervix.
Longest stage (more than 2 or 3rd combined)
First time moms- up to 20 hours
Divided into 3 phases(Refer to H.O.)
Describe the second stage of labor.
From fully dilated to birth(Pushing)
Describe the third stage of labor.
From the birth of fetus until placenta is delivered.
Describe the fourth stage of labor.
First hour after delivery of placenta
Name the cardinal movements of fetus during labor.
Internal Rotation
External Rotation & Restitution
("Every darn fool in Egypt eats raw eggs)
Name the factors that affect fetal circulation during labor & delivery.
Maternal position
Uterine contractions
Blood pressure
Umbilical blood flow
How does the umbilical cord keep from tangeling in the uterus?
It is covered in Warton's Jelly which causes it to float away from the fetus.
Describe the fetal respiration changes during labor & delivery.
Respiratory movements decrease
Oxygen pressure falls
Arterial CO2 pressure rises
Arterial pH falls (acidiosis)
Bicarbonate level falls
Fetal lung fluid clears during labor & vaginal birth
What initiates the newborn to take its first breath at birth?
The rise in CO2 and fall of O2 during birth triggers the first respiration.
Maternal adaptations occur in many body systems during labor & delivery. What are the 2 most important systems to monitor during this time?
Cardiovascular system changes
Respiratory system changes
Why should a laboring mom not hold her breath for long periods of time while pushing?
Increased holding of breath lowers BP & can cause fetal hypoxia.
This is called Valsalva manuver.
Don't want mom to hold breath for longer than 7 sec.
(count of 10 takes less than 7 sec.)
This would be a maternal adaptation of the cardiovascular sys.
Without proper teaching of breathing techniques, the mom may hyperventilate. What are some signs of symptoms, what may it lead to, what should you do?
May lead to respiratory alkalosis
Signs/Symptoms include:
tingling hands/feet
seeing spots
You should admin. O2 or have them cup their hands, place over mouth & breathe.
If the mom has a full bladder, how may this impede delivery?
The baby cannot descend if a full bladder is in the way. Mom will need an in & out cath.
Some women may spill protein into their urine while pregnant. What is an acceptable amount?
up to 1+ is acceptable
What are a few integumentary changes the mom may experence during labor & delivery?
They may perspire or have flushing of the skin
What are some musculoskeletal changes the mom may experence during labor & delivery?
joint pain
The release of endorphins during labor & delivery is a ______ maternal adaptation.
What are some gastrointestinal changes the mother may experence during labor & delivery?
Gut slows
May have n&v
Some may have diarrhea
What is the name of the reflex responsible for the urge to push?
Ferguson Reflex
The intital admission assessment is often taken over the phone as a women starts to have regular contractions. List areas to assess.
Name and age
Attending caregiver
Gravida and Parity, EDC, EGA
Current Labor Status
Support System
Prenatal Classes for Labor & Delivery
Labor and Delivery Plan
History Current Pregnancy
Past Pregnancy History
Medical History
Of the many areas of assessment during the initial assessment, which four are the most pertinent?
Support System
Prenatal Classes for Labor & Delivery
Labor and Delivery Plan
Diagnostics (GBS status & blood type)
Why is it necessary to assess gravida, parity, EDC, & EGA at admission?
To make sure mom and baby are ok to go into labor.
When assessing current labor status, what do you want to know?
You want to know if the mom has ruptured her membrane (water broke) & her contraction history
When assessing the history of current pregnancy, what are you looking for?
You want to know if the mom has had any issues with the pregnancy along the way such as:
Gestational diabetes
At admission, what will the good nurse always ask?
Do you have a Birth plan? (Labor & delivery plan)
During the initial assessment, what diagnostics are reviewed?
GBS status
Blood Type
If the mom tests positive for GBS and medication is given, who is the medication for, the baby or the mom?
The med is for the baby's benifit.
A labor assessment is different than the initial assessment. What areas are assessed during the labor assessment?
Vital Signs, FHR, Edema, Reflexes
Status of Membranes-Test for Fluid. Amniotic fluid is slightly alkoline-will turn blue. Pg. 400
Contraction-Onset, Frequency, Duration, Intensity
SVE-Dilatation, Effacement, Station, Presenting Part
Diagnostics, (Fundal Height, Urine)
Assessment of Discomfort
During Labor, much information is gathered from the labor assessment. This data must be analyzed. What is it important to determine?
-Is mom having True or False Labor? (Page 395-teaching guidelines)
-What Phase & Stage of Labor is mom in?
-Is their history of or current complications / Problems (PIH, PTL,Post Term Labor, GD, Bleeding, Infection)
Ongoing Assessment during the 1st stage of Labor & Delivery includes what areas?
Maternal Assessment
Uterine Activity
Fetal Assessment
Check Leopold’s maneuvers (abdominal palpation) Page 412
What is the name of the 'status of membranes-test' which is looking for presence of amniotic fluid?
Fern test
What areas do you assess with the maternal assessment of the 1st stage of labor?
VS, BP, FHR, Pain(q 30 min)
Blurred vision
Breath sounds
Heart sounds
Skin, Edema
Reflexes, Clonus
What is clonus?
A test for hyperactive reflexes in which you dorsiflex the foot & look for a jerking response. A positive test (the foot jerked) means the pt is at risk for seizures.
When is the mom in true labor?
When the contractions are regular with cervical changes.
What areas do you assess with the uterine activity of the 1st stage of labor?
1. Contractions, Frequency, Duration, Intensity, Resting Tone
2. Cervical Assessment-Dilatation, Effacement, Station, Presenting Part. Determines if woman is in true labor
3. Amniotic Fluid, Intact or Ruptured, Odor, Amount, Color, Time of rupture. (Always concerned about infection if ruptured for more than 20-24 hours)
What areas do you assess with progress of the 1st stage of labor?
Length of the Latent, Active, Transitional Phases of the 1st Stage of Labor
Risk for infection: assessment for infection and interventions
S/S include:
-Elevation of maternal temp
-Rupture of membranes
-Fetal tachycardia
Interventions include:
-Monitor temp, resp., pulse
-Use of good aseptic techniques for all procedures
-Note time of ROM
-Monitor temp. q two if ROM has occurred
-Monitor fetal heart rate.
What areas do you assess with progress of the 2nd stage of labor?
Length of the Second Stage of Labor & Describe the Pushing Efforts
What areas do you assess with progress of the 3rd stage of labor?
Length of the Third Stage of Labor & Describe the Removal of the Placenta
What areas do you assess with progress of the 4th stage of labor?
Description of the 4th Stage of Labor
What areas do you assess with I & O of the 1st stage of labor?
IV Fluids
Urinary Output-Color, Protein, Ketones, Glucose, Amount
Need for a Catheter
What areas do you assess with the Fetal assessment of the 1st stage of labor?
Monitor-External or Internal
Fetal Movement
Amniotic Infusion
Other Measures to Correct Decreased FHR
Ongoing Assessment during the 2nd stage of L & D includes what areas?
Maternal Assessment
Uterine Assessment
Fetal Assessment (want early decelerations)
Assessment for Bulging and Crowning
Assessment of Bearing Down Efforts
At what point during the contraction do you want the mom to start pushing?
At the peak (acme)
How long should the mom push for?
No longer than 7 seconds per try/contraction
(Pushing is no longer effective after approx 2 hrs)
Ongoing Assessment during the 3rd stage of L & D includes what areas?
Length (want less than 30 min but could take up to an hour)
Presence of Contractions (should be present and mild)
Bleeding (3rd stage when most bleeding occurs)
Status of the Placenta
What stage of L & D does most bleeding occur?
The 3rd stage: placenta tearing away from uterine wall
Ongoing Assessment during the 4th stage of L & D includes what areas?
Fundus (Location), Lochia (Amount, Color, Odor)
IV Site
Family/Newborn Interaction
Possible Nursing Diagnosis for L & D.
Risk for Infection
Fluid Volume Deficit/Excess
Urinary Retention, Altered Pattern
Tissue Perfusion, Altered
Pain, Acute
Family Processes, Altered
Coping, Individual/Family, Ineffective
What are the Maternal objectives in regards to pain during L & D?
Relief of pain
Control of changes that accompany pain medication administration
Freedom from fear
Safe and less painful delivery
What are the Fetal objectives in regards to pain during L & D?
To provide a favorable physiologic milieu (environment/setting) for delivery
Fetal outcome is not compromised
Maternal assessment for pain management.
Vital signs are stable
Type, route, expected effects, safety measures are explained to laboring mother
Some pts may need quick education/teaching for med options
What Fetal assessments should you perform before administering pain meds to laboring mom?
Good variability
Normal fetal movement
Gestational assessment is accurate
No meconium staining
If FHR is not stable, is mom still a good canidate for analgesics?
No, mom will not be loaded up on a bunch of meds if FHR not stable. (May be a canidate for epidural as it does not affect the fetus)
What is meconium staining an indication of?
It is an indication that the baby as endured stress. (Remember, you must call NICU/respiratory for baby to be suctioned before 1st breath)
Labor Assessment: Describe what must happen before we start administering medications.
Contraction pattern is well established
Cervix is dilated:
4-5cm nulliparous
3-4cm multiparous
Fetal presenting part is engaged
Progressive descent is present (station)
Describe the ideal outcomes of med administration during L & D.
Mother’s health is not endangered
Newborn is not depressed at birth
Pain is effectively controlled
Labor is not prolonged
Patient is able to cooperate intelligently
Method is relatively safe to use
Under what classification is Demerol?
Opioid agonist analgesics
Under what classification is Butorphanol Tartrate (Stadol)?
Opioid agonists/antagonists analgesics
Under what classification is Nalbuphine (Nubain)?
Opioid agonists/antagonists analgesics
Under what classification is Narcan?
Opioid antagonists/antidote
*Not for use with street drugs or pts physically dependent on opioids - use only when you give too much opioid med)
Local analgesics are injected to block a group of nerves leading to a region of the body. Name the types of local infiltration that may be used during L & D
Risk for Ineffective Coping
Woman’s desire
Knowledge base
Ability to verbalize needs
Ability to push effectively
Ability to ask questions
Risk for Ineffective Coping
Provide info as needed
Reinforce knowledge
Answers questions
Strive to meets wishes
Provide support
Provide positive feedback
Provide information as needed and/or desired
Encourage woman to be involved to the extent that she wishes to be.
Provide encouragement
Why would some pts be given pitocin?
1. Induction of Labor
-medical problems
2. Augmentation
-labor is not progressing
The rule of Pitocin. (How many ml = unit & how many units = miliunit)?
1 ml = 10 units
1 unit = 1,000 miliunits
1 ml = 10,000 miliunits
What is a disadvantage to forceps assisted extraction of the baby?
Maternal vaginal tears
Describe a vacuum assisted extraction of the baby.
The vacuum is attached to the baby's skull and negative pressure is used. Baby must be vertex (head down).
What does TOL stand for?
Trial of labor
(to see how you tolerate labor)
What does VBAC stand for?
Vaginal birth after cesarean
What are the 3 kinds of Cesarean births?
Classical incision
Low cervical
1. Transverse cut through skin with a vertical cut through uterus
2. Transverse cut through both skin & uterus
True or False? The false pelvis plays no part in childbearing.
One of the factors that affect the way the fetus moves through the birth canal is the size of the fetal head. When the head is in complete flexion (chin to chest), what is the name of the smallest anteroposterior diameter?
Suboccipitobregmatic diameter
Which lie is preferred for ease of delivery, longitudinal or transverse?
Longitudinal lie is preferred
_____ refers to the part of fetus that enters the pelvic inlet first.
_____ is the relationship of the presenting part of fetus (occiput, sacrum chin, shoulder) to the four quadrants of mother’s pelvis & is denoted by a three-letter abbreviation.
Which fetal fontanel is the preferred fontanel to be felt when a vaginal exam is done? Why? What will this fontanel feel like?
The posterior fontanel is preferred because it indicates head is flexed forward to the chest which will allow the smallest diameter (suboccipitobregmatic diameter) to pass through birth canal. This fontanel is triangular in shape
When feeling the lower left side of the mother’s abdomen, you notice a hard movable mass, & from a vaginal exam you determine infant’s face is pointing toward mother’s right side. Which is the most likely position of this infant?
What is the presenting part in an RSA position?
What station is indicative that birth is imminent?
+4 or +5
What are the three parts of a contraction?
Increment, Acme, Decrement
What are the three parts of a contraction?
Think of graph & lable parts
_____ is the length of a contraction & _____ is the strength of a contraction.
Duration, Intensity
_____ is the time interval between the end & beginning of a contraction.
Resting tone
True or False? Stronger Braxton Hicks contractions, weight loss (0.5-1.5kg), & increased vaginal discharge are signs that precede labor.
The first stage of labor is divided into three phases. What are they?
Latent/early (0-3cm)
Active (4-7cm)
Transition (8-10)
Which stage & phase of labor does the woman desire companionship & encouragement, & have some difficulty following directions.
First stage, second phase (active)
Your patient is complaining of severe back pain, is very irritable, her contractions are 2-3 minutes apart, & feels like she has to defecate. What stage & phase is she most likely in?
First stage, third phase (transition)
Which stage & phase of labor is associated with an increased urge to push?
Second stage, second phase (descent)
The “Ring of Fire” occurs in what stage & phase?
Second stage, third phase (transition)
What type of feelings are experienced in second stage first phase of labor?
Feels fatigue & sleepy
sense of accomplishment & optimism
feels in control
True or False? Pain during first stage of labor is mainly caused from stretching of perineal tissues & from pressure on the bladder & bowels.
Pain in the first stage is mainly from cervical dilation, effacement, & uterine ischemia.
Pain in the second stage is from stretching of perineal tissues & from bladder & bowel pressure
What position can be used to decrease back labor? What other nonpharmocological measure helps relieve back labor?
On hands & knees
Counter-pressure on sacrum
Walking may promote progression of labor. Why would you not want to send your patient off for a walk if engagement & rupture of membranes has not occurred?
Rupture of membranes & prolapsed cord could occur
What are the three types of decelerations? Which are good? Which are bad?
Early, Late, Variable
Early is good
Late is bad
You are looking at a fetal monitor strip & notice the baby’s heart rate drops at onset of the contraction & increases at end of the contraction. What corrective action is required?
These are early decelerations & no corrective action is required
What causes early decelerations?
Head compression during labor
Variable decelerations are usually shaped like a V & may occur any time during the contraction, & are usually caused by cord compression. What is the first nursing intervention that should be done if the variables are short in duration (less than
Change position of mother
True or False? Late decelerations are an indication of uteroplacental insufficiency.
Your patient is receiving Pitocin & while watching the fetal monitor you notice several late decelerations. You patient is in the supine position. List three nursing interventions that should be implemented.
Turn off oxytocin (Pitocin)
Position patient on left side
Provide oxygen by mask (8L/min)
_____ is a procedure used during labor to supplement inadequate amounts of amniotic fluid that is used for patients with variable decelerations due to umbilical cord compression.
What effect do uterine contractions during labor have on the cardiovascular system?
Cardiac output increases
Pulse increases
Blood pressure increases
(due to 400 cc of blood being squeezed from the uterus back into the maternal vascular system)
Does the mother’s white blood cell count increase or decrease during labor?
Why is the IV route preferred for administering systemic analgesics?
IV route provides a faster more reliable onset of medication resulting in more effective pain relieve than other routes
An opioid antagonist (Narcan) is given if labor is more rapid than expected & birth is anticipated when the opioid is at its peak effect. What is the “window” time that is used to determine if Narcan is to be administered?
If delivery is 1-4 hours after opioid administration
True or False? Disadvantages associated with epidural use include the potential to prolong the second stage of labor, & the risk for maternal hypertension.
Epidurals may prolong second stage of labor but there is a risk for hypotension (not hypertension)
What are some advantages of an epidural?
Excellent pain relief
Mother remains alert & cooperative
Airway reflexes remain intact
Fetal distress is rare
Dose & volume can be adjusted to allow mother to push effectively
After the administration of an epidural, your patient complains of a metallic taste, numbness of lips and tongue, ringing in her hears, and has severe hypotension and bradycardia. What do you suspect is causing these symptoms? What would you do?
Toxicity from the epidural medications
Manage airway
Administer Oxygen
Be prepared to administer emergency code procedures
Before administering an epidural, the anesthesiologist usually orders a rapid infusion of fluid such as 500-1000 mL of Lactated Ringer’s. Why?
The infusion of fluid before the epidural will maintain blood pressure
What type of incision is the preferred method for Cesarean deliveries? Why?
Transverse incision is preferred because there is less blood loss, it is easier to repair, less likely than classic cut to rupture with future pregnancies, & it does not promote adherences of the bowel to the incision line
What effects can prolonged labor have on the fetus?
Hypoxia that can lead to fetal demise is the most serious effect. Prolonged labor can also cause increased intracranial pressure & intracranial hemorrhage
What are some fetal indications for Cesarean delivery?
Fetal hypoxia
Prolapsed cord
Breech presentation or other mal-presentation (shoulder)
Fetal anomalies (hydrocephalus)
What is Early Deceleration?
Occurs during the active phase of labor
caused by fetal Head Compression
Onset, fall & recovery of the heart rate coincide with the onset, peak and end of the contraction
does not indicate a problem
Early Decelerations are considered to be benign
Interventions are not necessary
FHR will go down – able to tolerate contractions
What do late decelerations indicate?
uteroplacental insufficiency (which causes fetal hypoxia)
Nurse interventions for late decelerations…
What is the cause of Variable Decelerations?
Umbilical cord compression (Does not have a relationship with the Contraction)
What is an Amnio-infusion?
Procedure used during labor to either supplement inadequate amounts of amniotic fluid or dilute meconium-stained amniotic fluid with saline or lactated Ringer’s solution
What kind of symptoms will the mom report that we will tell her to come in to be examined?
▪When contractions are 5 minutes apart
▪ROM (rupture of membranes – Water Breaks)
▪Change in fetal movements
▪Vaginal bleeding
If fundal height has dropped & there is an increase in urine frequency, then what has probably happened?
the membranes have ruptured
The first thing you do when a woman has ROM or suspects ROM is to…
▪Check for FHR
▪Assess for cord prolapse with a doppler
What happens if the mother has BP problems (PIH)?
▪Edema may occur along with CNS disturbances including clonus or hyperactive reflexes, blurred vision, headache
▪Magnesium sulfate is administered to control symptoms
▪If no intervention, pt may have seizure
▪Monitor VS, BP, FHR (NST, CST, BPP, ultrasound), heart sounds, breath sounds, skin & pain.
What do you check when performing a Sterile Vaginal Exam?
dilation, effacement, station, & presenting part.
When should a SVE be performed?
▪On admission
▪When significant change has occurred in uterine activity
▪On maternal perception of perineal pressure or the urge to bear down
▪When membranes rupture
▪When variable decelerations of the FHR are noted.
Which is more accurate, a SVE or Leopolds Maneuvers?
Leopold’s Maneuvers are considered more accurate
Side effects of Demerol
causes CNS depression in mother & causes FHR & variability to decrease in the baby
(Have Narcan (antagonist) ready 1-4 hrs. post administration for baby if born b/c it is heaviest in system)
Side effects of Stadol and Nubain
cause sedation in mother and a decrease in FHR and variability in the baby.
Describe the routes of Systemic Analgesics
▪Demerol: IM, SC or IV
▪Stadol: IM or IV
▪Nubain: IM, SC, IV
▪Narcan IM, SC, IV
Describe the Epidural procedure
Epidural is local anesthetic injected into the epidural space when the mother is in active labor
Do not place unless she is well into the stages of labor (4-5 cm)
Prior to epidural you should place mom
1)left lateral position
2)administer oxygen at 8-10L/min
3)begin IV and hydrate (#1)!!
1st intervention (after admin) is to take BP
More fluid volume < hypotension.
How often do you perform assessments on mom with an epidural?
continuous fetal monitoring
take maternal BP & Resp q 15min.
When would you D/C Pitocin?
-when the fetus is in distress (bradycardia, late/variable decal, meconium staining
-uterine contractions are more frequent than every 2 mins
-sustained uterine contractions are seen
-insufficient relaxation of the uterus between contractions
-steady increase in resting tone
(If d/c: turn client on side, administer O2 and notify MD).
If you are going to give 1ml. of pitocin in 1,000 ml of LR. To be infused at 0.5mu/min. How many ml/hr is the pump set to?
Have 1ml pit : 1000 ml LR (change pit to mu)
Need 0.5 mu/min
10,000mu : 1000ml = 0.5 mu : x ml
=0.05 ml (x 60 min), = 3 ml/hr
A pt. with _____ uterine dysfunction would be give oxytocic stimulation.
A pt. with _____ uterine dysfunction would be exhausted an receive relief of pain so she could rest, when she awakens normal uterine activity may begin.
What is Pelvic dystocia?
Pelvis is not adequate for vaginal delivery (can cause prolonged labor)
What is Inlet contracture?
Diagonal conjugate (DC) < 11.5 cm
What is Midpelvic contracture?
Ischial spines < 9cm.
A few hazards of prolonged labor for mom include…
PP hemorrhage
A few hazards of prolonged labor for fetus include…
Intracranial Hemorrhage
fetal demise
What are some maternal indications for c-section?
1. Fetopelvic disproportion (baby too large to fit thru birth canal) or CPD (cephalopelvic disproportion) (pelvic bones are too small to support vaginal delivery)
2. Previous c/s
3. Breech presentation
4. Medical abnormalities (i.e. PIH)
5. Placental abnormalities (previa, premature separation of placenta)
6. Infections
7. Trauma to the pelvis
What are some Fetal indications for c-section?
1. Fetal hypoxia
2. Prolapse of cord
3. Breech
4. Malpresentation (e.g. shoulder)
5. Fetal anomalies (e.g. hydrocephalus)
When would we give a TOL (trial of labor)?
For a woman who had a prior transverse C-section and hope for a VBAC (vaginal birth after cesarean)
When would we allow a VBAC?
Only if the previous C-section cut was transverse and the reason for that c/s is not relevant this time.
What causes pain during labor?
-1st stage: cervical dilation, effacement, & uterine ischemia (all caused by uterine contractions)
▪Visceral pain
▪Usually only experiences discomfort during uterine contractions
▪Mild pain throughout abdomen and lower back, intense pain in central lower abd., sides of abd., & lower back
-2nd stage: R/T expulsion of baby
▪Perineal or somatic pain, stretching of perineal tissues & traction on the Peritoneum and uterocervical supports during uterine contractions
▪Pressure on the urethra, bladder, & rectum
-3rd stage: pain is similar to that experienced early in 1st stage of labor
What is the gate control theory?
▪Pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations can travel thru the nerve pathways at one time.
▪Using distraction techniques such as massage or stroking, music, and imagery reduces or completely blocks the capacity of nerve pathways to transmit pain.
▪The distractions are thought to work by closing down a hypothetic gate in the spinal cord, which prevents pain signals from reaching the brain. Perception of pain is diminished.
What influences pain in Labor?
1. Culture
2. Anxiety & fear
3. Previous experience
4. Childbirth preparation
5. Comfort
6. Support
7. Endorphins
What are the different childbirth prep methods?
What is the Dick-Read method of childbirth preparation?
▪replace fear of unknown with knowledge & understanding
▪Conscious relaxation techniques & breathing patterns, not popular in this area
What is the Lamaze method of childbirth preparation?
▪Pain is a conditional response, concentrate on focal point, maintain control, have a support person
What is the Bradley method of childbirth preparation?
▪Husband takes a more active role as coached childbirth
▪Prefer darkness in room, quiet and solitude
▪For more “laid-back” people
Where is the External Fetal Monitor placed?
mom’s abdomen
Toco placed at top of fundus where contractions start
Transducer is placed on baby’s back (feel for curved, rounded part of baby)
What does the TOCO fetal monitor detect?
What does the Transducer fetal monitor detect?
Picks up FHR
What are some advantages of external fetal monitors?
continuous fetal monitor, non-invasive, doesn’t hurt mom or baby
What are some disadvantages of external fetal monitors?
Not as accurate
depends on mom’s cooperation
limits mom’s movement
When are Internal Fetal Monitors used?
usually for high risk patients or anytime determination of strength of contractions is necessary
Where is the internal fetal monitor placed?
Place it under the babies scalp (surface of the skin)
What are some advantages of internal fetal monitors?
very accurate to hear FHR
mom can move around
measures the intensity of the contraction
What are some disadvantages of internal fetal monitors?
electrode in babies scalp
possible infection
cannot place on mom unless membranes have ruptured
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