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What are the signs and symptoms of impeding labor?
- Braxton-hicks contractions
- Cervical changes
- surge in energy
- diarrhea, indegestion, N/V, weight loss
- bloody show
What is lightening and when does it usually occur?
the descent of baby, and occurs roughly 2 weeks before term in first time pregnancy the woman may feel like she can breathe more easily but has more pressure on bladder
What are Braxton-Hicks contractions?
irregular uterine contractions that do not result in cervical change and are associated with false labor, but begin to coordinate the many muscle layers of the uterus to perform when true labor begins
What is nesting?
a surge in energy and may feel the need to put everything in order
What is bloody show?
brownish or blood tinged mucus discharge; a breakage of capillaries = cervix is dilating and labor will probably occur in 24-48 hours
The process by which the uterus expels the fetus, placenta and amniotic sac is known as the 5 "Ps" what are the five Ps?
- Powers: Uterine contractions & bearing down/pushing
- Passageway: Bony pelvis, cervix, vagina and the pelvic floor
- Passenger: Fetus
- Psyche: ability to cope with labor process
- Position: maternal posture
Contractions are both rhythmic and ? What do contractions cause? How are they assessed? What are the phases?
- Rhythmic: and intermittent
- They cause: dilation and effacement
- Assessment: Frequency, duration, and intensity( milf moderate or severe)
- Phases: increment, acme, decrement and resting phase
What is bearing down and when does it occur?
occurs once the cervix is 10 cm dilated, and the woman feels the urge to push and she will involuntary "bear down" triggered by Ferguson's reflex (presenting part stretches pelvic floor muscles, stretch receptors are activated, releasing oxytocin which stimulates contractions) they are enhanced when the woman contracts her abdominal muscles and pushes
How is frequency of a contraction measured? duration?
- Frequency: The start of one contraction to the start of the next; recorded in minutes
- Duration: time from the start of the contraction to the end of the same contraction; measured in seconds
The ascending or build up of the contraction that begins in the fundus and spreads throughout the uterus; the longest part of the contraction.
the peak of intensity; the shortest part of a contraction?
The descending or relaxation phase of the uterine muscle
What is the resting phase?
The period with each contraction that allows the woman and the uterine muscle to pause; during the pause blood flow to the fetus returns. (with every contraction 500ml of blood leaves the utero-placental unit and moves back into maternal circulation)
What is the passageway?
- Soft tissue: the cervix (dilates and effaces); pelvic floor ( supports fetus during birth); Vagina ( expands during birth); Bladder ( full bladder may interfere with birth)
- Bony pelvis: There are different shapes of pelvis'; false vs true pelvis; pelvic joints (relaxin and estrogen soften cartilage and increase elasticity of ligaments to allow room for fetal head during birth)
What is the most common/favorable pelvis for birth? What is the least common?
What is the false pelvis? The true pelvis?
- False: the shallow upper section of the pelvis
- True: the lower part of the pelvis and consists of three planes (inlet, midpelvis, outlet) which define obsetric capacity of the pelvis
What is the passenger?
- It i the relationship between the fetus and the passageway; will influence the birth process.
- Fetal skull:
- Fetal attitude:
- Fetal Lie:
- Fetal presentation:
- fetal position:
- fetal size:
How does the fetal skull influence the birth process? Fetal attitude? Fetal lie? Fetal presentation? Fetal position? Fetal size?
- Skull: largest part of the fetus; must pass through the birth canal(pelvis;vertex is presneting part;is usually flexed so that the smallest part enters pelvis first (biparietal diameter = 9.25 cm)
- Attitude: aka postures is the relationship of fetal parts to one another; noted by the flexion or extension of fetal parts
- Lie: relationship between long axis(spine) of fetus to long axis of mother; longitudinal vs transverse
- Presentation: The part of the fetus that is coming first (vertex, breech, shoulder, compound)
- Position: Relationship between a point of reference on the presenting part and the four quadrants of the maternal pelvis; can change fetal position by changing maternal position
There are 6 positions for each presentation;the position is designated by a 3 letter acronym. What does the first letter designate? The second? the third?
- First: the location of the presenting part to the left (L) or to the right (R) to the womans pelvis
- Second: The specific fetal part presenting; occiput (O); sacrum (S); mentum [face](M); acromion [shoulder] (A)
- Thrid: the relationship of the presnetingfetal part to the woman's pelvis; Anterior (A); Posterior (P); transverse (T)
What is molding?
the fetal skull changes to fit through maternal pelvis
What is the station?
- The relationship of presenting part to the ischial spines of maternal pelvis.
- 0 = at the level of the spines
- minus (-) = presenting part is above the ischial spine
- plus (+) = presenting part is below level of spines
What is engagement? when in labor does it occur?
is also known as 0 station; prior to labor in primigravidas and during labor for multigravidas
What is the psyche? Why is it important? How can the nurse promote a positive experience?
The woman's cultural and individual values influence how she will be able to cope with child birth; a very emotional time; by incorporating as many of the family's birth expectations as possible
What kind of support during labor does the nurse give?
- Emotional: continuous presence, reassurance, praise
- Informational: progress of labor, coping techniques
- Comfort: touch, massage, baths/showers, adequate fluid intake, output
- Advocacy: assist family and woman to be involved in decision making
What is the [maternal] position and why is it important? What should be done in the first stage of labor? second?
- maternal position influences anatomical and physiological adaptions to labor;
- first: upright; walking, sitting, kneeling, squatting, lateral; decreases compression of descending aorta and ascending vena cava; aids in the descent of the fetus; and position changes reduces fatigue, increases comfort, improves circulation
- second: upright increases the pelvic outlet and helps to align fetus with the pelvic outlet; lithotomy position is most common in the USA
What is true labor vs false labor?
- False: irregular contractions that are relieved with walking or change in activity, bloody show is usually not present; there is no change in dilation or effacement of cervix
- True: contractions gradually develop a regular pattern; become stringer and more effective wit walking, discomfort in lower back/ abdomen, bloody show is often present; progressive effacement and dilation of cervix must have both cervical changes and regular contractions
What does AROM stand for? SROM? PROM? PPROM?
- AROM: artificial rupture of membranes
- SROM: spontaneous rupture of membranes
- PROM: premature rupture of membranes ( at term, but before onset of labor)
- PPROM: preterm premature rupture of membranes
What can we do to verify amniotic fluid?
- Nitrazine paper: turns blue when in contact with amniotic fluid, can be dipped in vaginal fluid or Q-tip can be rolled over paper
- Speculum exam: observe for pooling in vaginal "vault"
- Ferning: during a sterile vaginal exam, a sample of fluid in the upper vaginal area is obtained. the fluid is placed on a slide and assessed for a ferning pattern
What is the first thing to do when ROM occurs? why?
Assess FHR; there is an increased risk for cord prolapse when the presenting part is not engaged.
What do we assess when assessing the amniotic fluid? What do we documnet after SROM?
- Color: clear or cloudy not green
- Odor: smells similar to ocean water not malodorous
- Time: we don't want ROM too early because HRO infection
- Document: date, time of SROM, characteristic of fluid and FHR
Is meconium in the amniotic fluid normal?
no, it should be reported to HCP; could be sign of fetal compromise in utero
What are the "mechanisms of labor or cardinal movements?
- Internal rotation:
- External rotation:
First stage: Latent phase
- Dilation: The onset- 3 cm
- Lasts: 8-10 hours
- Contractions: 5-10 minutes apart; mild in intensity (strong menstrual cramps) lasting 30-45 seconds; often irregular
- Mom's attitude: excited, calm and active
First stage: active phase:
- Dilation: 4-7 cm
- Lasts: 3-6 hours
- Contractions: 2-5 minutes apart; moderate in Intensity: 45-60 seconds long; regular
- Mom's attitude: more serious; attention to internal sensations; ignoring everyone in room
- mom should come to the hospital if not already there
First stage: Transition
- Dilation: 8-10 cm
- Lasts: 1-3 hours
- Contractions: 1-2 minutes apart; lasts 60-90 seconds; strong in intensity
- Mom's attitude: she's working hard, may be discouraged, and irritable
- AKA pushing stage; begins with full dilation and ends with birth of baby
- Lasts: several minutes- 2 1/2 hours
- Women should wait till she feels the urge to push
- begins with birth of baby and ends at birth of placenta; decrease in size of uterus results in the placenta separating from the uterine wall.
- lasts: 5-30 minutes
begins with delivery of placenta and lasts about 4 hours until mom is stabalized; monitor vitals q 15, check fundus, lochia, bladder, mother/baby interaction; onset of postpartum
during admission data collection, there are which three major, prompt assessments done?
- First: make sure there is not an impending birth
- Next: assess fetal condition (very important
- Third: Maternal condition
What are the signs and symptoms of impending birth?
- sitting on one buttocks
- making grunting noises
- bearing down
- saying "the baby's coming"
- bulging perineum
- fetal presenting part is visible
Admission to birth unit includes what?
- admission record
- review prenatal record
- review birth plan
- start IV (18 guage in case you need blood product; usually LR)
- send blood for lab work
- GBS status
- assess cultural needs
- establish therapeutic relationship
- explain procedures, answer questions, address concerns or woman in support people
When is GBS treated?
prophylaxis antibiotics at 35-37 weeks; during labor; if its in urine maybe treated sooner
after admission to the unit nursing care includes what?
- monitoring the fetus: (FHT)
- Monitor the laboring women: contractions, cervical changes, vital signs and pain
- Help woman cope
What is the goal of fetal heart rate assessments?
the interpretation and ongoing assessment of fetal oxygenation
FHR assessments are based on what? When do they increase? how often in active phase? when pushing? how should it be assessed for ROM? for basline/ admission?
- Based on: risk status, stage of labor, ongoing clinical assessment
- Increased: when abnormalities are present or are suspected
- Active phase: q 15 minutes
- Pushing: q 5
- ROM: before and after ROM
- Baseline: for 20 minutes when first evaluated/admitted for labor
Where is the best placement for an external fetal monitor? what is the advantage? the disadvantage? What does it detect?
- best heard over the fetal upper back;
- Advan: it is noninvasive
- Disadvan: less accurate
- detects: FHR baseline, variability, accelerations and deceleration
What is an internal fetal monitor? how is it used? what is the advantage and what is the disadvantage
What is the baseline FHR?
The average FHR over 10 minutes
What is the variability? Accelerations? Decelerations? Tachycardia? Bradycardia?
What is the most important predictor of adequate fetal oxygenation?
What is fetal variability?
- the normal irregularity(fluctuations) of cardiac rhythm. D/T continuous balancing interaction between the sympathetic (increases HR) and parasympathetic (decreases HR) nervous system of the fetus; accels and deccels are excluded from evaluation of variability
- visually measured as the amplitude of the peak-to-trough in beats per minute. 4 kinds
What are the four kinds of variability?
- Absent: amplitude range not detected
- Minimal: amplitude at < 5bpm
- Moderate: 6-25 bpm
- Marked: >25
What are some of the causes of minimal and absent variability? and what can be done?
- Fetal: prematurity, state of sleep (babies sleep in 20-30 minute increments
- Maternal: drugs (sedatives, narcotics), supine hypotension, cord compression, uterine tachysytole (doesn't stop contracting)
- Nursing action: turn mom on side, IV at High rate, O2 for mom
What are fetal accelerations?
The normal increase from baseline in FHR that occurs with fetal movement or stimulation. Minimum 15 bpm above baseline for a minimum of 15 seconds
What are fetal decelerations?
are classified by shape, timing and duration in relationship to contractions; 4 kinds, recurrent when occuring with at least 50% of contractions over a 20 minute period
In relation to decels, what does onset mean? descent? nadir? recovery? duration?
- Onset: point at which FHR drops below baseline
- Descent: the onset to nadir (how long?)
- Nadir: lowest point of the decel
- Recovery: nadir to return to baseline
- Duration: onset to return to baseline (how long)
What are early decels?
- they are due to head compression (babies head coming down)
- Shape: inversely mirrors contraction
- Onset: just prior to or early in UC
- Returns to baseline with the end of UC
- Onset to nadir: 30+ seconds
- Treatment: none
What are variable decels? treatment?
- Due to cord compression
- Shape: Variable sharp drops & return to baseline (U, W, V shaped)
- Onset: abrupt; often not R/T UC
- Onset to nadir: < 30 seconds
- most common decel
- Nursing action: change maternal position, o2 via face mask 10 L; decrease or stop pit; sterile vag exam to monitor cord and labor progress (you don't want to feel cord)
- amnioinfusion to alleviate cord compression
- tocolytics (terbutaline) internal fetal monitor for more accurate assessment, modify pushing, emotional support, notify physician
What are late decels? Tx?
- Due to utero-placental insufficiency
- Shape: waveform uniform; shape reflects uterine contractions
- Onset: after start of uterine contraction with nadir occurring after peak of contraction
- Onset to nadir: > 30 seconds
- Nadir: 10-20bpm decrease, rarely 30-0 bpm; not very deep, but most dangerous
- Nursing actions: Turn mother on left side(perfusion back to the heart) increase IV rate, stop pitocin, administer )2 at 10 l via mask; fetal stimulation; scalp or vibroacustic; internal fetal monitor; emotional support; notify HCP
What are prolonged decels?
- FHR decreases below baseline > or = to 15 bpm; decrease lasting >2 minutes and < 10 minutes
- may be abrupt or gradual
- caused by any mechanism that causes profound change in fetal O2
- Nursing action: change maternal position, O2 at 10 L via face mask, increase IV, D/C pitocin, Tocolytics (terbutaline [stops contractions to give better perfusion to placenta which increase O2 to baby] )
- if it lasts longer than 10, headed to OR
What does VEAL CHOP stand for?
- V: Variability decelerations = Cord compression
- E: Early decelerations = Head compression
- A: accelerations = Ok
- L: Late Decelerations = Placental Insufficiency
Why is preparation for childbirth recommended?
it is proven to reduce need for analgesics
What are factors that affect a woman's reaction to pain?
- Anxiety: reduces tolerance of pain and causes release of stress compounds (catelcholamines)from the adrenal glands which inhibits uterine contraction (relaxed women tend to tolerate labor pains better)
- perception: of pain influenced by cultural patterning
- Fatigue: x
- Previous experience: x
What nursing measures can be done to support pain management?
- encourage position changes
- Assist with personal comfort measures
- decrease anxiety
- provide information
- use specific supportive relaxation techniques
- encourage paced breathing
- administering pharmacological agents as requested by woman
- support the woman and her support group
What are non-pharm comfort measures
ice chips, hygiene (mouth pericare) positioning, massage, ambulation, heat and cold application, hydrotherapy, calm environment, childbirth, preparation, breathing, aromatherapy, birthing ball, hypnosis
What are the three types of analgesia used in labor?
meperidine (demerol); butorphanol (stadol); sublimaze (fentanyl)
What are the two types of antianxiety meds used in labor?
promethazine (phenergan); hydroxyzine (vistaril)
What two meds are used in prolonged latent phase?
- zolpidem (ambien)
What nursing actions are used for analgesia?
- pain assessment
- (neonatal depression may occur if medication given within hour of delivery)
- women with drug history need higher dose to achieve relief of pain
What are the different types of anesthesia used?
- pudendal block
- epidural block
- spinal block
- general anesthesia (most gen anesth. usually reach infants in 2 minutes; infant needs to be delivered quickly)
What are the side effects of anesthesia and what are the nursing actions for each?
- vasodilation of blood vessels leading to hypotension: (poor perfusion to baby) preload mother with IV fluids prior to giving anesthesia; monitor BP and vitals; avoid supine hypotension; assess FHT for bradycardia
- Loss of stimuli to void: empty bladder on a regular basis until birth; may need to empty bladder during recovery period
- Uterine Contractions: frequency may decrease
- no action, but may start pit
- Spinal headache: monitor for headcahe; notify anesthesiologist
What is a pudendal block and when is it used?
it is injected into the pudendal nerve via needle know as trumpet; second stage of labor, prior to time of delivery; numbs the vulva, lower vagina and part of perineum for episiotomy and use of low forceps
what is an epidural block and when is it used?
injected into the epidural space ( between the dura and spinal canal via epidural catheter); first stage (after 5cm dilated) or second stage; ca be used for vag and cesarean births, up to 100% blockage; # 1 side effect is hypotension; may be combined with analgesic like fentanyl for walking epidural
what is a spinal block and when is it used?
injected into subarachnoid space, used in 2nd stage or for c-section; rapid acting with 100% blockage of sensory and motor function; can last up to 3 hours
What is general anesthesia and when is it used?
use of IV injection or inhalation of anesthetic agents that render the woman unconscious. Used mainly in emergency c-birth; risk for fetal depression; uterine relaxation; maternal vomiting and aspiration
What is local anesthesia and when is it used?
injected into perineum for episiotomy. second stage of labor, immediately before delivery; numbs local tissue before repair;