Maternal/OB

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maricar2517
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Maternal/OB
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2012-05-13 03:34:09
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Unit 8
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  1. What is the Dick-Read Method
    Without fear

    • Breathing techniques for relaxation; to break the
    • fear-tension-pain syndrome
  2. What is Lamaze Method
    • Psychoprophylactic Method (PPM) Neuromuscular control – conscious relaxation –
    • 1998 Lamaze International . “Mothers know how to give birth”
  3. What is Bradley Method
    • Husband Coached Childbirth environment control; meds
    • discouraged
  4. What are the 6 care principles from WHO
    • 1. labor to begin on it’s own
    • 2. Freedom of movement throughout LABOR
    • 3. Continuous labor support-does not have to be a nurse
    • 4. No routine interventions
    • 5. Nonsupine positions for birth-vena cava syndrome
    • 6. No separation of mom and babe; promote breastfeeding
  5. Five factors affect process of labor and birth
    • ◦Passenger (fetus and placenta)
    • ◦Passageway (birth canal)
    • ◦Powers (contractions)
    • ◦Position of mother
    • ◦Psychologic response
  6. What is Passenger comprised of?
    • ◦Size of fetal head
    • ◦Fetal presentation
    • ◦Fetal lie
    • ◦Fetal attitude
    • ◦Fetal position
  7. What is Passageway, or birth canal, is composed of?
    • –Bony pelvis
    • –Lower uterine segment
    • Cervix
    • Pelvic floor muscles
    • Vagina
    • Introitus (external opening to the vagina)
  8. Types of pelvis
    • ◦Gynecoid – round shaped (SVD), classic female type; 50% of females
    • ◦Android – heart shaped (C/S), resembling the male pelvis; 23%
    • ◦Anthropoid – oval shaped (C/S), resembling the pelvis of anthropoid apes; 24%
    • ◦Platypelloid – flat shaped (SVD), the flat pelvis; 3%
  9. What are the soft tissue of the passageway?
    • a.After labor begins, uterine body becomes a thick and muscular upper segment, and thin-walled passive muscular segment
    • b.Physiologic retraction ring – separates the above segments
    • c.The cervix effaces (thins) and dilates (opens) to allow fetus to descend into the vaginal canal
  10. What are the primary powers?
    • –Effacement-measured in %
    • Dilation-measured in cm
    • Ferguson reflex-when the head is hitting the perineum floor
  11. What are the secondary powers?
    Bearing-down efforts
  12. Factors affecting the Position of laboring woman
    • ◦Position affects woman’s anatomic and physiologic adaptations to labor
    • ◦Frequent changes in position
    • Relieve fatigue
    • Increase comfort
    • Improve circulation
    • ◦Laboring woman should be encouraged to find positions most comfortable to her
  13. Describe the process of labor
    • }Labor: process of moving fetus, placenta, and membranes out of uterus and through birth canal
    • }Various changes take place in woman’s reproductive system in days and weeks before labor begins
    • }Labor can be discussed in terms of mechanisms involved in process and stages woman moves through
  14. Describe the 1st Stage of labor
    • onset of regular contractions to full dilation
    • Latent 0-3 cm
    • Active 4-7 cm
    • Transition 8-10 cm
  15. Describe the 2nd Stage of labor
    • full dilation to birth
    • phases-
    • latent 0 to +2 station
    • descent +2 to +4
    • transitional +4 to birth
  16. Describe the 3rd Stage of labor
    birth to delivery of placenta
  17. Describe the 4th Stage of labor
    • next two hours after placenta delivery
    • Reestablishment of homeostasis
    • Observation for complications
  18. What are the 7 cardinal movments of mechanism of labor that occur in the vertex position?
    • Engagement
    • Descent
    • Flexion
    • Internal rotation
    • Extension
    • –Restitution and external rotation
    • Expulsion (birth)
  19. Describe Engagement?
    the fetal presenting part as its’ widest diameter reaches the level of the ischial spines of mother’s pelvis
  20. Describe Descent
    the descent fetal presenting part through true pelvis
  21. Describe flexion
    Flexion of fetal head so that the smallest head diameters pass through the pelvis
  22. describe Internal rotation
    to allow the largest fetal head diameters to match the largest maternal pelvic diameters
  23. Describe Extension
    of the fetal head, allowing the shoulders to rotate internally to best fit the mother’s pelvis
  24. Describe Expulsion
    of the fetal shoulders and fetal body
  25. Neurological origins of discomfort
    • Visceral pain
    • Somatic pain
  26. Factors influencing pain response
    • ◦Culture
    • ◦Anxiety & fear
    • ◦Previous experience – difficult, painful
    • ◦Childbirth preparation – family support
  27. Cause of pain in the First stage of labor
    • causes
    • 1) cervical dilation and effacement
    • 2) uterine ischemia
    • a.Pain impulses during this stage – transmitted via T11-T12
    • b.Visceral pain = from cervical changes and uterine ischemia
    • c.Visceral pain – located over lower portion of abdomen, radiates to lumbar area of back and down thighs
  28. Cause of pain in the Second stage of labor
    • during this stage of expulsion, woman experiences perineal or somatic pain
    • a.Pain impulses during this stage – transmitted via S1-S4
    • b.Somatic pain – results from stretching of perineal tissue to allow passage of fetus, and from traction on peritoneum and uterocervical supports during contractions
  29. Cause of pain in the Third stage of labor
    • also called afterpains; similar to stage I
    • a. Pain localized w/cramping and a tearing/bursting sensation resulting from distention and laceration of cervix, vagina and perineal tissue
  30. What is the Gate controlled theory of pain
    • saturation point of which the brain cannot absorb anymore pain
    • Limited number of sensations or messages can travel through sensory nerve pathways to the brain at one time.
    • Can reduce or block pain by closing hypothetic gate in the spinal cord
    • Perception of pain
    • stimuli diminished
  31. Things to do to cope with Labor
    • }Relaxation, Visualization, Imagery, Music, Massage, Energy Work
    • }Conscious Breathing, Hypnosis
    • }Water therapy
    • }Transcultaneous E N S
    • }Acupressure/acupuncture
    • }Heat/cold, Aromatherapy, Biofeedback
    • }Intradermal water block-
  32. Types of breathing techniques
    • 1.Cleansing breath – relaxed breathing in through nose and out through mouth
    • 2.Slow paced breathing: approximately 6-8 breaths per minute
    • a.“In-2-3-4/Out-2-3-4 . . .”
    • 3.Modified paced breathing: approximately 32-40 breaths/minute
    • a.In-Out/In-Out/In-Out. . .
    • 4.Patterned paced breathing – same rate as modified
    • a.3:1 or 4:1 breathing pattern
    • b.Coach called breathing – helps for concentration
  33. What are breathing techniques used for
    • used as tool to help woman maintain control during contractions
    • a.Stage One – promotes relaxation of abdominal muscles to help enlarge abdominal cavity
    • b.Stage Two – increases abdominal pressure to assist in expulsion of fetus
  34. Factors of Sytemic drugs
    • Cross the blood-brain barrier- to provide central analgesic effects
    • ◦Cross placental barrier
    • Effects of fetus
    • Classes include:
    • ◦Narcotic analgesics
    • ◦Mixed narcotic agonist-antagonist compounds-still do affect baby less but also leave the body faster
    • ◦Analgesic potentiators
    • ◦Narcotic antagonists
    • ·IV is immediate effect
  35. Systemic analgesia
    remains major form of analgesia for relief of labor pain; when regional anesthesia no available
  36. Effects of fetus from systemic drugs are dependent on what?
    • a.Maternal dosage
    • b.Pharmacokinetics of specific drug
    • c.Route and timing of administration
    • d. IV preferred over IM – onset of drug faster and more reliable
  37. Classes of systemic drugs
    • ◦Narcotic analgesics (meperidine, fentanyl)
    • ◦Mixed narcotic agonist-antagonist compounds-(Stadol, Nubain) still do affect baby less but also leave the body faster
    • ◦Analgesic potentiators (tranquilizer type drugs, Phenergan, vistaril)
    • ◦Narcotic antagonists (Narcan)
  38. Describe Regional Anesthesia Epidural Block
    • }Complete lumbar epidural block – requires block from T-12 to S-5
    • }Disadvantages of epidural
    • ◦Need for IV line, occasional dizziness, weakness of the legs
    • ◦Difficulty emptying bladder, shivering
  39. Describe Regional Anesthesia Spinal Block
    • }Anesthetic – injected via 3rd, 4th or 5th lumbar interspace into arachnoid space and mixes with CSF
    • }Commonly used for c-sections
    • }Complications
    • ◦General
    • ◦Postspinal headache
    • Blood patch procedure
    • }Advantages
  40. Complications of Spinal Block
    marked hypotension, decreased cardiac output and placental perfusion, and respiratory inadequacy
  41. Advantages of spinal block
    • a.Ease of administration, absence of fetal hypoxia
    • b.Maternal consciousness maintained, no blood loss
  42. Disadvantages of Spinal Block
    • a.Allergy to anesthetic
    • b.Hypotension, respiratory paralysis
  43. Etiology of Post lumbar spinal headache due to Spinal block
    • leakage of CSF from puncture site
    • a.headache, auditory and visual problems for weeks
    • b.Initial treatment – analgesics, bed rest, caffeine, increased fluid intake (150 ml/hr)
    • c.Prolonged problems – autologous blood patch – repairs tear in dura mater of spinal cord
  44. Advantages and Side effects of Epidural
    • }Advantages
    • ◦No maternal hypotension
    • ◦Mom feels contractions but no pain
    • ◦Early ambulation post c-section
    • Allows Mom to care for infant
    • –Facilitates bladder emptying
    • ◦Side effects
    • Nausea, vomiting, pruritus
    • –Urinary retention, delayed respiratory depression
  45. General Anesthesia
    • }Rarely used for uncomplicated vaginal delivery or c-section
    • }Preoperative prep
    • }Recovery room nursing care:
    • ◦Maintain an open airway
    • ◦Maintain cardiopulmonary functions
    • ◦Prevent postpartum hemorrhage
    • ◦Facilitate parent-child attachment
  46. Physiologic Adaptation to Labor - Fetus
    • }Heart rate
    • ◦Normal range 110-160 beats/min
    • }Circulation – affected by:
    • ◦Maternal position, uterine contractions
    • ◦Blood pressure, umbilical cord blood flow
    • }Respiration – review the changes that occur to prepare fetus to initiate breathing immediately after birth
  47. Changes to prepare fetus for breathing
    • a.Fetal lung fluid is cleared from air passages during labor and vaginal birth
    • b.Fetal oxygen pressure (Po2) falls
    • c.Arterial carbon dioxide pressure (PCo2) rises
    • d.Arterial pH falls
    • e.Bicarbonate level falls
    • f.Fetal respiratory movements decrease during labor
  48. When performing auscultation....
    • a.Perform Leopold’s maneuvers to identify fetal presentation and position
    • b.Place listening device over area of maximum intensity and clarity of fetal heart tones
    • c.Palpate abdomen for absence of uterine activity to count FHR between contractions
    • d.Count maternal radial pulse while listening to FHR; to differentiate from infant’s
    • e.Count FHR 30-60 seconds between contractions to identify baseline rate
    • f.Auscultate FHR during contraction and 30 seconds after end of contraction; to identify increases and decreases
  49. When assessing uterine activity...
    • examiner should place hand over fundus before, during and after contraction
    • a.Intensity – describe as mild, moderate or strong
    • b.Contraction – measured in seconds, from beginning to end of ctx
    • c. Frequency – measured in minutes from beginning of one contraction to beginning of next ctx
  50. Fetal oxygen supply...
    must be maintained during labor to prevent fetal compromise and promote newborn health after birth
  51. Reasons for reduction...
    reduction of blood flow thru maternal vessels, reduction of oxygen content in maternal blood, alterations in fetal circulation, reduction in blood flow to the intervillous space in the placenta
  52. Normal uterine activity pattern in labor
    • a.Contractions occurring every 2-5 minutes, lasting less than 90 seconds
    • b.Contractions are moderate to strong in intensity, as evidenced by palpation
    • c.Contractions intensity is < 100 mm Hg, as measured by intrauterine pressure catheter
    • d.30 seconds or more should elapse between end of one contraction and beginning of the next
    • e.Between contractions uterine relaxation should be detected by palpation or by average intrauterine pressure of 15 mm Hg or <
  53. Goals of intrapartum FHR monitoring
    to identify and differentiate the reassuring patterns from the nonreassuring patterns, which may be indicative of fetal compromise
  54. Non-reassuring patterns of intrapatum FHR monitoring are associated with
    • a.Fetal hypoxemia – a deficiency of oxygen in the arterial blood. If uncorrected, hypoxemia can lead to severe fetal hypoxia
    • b.Fetal hypoxia – an inadequate supply of oxygen at the cellular level
  55. Typical non-reassuring FHR patterns include:
    • a.Progressive increase or decrease in baseline rate
    • b.Tachycardia of 160 beats per minute or more
    • c.Progressive decrease in baseline variability
    • d.Severe variable decelerations – FHR < 60 bmp lasting longer than 30-60 sec., with rising baseline, decreasing variability, or slow return to baseline
    • e.Late decelerations of any magnitude, especially those that are repetitive and uncorrectable, with decreasing variability or rising baseline FHR
    • f.Absence of FHR variability
    • g.Prolonged deceleration - > 60-90 seconds
    • h.Severe bradycardia - < 70 BPM
  56. Baseline FHR reanges
    • Baseline- ranges 110-160 beats/minute
    • ◦Tachycardia - > 160 beats/minute
    • ◦Bradycardia - < 110 beats/minute
  57. What is the basline FHR stand for
    average rate during 10 minute segment that excludes periodic or episodic changes, periods of marked variability, and segments of baseline that differ by > 25 bpm
  58. Clinical significance of tachycardia
    early sign of fetal hypoxia; resulting from maternal or fetal infection, maternal hyperthyroidism, fetal anemia, or response to drugs
  59. Clinical significance of Bradycardia
    a later sign of fetal hypoxia, occurs before fetal demise; resulting from placental transfer of drugs, prolonged compression of umbilical cord, maternal hypothermia, maternal hypotension
  60. Clinical significance of Stages of Variability
    • 1.based on visualization of amplitude in the peak to trough segment in beats/minute
    • a.Absent or undetected variability
    • b.Minimal - > undetected but not > 5 beats/minute
    • c.Moderate – 6-25 beats/minute
    • d.Marked - > 25 beats/minute
  61. Valsalva manuever
    • a.Increases intrathoracic pressure t reduces venous return t increases venous pressure
    • b.Cardiac output and blood pressure m and pulse rate o temporarily
    • c.During this period; fetal hypoxia can occur
    • d.Process is reversed when mother takes a breath
  62. Why is valsalva manuever discouraged?
    • }increased WBC, temperature and respirations
    • }Proteinuria
    • }decreased gastric motility, absorption of food
    • }decreased blood glucose
  63. What is assessed in 1st Stage
    • }History-prenatal record:
    • ◦potential complications ?
    • ◦last food/fluid intake?
    • ◦Ask re: spontaneous rupture of membranes (SROM).
    • }Vitals
    • }Labs
    • ◦blood,
    • ◦Urine
  64. ?What does Leopold's Manuever's help identify?
    • ◦Number of fetuses
    • ◦Presenting part, fetal lie, fetal attitude
    • ◦Degree of presenting part’s descent into the pelvis
  65. what is the Nitrazine test?
    • differentiates amniotic fluid, which is slightly alkaline, from urine and purulent material which are acidic
    • a.Membranes intact 5.0 – 6.0 (acidic)
    • b.Membranes ruptured 6.5 – 7.5 (alkaline)
    • c.Document as positive or negative
  66. What is Artificial (AROM) or amniotomy
    • Sterile procedure; often hastens labor
    • ◦Check color (what does it mean?)
    • 1.Color – pale straw colored with white particles
    • 2.Viscosity and odor – watery and lacks strong odor
    • 3.Amount – expected amount of 500-1200 ml

    • ◦Potentially hazardous (cord prolapse)
    • ◦Nitrazine test for pH
  67. When to reasses with signs of labor progression
    • Sudden change in UC’s
    • }Request for pain meds (often 1st sign)
    • }Change in behavior (transition), vomits
    • }ROM
    • }Urge to defecate
    • ®Check FHT & do vag exam
  68. Emergency Interventions – 1st Stage
    Signs necessitating immediate intervention
    • ◦Non-reassuring FHR patterns
    • ◦Inadequate uterine relaxation
    • ◦Vaginal bleeding
    • ◦Infection
    • Prolapse of cord
  69. Nursing Care 2nd Stage
    • Begins with anticipation of birth
    • ◦Full cervical dilation & effacement
    • }Phases (check station)
    • ◦Latent – rest and relative calm
    • ◦Descent – strong urges to bear down
    • ◦Transition – presenting part of head is on perineum
  70. Nursing Care: 2nd Stage
    Episiotomy (routine use controversial)
    • most common = midline
    • ◦d/t crowning, anesthesia not needed
    • ◦minimal bleeding
    • }[From readings: know laceration degrees]
    • }“Circle of fire” with birth of head
  71. Types of episiotomies
    • a.Midline (median) – most common in US
    • i.Third degree laceration/extension – midline episiotomy extending through renal sphincter
    • ii.Fourth degree – extending into anal canal
    • Mediolateral – greater blood loss, more difficult to repair
  72. Types of perineal lacerations
    • a.First degree – laceration extends through the skin and structures superficial to muscles
    • b.Second degree – laceration extending through muscles of perineal body
    • c.Third – laceration continues through anal sphincter muscle
    • d.Lacerations can also involve anterior rectal wall
  73. Attendant checks for nuchal cord, delivers body & announces sex
    Nurse notes delivery time
    • }Infant placed on abdominal or warmer
    • }Cord clamped & cut
    • }Nurse performs:
    • ◦drying, applies cap
    • ◦does APGAR scoring 1min. and 5min.
    • }If stable, wraps & presents infant to parents (critical for bonding)
  74. Infant assessment
    • 1.Checking airway and APGAR scoring
    • 2.Identification procedures
    • 3.Checking cord for three vessels
  75. Nursing Care: 3rd Stage
    • }Placenta delivered by attendant (spontaneously or manually extracted)
    • ◦Nurse notes time
    • }attendant inspects placenta: intact? quality?
    • }Promote uterine involution:
    • ◦Prepare Pitocin if ordered, fundal massage
    • ◦Baby to breast
    • }Perineal suture (but give mom attention)
  76. Goal of 3rd stage
    • 1.Goal – prompt separation and expulsion of placenta, achieved in safest and easiest manner
    • 2.Placenta separation
    • a.Firmly contracting fundus
    • b.Change in uterus from discoid to globular ovoid shape
    • c.Sudden gush of dark blood from introitus
    • d.Lengthening of umbilical cord
    • e.Vaginal fullness
  77. Nursing Care: 4th Stage
    • }Vital signs per policy (cardiac output change)
    • }Monitor amount of vaginal flow
    • }Assess for bladder distension, cath prn
    • }Clean her up, clean peri-pad & gown
    • }Let her get some sleep

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