304 exam 2: electric boogaloo

5 P's (factors affecting labor)

Passageway (birth canal)
- gynecoid is preferable type of pelvis, anthropoid ok too
Passenger (fetus and placenta)
Powers
- Involuntary contractions which aids in:
+ Effacement: shortening and thinning (0-100%)
+ Dilation: widening and retraction of cervi

Engagement

Presenting part reaches the pelvic inlet and is at the level of the ischial spines

Fetal position

Relationship of a reference point on the presenting part to the four quadrants of the maternal pelvis
?Occiput (O)
?Sacrum
?Mentum (chin)
?Sinciput (deflexed vertex)

Station

Relationship of the presenting part to the ischial spines
Negative is above the ischial spine, positive is below

True vs false labor

True Labor ? regular contractions w cervical dilation and shortening, back pain, not relieved by ambulating
False labor ? irregular contractions (not progressively stronger), w/out cervical changes., lower abdomen/groin pain, pain is more easily relieved

Stages of Labor

First stage
- Onset of regular contractions to 10 cm dilation
Second stage
- 10 cm (or onset of pushing) to birth of fetus
Third stage
- Birth of fetus to birth of placenta
Fourth stage
- Return to homeostasis (about 2 hours after birth of placenta)

First stage of labor (three phases)

Onset of regular contractions to 10 cm dilation
latent phase (6-8hrs)
- excited, communicative
active phase (3-6hrs)
- inwardly focused, serious, fatigue, pain
transition phase (20-40min)
- vague communication, severe, pain, irritable, loss of control

Second stage of labor

10 cm (or onset of pushing) to birth of fetus
This lasts about 2-3 hours, faster if multip and not using epidural

Mechanisms of labor

Descent
(Engagement)
Flexion
Internal rotation
Extension
Restitution
External rotation
Expulsion

Signs of placental separation

Firmly contracting fundus
Change in shape of uterus
Sudden gush of dark blood from introitus
Apparent lengthening of umbilical cord
Sensation of vaginal fullness
Do not massage fundus until placenta has detached

Admission interview (during intrapartum assessment)

Presenting symptoms
- Fetal movements
- Contractions
- Leakage of fluid/vaginal bleeding
- Pain
Prenatal data
Psychosocial factors
Stress in labor
Cultural factors

Cultural preferences (during intrapartum assessment)

Support people in the labor/birth room
Garments
Labor preferences
Birth position
Temperature of fluids
Privacy

Physical assessment (during intrapartum assessment)

Vital signs, weight
Lungs
Fundus
Edema
Hydration
Perineum
Fetal movement
Fetal heart rate
Presentation
Position
Uterine contractions
Cervical dilation
Cervical effacement
Fetal descent
Membranes

Uterine contractions - methods of assessment

External palpation
- Not continuous
- Provides timing, not strength
External monitoring
- Continuous
- Provides timing, not strength
Internal monitoring
- Continuous
- Provides timing AND strength

Leopold's maneuver

First maneuver
- Which part occupies the fundus?
- Am I feeling buttocks or head?
Second maneuver
- Where is the fetal back?
- Where are the small parts or extremities?
Third maneuver
- What is in the inlet? Does it confirm what I found in the fundus?
- I

Indications for Continuous External Fetal Monitoring (EFM)

Hx stillbirth at term
Presence of high-risk factors (Table 17-2)
Induction of labor
Preterm labor
Decreased FM
Non-reassuring fetal status
Meconium
Hx of C/S

Fetal heart rate baseline

Average rate during a 10 minute period, rounded to closest 5 bpm
Normal: 110-160 bpm

Fetal heart rate variability

Irregular waves or fluctuations in the baseline FHR measured in peak to trough
- Excludes accelerations and decelerations
Absent/minimal: undetectable to ?5 bpm
- Abnormal or indeterminate
Moderate: 6-25 bpm
- Normal
Marked: ?25 bpm
- Unclear significance

Fetal heart rate accelerations

Abrupt increase in FHR (onset-peak<30 seconds) of >15 bpm lasting >15 seconds but <2 minutes
- If <32 weeks GA: increase of 10 bpm for >10 seconds
Indicates fetal wellbeing

Decelerations acronym (VEAL CHOP)

Variable = Cord compression
Early = Head compression
Accelerations = Okay
Late = Placental insufficiency

Early decelerations

Gradual (?30 seconds) decrease in and return to baseline FHR
Mirrors uterine contractions
Indicates fetal head compression (normal, benign)

Late Decelerations

Gradual (?30 seconds) decrease in and return to baseline FHR
Begins AFTER the contraction has started, reaching lowest point after peak of contraction
Indicates disruption in fetal oxygenation
- Uteroplacental insufficiency
- Maternal hypotension

Nursing Interventions for late decelerations

Lateral position
Increase IV rate
D/C oxytocin PRN
O2 @ 8-10L/min via face mask
Elevate legs
Notify provider
Assess for tachysystole
Prepare for possible internal monitoring or immediate birth (C/S or assisted vaginal)

Variable decelerations

Abrupt (<30 seconds) decrease in FHR below baseline of >15 bpm for >15 seconds but <2 minutes
Causes
- Umbilical cord compression
- Occasional variables are typically benign
- Recurrent variables may result in hypoxemia

Nursing Interventions for recurrent variable decels

Change maternal position
D/C oxytocin PRN
O2 @ 8-10L/min via face mask
Notify provider
Prepare for possible SVE, amnioinfusion, C/S

Prolonged deceleration

Gradual or abrupt decrease in FHR of >15 bpm below baseline lasting 2-10 minutes
- If >10 minutes, this is a baseline change

Nursing interventions for prolonged decels

Notify provider
Vaginal exam
Lateral position
Increase IV rate
D/C oxytocin (if using)
O2 @ 8-10 L/min via face mask
Prepare for possible internal monitoring or immediate birth (C/S or assisted)

FHR tracing evaluations

Category 1 (normal)
Category 2 (indeterminate)
Category 3 (oh shit)

FHR category 1

Normal
FHR 110-160 beats/min
Normal FHR variability in the moderate range
No variable or late decelerations
Accelerations present or absent
Early decelerations present or absent
No specific action required

FHR category 2

Indeterminate
Baselines include bradycardia with continued variability or tachycardia
Baseline changes in variability
No accelerations with scalp stimulation
Episodic decelerations
Variable decelerations
Requires evaluation, continued surveillance, and re

FHR category 3

Abnormal
Absent variability in baseline FHR
Recurrent late decelerations, recurrent variable decelerations, and/or bradycardia
Sinusoidal FHR patterns may be present
Requires prompt evaluation and likely urgent birth

Amniotomy

Artificial Rupture of Membranes (AROM)
Induce or augment labor

Cervical ripening

the process of softening and thinning the cervix by artificial means
prostaglandins

Oxytocin (Pitocin) - given IV

Therapeutic use
- Induces or augments labor
- Prevents or treats PPH
Complications
- Uterine hyperstimulation
- Hypertensive crisis
- Water intoxication
Contraindications
- Cervix unripe
- Fetal distress
- Malpresentation
- Prolapsed umbilical cord
Intera

Preventing Episiotomies

Perineal massage during pregnancy
Guided vs directive 2nd stage
Side-lying position for 2nd stage
Warm compresses on perineum
Firm counterpressure on perineum
Gradual expulsion of neonate

Cesarean section risks

Maternal mortality is higher
Perinatal mortality is higher
Uterine rupture
Bleeding problems
Placenta previa
Abruptio placentae
Neonatal respiratory distress

Preparation for c section

Establishing IV lines
Placing urinary indwelling catheter
Performing abdominal prep
Good communication
Therapeutic touch and eye contact, if culturally appropriate for client

Care after C section

Routine postpartum care including
- Fundal checks
- Care of incision
- Monitoring intake and output and maintaining IV access
- Administer and teach about postoperative medications
- Assessment of respiratory system
- Assessment of bowel sounds

TOLAC and VBAC

Trial of labor after cesarean/ Vaginal birth after cesarean
Most common risks are:
- Hemorrhage
- Infection
- Operative injuries
- Thromboembolism
- Hysterectomy
- Death
- Uterine rupture
- Infant death or neurologic complications
Nursing management
- Con

Admission Care - advanced labor? painless bleeding?

If signs of advanced labor
- Visualize perineum
- Sterile vaginal exam?
- Contact provider
If painless bleeding
- Do NOT do a vaginal exam
- Contact provider

When to contact provider

?Vaginal bleeding
?Meconium-stained fluid
?Absence of fetal movement
?Prolapsed umbilical cord
?Birth imminent

Nursing Care for 1st Stage: goals

Maternal stability
Fetal well-being
duh (sorry this was a blue note I didn't wanna skip it)

Nursing Care for 1st Stage: assessments

FHR and pattern - every 15/30 min
Contraction pattern
Vaginal bleeding/ROM
Pain
Hydration
Elimination
Vital signs, especially pain

Nursing Care for 1st Stage: interventions

Communicate with MD/CNM
Intake/Output
Pain management
Position changes
Pericare
Medications
Labor support
Support of partner/family
Prepare for newborn stabilization (NRP)

Gate-Control Theory of Pain

A limited number of messages can travel along a pain pathway
Distraction may reduce or block the capacity of the pathway to transmit pain
e.g. use of effleurage (light rhythmic stroking)

Counterpressure

Pressure applied to the sacral area of the back during uterine contractions
Good for back pain

Nursing care for 2nd stage: goals

Maternal stability
Fetal well-being
ok laura we get it

Nursing care for 2nd stage: assessments

FHR and pattern
Maternal VS
Contraction pattern
Vaginal bleeding/ROM
Pain
Hydration
Elimination

Nursing care for 2nd stage: interventions

Communicate with MD/CNM
Position changes
Pericare
Medications
Pain management
Intake/Output
Labor support
Support of partner/family
Prepare for newborn stabilization (NRP)

Mechanism of Birth

Crowning signals impending birth of head
Birth of head
- Modified Ritgen maneuver
- Check of nuchal cord
- DO NOT SUCTION MOUTH AND NOSE (PER AAP)
Birth of shoulders
Birth of body and extremities

Precipitous Birth

Support client
Send for help and "precip pack"
Comfortable position
Clear, reassuring communication
Do not leave the client!
Wash hands and glove

Immediate Care of Newborn

Maintain warmth and airway
APGAR scoring at 1 and 5 minutes
Cut umbilical cord
Identification bands

Nursing Care for 3rd Stage: goals

Maternal stability
Deliver placenta
Prevent postpartum hemorrhage

Nursing Care for 3rd Stage: assessments

Bleeding
Maternal VS
Signs of placental detachment
Bonding/attachment
Breastfeeding

Nursing Care for 3rd Stage: interventions

Medication administration
Assist MD/CNM with suturing
Fundal massage
Hygiene
Support bonding, attachment, breastfeeding
Education
Safety

Priorities for 4th Stage

Maternal stability
Newborn stability
Monitor for complications
?Bleeding
?(More details during high-risk)
Support transition to parenthood
Education

Pain During Labor

1st stage: Visceral
Transition and early 2nd stage: Somatic
Late 2nd stage and birth: Visceral

Pharmacologic Pain Management

Combine nonpharmacologic and pharmacologic measures
Informed consent!
- Med, route, expected effects, implications for fetus/newborn, safety measures
Consider timing to minimize negative impacts

Nursing Considerations Before Med Administration

Goal
- Provide maximum relief with minimal risk
+ All medications cross placental barrier
+ Action depends on rate it is metabolized
Interventions
- Void
- Assume comfortable and safe position
Mom
- vitals stable, in labor, consent
Baby
- category 1 FHR t

Analgesia vs Anesthesia

Analgesia
?Alleviates pain by decreasing sensation or increasing pain threshold
?No loss of consciousness
Anesthesia
?Analgesia, amnesia, relaxation, reflex activity
?Interrupts nerve impulses to brain
?+/- loss of sensation and/or consciousness

Maternal Hypotension

Signs: Fetal bradycardia, minimal FHR variability
Nursing Interventions
?Lateral position
?Maintain or increase IV rate
?O2 via nonrebreather at 10-12L/min
?Elevate legs
?Notify provider and/or anesthesia team
?IV vasopressor per protocol (ephedrine or ph

Stadol (butorphanol tartrate)

Use: opioid analgesic
Contraindication: narcotic dependency
Side effects: respiratory depression in neonate

Nubain (nalbuphine hydrochloride)

Use: opioid analgesic
Contraindication: narcotic dependency
Side effects: respiratory depression in neonate

Fentanyl (Sublimaze)

Use: opioid analgesic
Contraindication: narcotic dependency
Side effects: respiratory depression in neonate (even though it does not cross the placenta)

Analgesic potentiators

e.g. Promethazine, hydroxyzine, promazine
?Sedation to promote rest
?Reduce side effects of pain meds

Naloxone (Narcan)

Use: opioid antagonist -- reverses respiratory depression
Contraindication: narcotic dependency (can cause severe withdrawal)

Epidural

Client Preparation
Void
CBC
18 gauge IV: Bolus of 500-1000 mL of IV fluid
Assessments
?VS frequently?Sensorimotor ability?Bladder distension
Interventions
?Position changes?Protect lower extremities from injury
Side effects
?Breakthrough pain?Sedation?N/V

Spinal anesthesia

Client Preparation
16- to 18-gauge intravenous (IV) catheter: Bolus 500 to 1000 mL IV fluid
Position woman sitting or lateral
Assessments
?BP and pulse?Uterine contractions
Intervention
?Position woman supine with left uterine displacement (rolled towel o

General Anesthesia

If epidural or spinal is contraindicated or insufficient time to place
Risks
?Difficulty with or inability to intubate
?Aspiration of gastric contents
?Fetal depression -> hypoxia
Client education: Facilitate bonding ASAP
Assess for atony