maternity nursing Flashcards

Terms Definitions
integumentary system physiological changes during pregnancy
estrogen induced vascular and pigment changes

increased pigmentation = chloasma and linea nigra
striae gravidarum (stretch marks)
increased sebaceous and sweat gland activity
palmar erythema
angomas--vascular spiders
alterations affecting comfort rest mobility musculoskeletal system
progesterone, estrogen, and relaxin induced relaxation of joints, cartilage, and ligaments

function in childbearing--increases anteroposterior diameter of rib vcage and enlarges birth canal
lab test during pregnancy
1. urinalysis - for protein, sugar, signs of asymptomatic infection; drug screen for high risk groups
2. venous blood-Hgb, Hct, blood type and Rh; RPR, rubella titer, antibody titer, sickle cell. HIV and hepatitis antigen recommenced for all preg. clients
3. cultures (vaginal discharge; cervical scrapings, for chlamydia trachomatis, neisseria gonorrhoeae
4. TB screening in high risk areas
5. maternal alpha fetoprotein screen 16-18 wk optimum time
6. serum glucose screen 24-48 wk; 1 hour glucose tolerence test
if TB is positive during pregnancy how is it treated
isoniazid (INH) and regampin given daily. INH is associated w/ increase in fetal malformations, particularly neurotoxicity.

Pyridoxine administered simultaneously to prevent thier developemnt
signs of preeclamsia are
visual disturbances--blurring, double vision, spots before eyes

swelling of fingers, ankles, hands, feet, or face

severe freqiemt pr continual headache

rapid weight gain not associated w/ eating
If there is persistant vomiting beyond first trimester or sever vomiting at any time what is possible cause
hyperemesis gravidarum
Fluid discharge from vagina---bleeding or amniotic fluid (anything other than leukorrhea--what are possible causes of this
placental problem, rupture of membranes
possible cause fo severe or unusual pain: abdominal
abruptio placentae
possible cause of abscence of fetal movmement after quickening, lasting more than 24 hours
intrauterine fetal death
who would you give RhoGAM to
1. mother who is Rh neg who gives birth to neonate who is Rh positive
2. nother who is Rh neg after spontaneous or induced abortion (>8week)
3. mother who is Rh neg after amniocentesis or chorionic villus sampling
4. mother who is Rh neg between 28 and 32 weeks gestation
Older mother over age 35 primigravida ...what are some issues in pregnancy
1. higher incidence of congenital anomolies (down syndrome) increased possibility of complications
older mother over age 40 miltipara....what are some issues of pregnancey
increased incidence of preexisting and coexisting medical disorders (hypertension, diabetes, arthritiis)
increased incidence of complications such as preeclampsia/eclampsia, hemorrhage
smoking major factor
what is lightening
process in which fetus drops into pelvic inlet
1. nullipara - usually occurs 2-3 week before onset of labor
2. multipara - commonly occurs w/ onset of labor
how much should protein be increased during pregnancy
30 g/day
folic acid during pregancy
800-1000 mcg through diet and supplements---prevents neural tube defects some places say 400 micrograms (0.4 milligrams) daily which is what I learned in school..the other number is coming from a hesi book
what maternal position provides optimum fetal and placental perfusion during pregnancy
the knee chest position---but ideal comfort for mother which supports fetal, maternal, and placental perfusion is the side lying position (removes pressure from abdominal vessels (vena cava, aorta)
what is ultrasonography used for in first trimester
number of fetuses
presence of fetal cardiacc movement and rhythm
uterine abnormalities
gestational age
what is ultrasonography used for in 2nd and third trimester
fetal viability
size-date descrepancies
amniotic fluid volume
placental location and maturity
uterine anomalies and abnormalities
results of amnocentesis
findings on ultrasonography 2nd and third trimester
1.fetal heart activity is apparent as early as 6-7 weeks gestation
2.serial evaluation of biparietal diameter and limb length can differentiate between wrong dates and true intrauterine growth restriction (IUGR)
3. A biophysical profile (BPP) is made to ascertain fetal well being
-----a. five variables are assessed; fetal breathing movements, gross body movements, fetal tone, reactivity of fetal heart rate, and amniotic fluid volume
----b. a score of 2 or O can be obtained for each variable. An overal score of 10 designates that the fetus is well on the day of the exam
how is gestational age best determined
by early sonogram rather than later one
what is chorionic villi sampling
removal of a small piece of villi during the period between 8 and 12 weeks gestation under ultrasound guidance (cannot replace amniocentesis completely b/c no sample of amnoitic fluid can be obtained for AFB or Rh disease testing
findings in chorionic villi sampling
1. the test determines genetic diagnosis early in first trimester
2. results obtained in 1 week
nursing care for ultrasound
instruct woman to drink 3-4 glasses of water prior to coming for exam and not to urinate
when fetus is small in first and second trimester the clients bladder must be full during exam in order for the uterus to be supported for imaging

Remember a full bladder is not needed if ultrasound is done transvaginally instead of abdominally

postition woman w/ pillows under neck and knees to keep pressure off of bladder---late in third trimester, place wedge under right hip to displace uterus to the left
nursing care for chorionic villi smapling
have informed consent signed before any procedure

place woman in lithotomy position using stirrups

warn of slight shapr pain upon catherter insertion

complications are spontaneous abortion (5%)
contraversy regarding fetal anomalies (limb)
what is amniocentesis
removal of amniotic fluid sample from uterus as early as 14-16 weeks
what is amniocentesis used to determine
1. fetal genetic diagnosis (usually in first trimester)
2. fetal maturity (last trimester)
3. fetal well being

it is performed when uterus rises out of symphysis at 13 weeks and amniotic fluid has formed

it usually takes 10 days to 2 weeks to develop cultured cell karotype--therefore woman could be well into second trimester before diagnosis is made...making choice for abortion more dangerous
what are finding in amniocentesis
1. genetic disorders
a. karyotype: determines down syndrome (trisomy 21), other trisomies, and sex chromatine (sex linked disorders)
b. biochemical analysis: determines more that 60 types of metabolic disorders (tay-sachs)
c. AFP: elevations may be associated w/ neutral tube defects.....low levels may indicate trisomny 21

2. fetal maturity
a. lecithin: sphingomyelin (L:S) ratio: 2:1 ratio indicates fetal lung maturity unless mother is diabetic or has Rh disease or fetus is septic
b. L:S ration and presence fo phosphatidylglycerol (PG) : most accurate determinatio of fetal maturity. PG is present after 35 weeks gestation
c. lung maturity is the best predictor of extra uterine survivial
d. creatinine: renal maturity indicator >1.8
e. organge staining cells: lipid containing exfoliating sebaceous gland maturity >20% stained orage means 35 weeks or more

3. Fetal well being
a. bilirubin delta optical denisity assessment s/b performed in mother previously sensitized to the fetal RH+ RBC and having antibodies to the RH+ circulating cells. The delta OD test measures the change in optical density of the amniotic fluid caused by staining w/ bilirubin-----done at 24 weeks gestation
b. meconium in amniotic fluid may indicate fetal stress
nursing care for baseline for amniocentesis
obtain base line vital signs and FHR
place client in supine position w/ hands across chest
if prescribed shave area and scrub w/ bedadine (povidone/iodine)

draw maternal blood sample for comparison w/ postprocedure blood sample to determine maternal bleeding

provide emotional support, explain procedure, stay w/ the client (DO NOT LEAVE HER ALONE)

label samples; if bilirubin test is prescribed darken room and immediately cover the tubes w/ aluminum foil or use opaque tubes

after speciman is drawn, was abdomen, assist woman to empty bladder (a full bladder can irritate the uterus and cause contractions)

monitor FHR for 1 hour after procedure and assess for uterine contractions and irritability

instruct woman to report any contractions, change in fetal movement, or fluid leaking from vagina
complications of amniocentesis are
spontaneous abortion (1%)
fetal injury
when amniocentesis is done in early pregancy the bladder
must be full to help support the uterus and to help push the uterus up in the abdomen for easy access
when amniocentesis is done in late pregnancey the bladder
must be empty so it will not be punctured
Variables measured by fetal monitoring
1. begining, peak, and end of each contraction
2. duration: length of each contraction from beginning to end
3. frequency: beginning of one contraction to beginning of the next (3-5 contractions must be measured
4. intensity: measured not by external monitoring but in mmHg by internal (intrauterine) montoring after amniotic membranes have ruptured: ranges from 30mmHg (mild) to 70 mmHg (strong) at peak
what is baseline fetal heart rate
the range of FHR (avg. 110-160bpm) between contractions, monotored over a 10 min period

2. the balance betwen parasympathetic and sympathetic impulses usually preduces not observable changes in the FHR during uterine contractions (w/ healthy fetus, a healthy placenta, and good uteroplacental perfusion)
baseline FHR
1. normal rhythmicity
2. average FHR 110-160.
3. description
--a the FHR results from the balance between the parasympathetic and the sympathetic branches of the autonomic NS
b. it is the MOST IMPORTANT indicator of the health of the fetal central NS
baseline variability
1. normal irregularity of cardiac rhythm
2. description
a. short term variability (STV): change in fetal HR from one beat to the next
--1. fetal scalp electrode (internal monitoring) is necessary to evaluate STV
--2. if STV is present, the fetus is not experiencing cerebral asphyxia; therefore ITS PRESCENCE IS A REASSURING SIGN

b. Long ter variability (LTV): avg 6-10 changes per minute; ie heart rate may avg 140 bpm but change from 137-149 during that minute when LTV can be evaluated by external or internal monitoring
fetal accelerations
1. caused by sympathetic fetal response
2. occur in response to fetal movement
3. indicative of a reactive, healthy fetus
early decelerations
1. benighn pattern caused by parasympathetic response (head compression)
2. heart rate slowly and smoothly decelrates at beginning of contraction and returns to baseline at end of contraction

No nursing actions except to monitor the progress of labor

document the processes of labor
what are nonreassuring warning signs
1. variability
2. bradycardia
3. tachycardia
non reassuring variability
1. FHR is abscent or minimal
2. short term variability is abscent
3. long term variability is minimal (3 changes per min)
4. Causes
--hypoxia (asphyxia)
--maternal drug ingestion (narcotics, CNS depressants such as MgSO4)
--fetal sleep
non reassuring bradycardia
1. baseline FHR is below 110 bpm (assessed between contractions) for 10 minutes (as differentiated rom a periodic change

--late manifestation of fetal hypoxia
--medication induced (narcotics, MgSO4)
--maternal hypotension
--fetal heart block
--prolonged umbilical cord compression
non reassuring tachycardia
1. baseline FHR is above 160 bpm (assessed between contractions) for 10 minutes

--early sign of fetal hypoxia
--fetal anemia
--maternal infection, maternal fever
--maternal hyperthyroid disease
--mediation induced (atropine, retodrine, terbutaline, hydroxyzine)
nursing actions for decreased variability, bradycardia, and tachycardia
treatment is based on cause

variable decel pattern
--most common periodic pattern
--occurs in 40% of all labors and is caused mainly by cord compression, but can also indicate rapid fetal descent
characterized by
--an abrupt transitory decrease in teh FHR that is variable in duration, depth of fall, and timeing relative to the contractions cycle
***an occasional variable is usually benign

change maternal postition
stimulate fetus if indicated
d/c oxytocin if infusing
administer oxygen at 10L by tight face mask
perform a vaginal exam to check for cord prolapse
report finding to DR and document
nonreassuring (omnious) Signs
Severe variable decelertion
1. FHR below 70bpm lasting longer than 30-60 seconds
2. slow return to baseline
3. decreasing or absent variability

late decelerations
1. an ominous and potentially disatrous nonreassuring sign
2. indicative of uteroplacental insufficiency
3. the shape of the decelration is uniform and the FHR returns to baseline after the contraction is over
4. the depth of the decelration does not indicate severity; rarely falls below 100 bpm
nursing actions for nonreassuring (omnious) signs severe variable deceleration
1, immediately turn client on side
2. D/C oxytocin if infusing
3. check scalp stimulation for accelerations (a non compromised fetus will demonstrate accelerations w/ scalp compression)
4. administer oxygen 10L by tight face mask
5. assest w/ fetal blood sampling if indicated
6. maintain intravenous line and if possible elevate legs to increase venous return
7. correct any underlying hypotension by increasing IV rate or w/ prescribed meds
8. determine presence of FHR variability
9. notify dr
early decelerations caused by head compression and fetal descent usually occur when?
between 4-7 cm and in the second stage-----check for labor progress if early decelerations are noted
what should be done if cord prolapse is detected
examiner should position the mother to relieve pressure on the cord (knee chest position) or push presenting part off of cord until immediate cesarean delivery can be accomplished
late decelerations indicate uteroplacental insufficiency and are associated w/ what?
diabetes mellitus
cardiac disease
abruptio placentae
when deceleration patterns (late and variable) are associated w/ decreased or absent variability and tachycardias---what does this mean
the situation is ominous (potentially disatrous) and requries immediate intervention and fetal assessment
a decrease in uteroplacental perfusion result in ?
late decelerations
cord compression results in
a pattern of variable decelerations
what is a non stress test used to determine
fetal well being in high risk pregnancy and especiall useful in postmaturity (notes response of the fetus to its own movement)

a healthy fetus will usually respond to its own movement by means of an FHR accelration of 15 beats, lasting for at least 15 seconds after the movement, twice in 20 min period

the fetus that responds w/ 15/15 acceleration is considered reactive and healthy
nursing care for non stress test
1. apply fetal monitor, ultrasound, and tokodynamometer to maternal abdomen
2. give mother handheld event marker and instruct her to push the button whenever fetal movement is felt or recorded as FM on the fetal heart rate strip
3. monitor for 20-30 minutes----observing reactivity

4.. suspect fetus is sleeping if there is no fetal movement---stimulate fetus acoustically or physically, or have mother move fetus around and begin test again
contraction stress test or oxytocin challenge test is
1. the fetus is challenged w/ the stress of labor by the induction of uterine contraction, and the fetal response to physiologically decreased oxygen supply during uterine contractions is noted

--an unhealthy fetus will develop nonreassuring fetal heart rate patterns in response to uterine contractions; late decelerations are indicative of UPI

Contractions can be induced by nipple stimulation or by infusing a dilute soln of oxytocin
nursing care for contraction stress test or oxytocin challenge test is
--assess for contraindications: prematurity, placenta previa, hydramnios, multiple getstation, and previous uterine classical scar, rupture of membranes

--place external monitors on abdiomen (FHR ultrasound monitor and tokodynamometer)

record a 20 minute baseline strip to determine fetal well being (reactivity) and presence or absence of contractions

--to assess fetal well being a recording of at least 3 contraction in 10 minutes must be obtained

if nipple simulation is attempted, have woman apply warm, wet washcoths to nipples and roll the nipple of one breast for 10 min. Begin rolling both nipples if contractions do not begin in 10 minutes. Preceed w/ oxytocin infusion if unsuccessful w/ nipple stimulation

Piggy back w/ oxytocin (10 units of pitocin) to main IV line. Begin at 0,5 mcg/min and increase by 0.5 mcg/min every 20 minutes to achieve three firm contraction, each lasting 40 seconds over a period of 10 min

a negative test suggest fetal well being (ie., no occurrence of late decelerations
danger in nipple stimulation
the danger in nipple stimulation lies in controlling the "dose" of oxytocin delivered by the posterior pitutary. the chance of hyperstimulation or tetany (contraction over 90 seconds or contractions w/ less than 30 seconds in between) is increased
Biophysical profile is used for what
ultrasonograpy is used to evaluate fetal health by assessing 5 variables
1. fetal breathing movements
2. gross body movements
3. fetal tone
4. reactive fetal heart rate (non stress test)
5. qualitative amniotic fluid volume

Each variable receives 2 points for a normal response or 0 points for abnormal or no response
fetal pH blood sampling tecnique
performed only in the intrapartum period when the fetal blood from the presenting part (breech or scalp) ca be taken, (when membranes have ruptured and the cervix is dilated 2-3 cm

this test is used to determine true acidosis when nonreassuring fetal heart rate is noted (late decel, severe variable decel unresponsive to tx, decreased variability unrelated to nonasphyxial causes, tachycardia unrelated to maternal variables)

because fetal blood gas values vary rapidly w/ transient circulatory changes, this test is usually done ONLY in tertiary centers that have the capability of repetitive sampling and rapid results
nursing care for Fetal pH blood sampling
place client in lithotomy position at end of labor bed and prepare w/ perineal cleansing and sterile draping

assist health care provider by gathering steril supplies and prviding ice in cup or emesis basin to carry pipette filled w/ blood to units pH machine or lab
accelerations are cause by
a burst of sympathetic activity; they are reassuring and require not tx
early decelerations are caused by
head compression; they are benign and alert the nurse to monitor for labor progress and fetal descent
variable decelerations are caused by
cord compression; change of position should be tried first
late decelerations are caused by
UPI and chould be treated by placeing client on her side and adminstering oxygen
what is the most important indicator of fetal autonomic nervous system integrity and health
fetal heart rate variability
stages of labor are
latent phase is
from beginning of true labor until 3-4 cm cervical dilation

contractions mild
initially 10-20 min apart
15-20 seconds durations
5-7 min apart
30-40 seconds duration
active phase of labor
from 4-7 cm cervical dialation
increased anxiety
increased discomfort
unwillingness to be left alone
contractions moderate to severe
2-3 min apart
30-60 seconds in duration
transition phase of labor
from 8-10 cm cervical dilation
changed behavior
sudden nausea, hiccups
extreme irritability and unwillingness to be touched
although desire of companionship
contractions severe 1 1/2 min apart
60-90 seconds duration
Intrapartum nusing care begins w/ true labor and consist of what 4 stages
1. from the beginning of regular contractions or rupture of membranes to 10 centimeters of dilation and 100% effacement
2. 10 cm to delivery
3. delivery of the placenta
4. first 1-4 hours following delivery
difference between true labor and false labor
true labor
--pain in lower back that radiates to abdomen
--pain accompanied by regular rhythmic contractions
--contractions that intensify w/ ambulation
--progressive cervical dilatation and effacement

false labor
--discomfort localized in abdomen
--no lower back pain
--contractions decrease in internsity or frequency w/ ambulations
prodromal labor signs include
1. lightening (fetus drops into true pelvis)
2. braxton hicks contractions (practice contractions)
3. cervical softening and slight effacement
4. bloody show or expulsion of mucousl plug
5. burst of energy ---nesting instinct
in prodromal labor determine the following
1. gravidity and parity >5 (grand multiparity)
2. gestational age 37-42 weeks (term gestation)
3. FHR best head over fetal back
4. maternal vital signs
5. contraction frequency, intensity and duration
perform vaginal exam to determine?
fetal presentation and position
cervical dilatation, effacement, position, and consitency
fetal station
assess the client for
status of membranes (ruptured or intact)
urine glucose and albumin data
comfort level
labor and delivery preparation
presence of support person
presence of true or false labor
vaginal exam is preceded by antiseptic cleansing, w/ client in modified lithotomy position then
sterile gloves are worn
exams are not done routinely..they are sharply curtailed after membranes rupture to prevent infection
vaginal exams are performed
prior to analgesia and anesthesia
to determine the progress of labor
to determine whether second stage pushing can begin
the purpose of a vaginal examination is to determine
1. cervical dilation: cervix opens from 0 to 10 cm
2. cervical effacement: cervix is taken up into th eupper uterine segment; expressed in percentage from 0% to 100%---cervix is shortened from 3 cm to <0.5 cm in length; often called thinning of the cervix an misnomer
3. cervical position: cervix can be directly anterior and plapated easily or posterior and difficult to palpate
cervical consistency: it is firm to soft
what is fetal station
location of presenting pare in relation to midpelvis or ischial spines; expressed as cm above or below the spinds
fetal station 0 is
station -2 is
2 cm above the ischial spines
fetal presentation is
the part of the fetus that presents to the inlet
vertex is
head, cephaic
shoulder is
breech is
other variations include
brow (sinciput) and chin (mentum)
fetal position
the relationship of the point of reference (occiput, sacrum, acromion) on the fetal presenting part (vertex, breech, shoulder) to the mothers pelvis. Most common is LOA (left occiput anterior) the point of freference on the vertex (occiput) is pointe up toward the symphysis and direct toward the left side of the maternal pelvis
fetal lie
the relationship of the long axix (spine) of the fetus to the long axis (spine) of themother. It can be either longitudinal (up and down) transverse (perpendicular), or oblique (slanted)
fetal attitude is
relations hipe of fetal parts to one another
flexion or externsion
flexion is desirable so that the smallest diameter of the presenting part move through the pelvis
normal findings for client in labor
--normal FHR in labor = 110-160 bpm
--normal maternal BP: <140/90
--normal maternal pulse: <100 bpm
--normal maternal temp: <100.4 F
--slight elevation in temperature may occur b/c of dehydration and the work of labor. Anything higher indicates infection and must be reported immediatly
determine FHR auscultation schedule
FHR every 30 min in latent phase

FHR every 15-30 minutes in midactive stage

FHR ever 15 minutes in trasition stage
assess maternal vital signs
1. take BP betwen contractions, in side lying position at least every hour unless abnormal (BP increases during contractions

2. take temp every 4 hours until membranes rupture, then every hour
determine birth plan desires for
analgesia and anesthesia
delivery situation
Urine s/b assessed
every 8 hours unless abnormal

normal findings
glucose = 1+ or less
assess contractions when assessing FHR
1. frequency: time contractions from beginning of one contraction to the beginning of next contraction (measured in minutes apart)

duration: time the length of the entire contraction (from beginning to end)

strength--assess intensity of strongest part (peak) of contraction. It is measured by clinical estimation of the indentability of the fundus (use gentle pressure of fingertips to determine it)
if membranes of bag of water has ruptured...signs are
1. nitrazine paper turns black or dark blue
2. vaginal fluid ferns under microscope
3. color and amoutn of amniotic fluid s/b noted
4. woman s/b allowed to ambulate during labor only if the FHR is w/in a normal range and if the fetus is engaged (0 station). if the fetus is not engage, there is an increased risk that a prolapsed cord will occur
begin a graph of labor progress....
1. prolonged latent phase lasts > 20 hours in primgravida
>14 hours in multipara

2. a primigravida dilates an avg of 1.2 cm/hr in the midactive phase; a multipara 1.5 cm/hr
client should be taken to the bathroom or offered a bedpan when during labor
at least every 2 hourse ( a full bladder can impede labor progress)
meconium stained fluid is what color and may indicate what
fluid is yellow green or gold yellow and may indicate fetal stress
should assist woman w/ the use of psychoprophylactic coping techniques such as
breathing exercises and effleurage (abdominal massage)
breathing techniques such as deep chest, accelerated, and cued are not prescribed by the stage and phase of labor but by
the discomfort level of the laboring woman----if coping is decreasing switch to another method
Hyperventilation results in
respiratory alkalosis that is caused by blowing off too much CO2

--tingling in fingers
--stiff mouth
--------have woman breathe into her cupped hands or in a paper bag in order to rebreathe CO2
anesthesia and analgesis is offered when
in midactive phase of labor----if given too early they will retard the progress of labor

if given too late, narcotics increase the risk of neonatal respiratory depression
notify dr if
1. labor progress is retarded
2. maternal vital signs are abnormal
3. fetal distress is noted
facts about 2nd stage of labor
1. Heralded by the involuntary need to push, 10 centimeter of cervical dilatation, rapid fetal descent
---second stage of labor avg. 1 hour for a primigravida and 15 min for a multipara

--the addition of abdominal force to the utrine contraction force enhances the cardinal movements of the fetus: engagement, descent, flexion, internal rotation, extension, restitution, and external rotation
nursing assessment 2nd stage of labor
assess BP and pulse every 5-15 min

detrmine FHR w/ every contraction

observe perineal area for
--increase in bloody show
--bulging perineum and anus
--visibility of the presenting part

palpate bladder for distention

assess amniotic fluid for color and consitency
nursing plans and interventions for 2nd stage of labor
1. document meaternal BP and pulse every 15 min between contraction
2. check fetal heart rate w/ each contraction or by continuous fetal monitoring
3. continue comfort measure: mouth care, linen change, positioning
4. decrease outside distractions
5. teach mother positions such as aquatting, side lying, or high fowler/lithotomy for pushing
6. teach mother to hold breath for no longer than 5 seconds during pushing
7. teach mother to exhale when pushing or use gentle pushing technique (pushing down on vagina, while constantly exhaing through open mouth, followed by deep breath)
determine cervical dilatation before allwoing client to push. Cervix should be completely dilated (10cm) before the client begins pushing or what can happen
if pushing starts too early, the cervix can become edematous and never fully dilate
procedures for delivering in another room
1. transfer multipara at 8-9 cm, +2 station

2. transfer primigravida at 10 cm, w/ presenting part visible between contractions and during contractions

3. set up delivery table, including bulb syringe, cord clamp, and sterile supplies
4. perform perineal cleansing
5. at crowning put gentle counterpressure against the perineum. Do not allow rapid delivery over womans perineum
6. make sure cleint and support person can visualize delivery if they so desire. I fsiblings are present, make sure they are clesly attended to by support person explaining their mom is all right

Record exact delivery time (complete delivery of baby)
third stage of labor
from complete expulsion of the baby to complete expulsion of the placenta

avg length of 3rd stage is 5-15 minutes

the longer the third stage of labor, the greter the chance for uterine atony or hemorrhage to occur
what are signs of placental separation
1. Lengthening of umbilical cord outside of vagina
2. gush of blood
3. uterus changes from oval (discoid) to globular

Mother describes a full feeling in vagina

firm uterine contractions continue
when do you give oxytocin
give oxytocin after the placenta is delivered b/c the drug will cause the uterus to contract. If the oxytocic drug is administered before the placenta is delivered, it may result in a retained placenta, which predisposes the client to hemorrhage and infection
Placental separation procedure
place hand under drap and palpate fundus of uterus for firmness and placement at or below the umbilicus----at signs of placental separation, instruct mother to push gently

take maternal BP before and after placental separation

check patency and site integrity of infusing IV

administer oxytocic medication immediately after delibery of the placenta

observe for blood loss and ask physicia for estmate of blood loss

dry and suction infant, perform apgar assessment, place blanket on mothers abdomen or allow skin to skin contact w/ mother after delivery

place stockinett cap on newborns head or cover head to prevent heat loss

allow faterh or other support person to hold infant during repair of episiotomy

allow siblings present to hold new family member

gently cleanse vulva and apply steril perineal pad

remove both legs simultaneously if legs are in stirrups

provide clean gown and warm blanket

lock bed before moving mother, and raise side rails during transfer
application of perineal pads after delivery
place 2 on perineum

do not touch inside of pad

apply from front to back, being careful not to drag pad across the anus
give immediately after delivery of placenta to avoid trapped placenta

10-20 units added to remaining IV fluid at least 50 ml

may stimulate let down milk reflexs and flow of milk when engorged
indications of oxytocin
uterine atony
adverse reactions of oxytocin
severe afterpains in multipara

methylergonovine maleate (methergine) nursing implications
usual dose: 0.2 mg IM followed by tabs of 0.2 mg every 4-6 hours

use w/ caution in clients w/ elevated BP or reeclampsia

take BP prior to administration and if 140/90 or above, w/ hold and notify dr
methylergonovine indications
uterine atony
methylergonovine adverse reactions

***not given to clients w/ hypertension b/c of its vasoconstrictive action

NEVER give methergine to a client while she is in labor or before delivery of placenta
prostaglandin F2 (Hemabate) nursing implications
contraindicated for clients w/ asthma

dose is 0.25 IM every 15-90 minutes; up to 8 doses

may be given intramyometrially by provider

check temperature every 1-2 hours

auscultate breath sounds frequently
prostaglandin F2 adverse reactions
nausea and vomiting
bronchospasm, wheezing
prostaglandin F2 indications
uterine atony

NEVER Give prostaglandin to a client while she is in labor or before delivery of placenta
fourth stage of labor
the fourth stage of labor is the first 1-4 hours after delivery of placenta
Nursing assessment for 4th stage of labor
A. Review antepartum and labor and delivery records for possible complications
1. postpartum hemorrhage
2. uterine hyperstimulation
3. uterine overdistension
4. dystocia
5. anterpartum hemorrhage
6. magnesium sulfate therapy
7. bladder distension

b. routine postpartum physical assessment

c. mother infant bonding
Nursing planas and interventions for 4th stage of labor
a. maintain bed rest for at least 2 hours to prevent orthostatic hypotension

b. assess bp, pulse, and respirations every 15 minutes for 1 hour, then every 30 minutes until stable (BP<140/90, pulse <100, and respiration <24

D. assess fundal firmness and height, bladder, lochia, and perineum every 15 minutes for 1 hour, then every 30 minutes for 2 hours
fundus should be
firm, midline, at or below the umbilicus. Massage if soft or boggy--------------suspect full bladder if above umbilicus and to the right side of abdomen
Lochia is
rubra (red), moderate, and clots <2 to 3 cm. Suspect undetected laceration if fundus is firm and bright red blood dontinues to trickle. Always check perineal pad and under buttocks
Perineum should be
intact, clean, and slightly edematous. Suspect hematomas if very tender or discolored or if pain is disproportionate to vaginal delivery
one of the most common reasons for uterine atony or hemorrhage in the first 24 hours after delivery
a full bladder--------------if the nurse finds the fundus soft, boggy and displaced above and to the right of the umbilicus, what action should be taken first--------------------perform fundal massage; then have the client empty her bladder-----recheck fundus every 15 minutes for 1 hour, the every 30 minutes for 2 hours
things that should be reported to the doctor are
1. abnormal vital signs
2. uterus not becoming firm w/ massage
3. second perineal pad soaked in 15 minutes
4. signs of hypovolemic shock---pale, clammy, tachycardic, light headed, hypotensive
what should nurse do if analgesics (codeine, meperidine) are given
raise side rails and place call light w/in reach

instruct client not to get out of bed or ambulate w/out assistance

caution client about drowsiness as a side effect
more nursing interventions in 4th stage of labor
Prevent discomfort of afterpains
--keep bladder empty---catherterize only if absolutely necessary
--place warm blanket on abdomen
--administer analgesics as prescribed (usually codeine, acetaminophen, or ibuprofen)

offer fluids PO when woman is alert and able to swallow

apply ice pack to perineium to minimize edema, especially if a thir or fourth degree episiotmy has been performed or if lacerations are present

apply witch hazel compresses for comfort
first degree tear involves
only the epidermis
2nd degree tear involves
dermis, muscle and fascia
a third degree tear
extends into anal sphincter
a fourth degree tear
extends up the rectal mucosa
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