Process of labor and birth part 2

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Prittyrick
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Process of labor and birth part 2
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2015-01-31 19:52:52
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  1. Leopold Maneuvers
    • identify the fetal part in the uterine fundus to determine fetal lie and presenting part
    • palpating the fetal back to identify fetal presentation
    • determining which fetal lies over the pelvic inlet to identify attitude
    • locating the fetal cephalic prominence to identify the attitude of the head
  2. Maternal Assessment During Labor and Birth
    • maternal Status (vital signs, prenatal, record review)
    • - sterile vaginal examination
    •    Use speculum if there is any question of rupture of membranes (SROM)
    • - Leopold Maneuvers (seeing nursing procedure 14-1) can watch on ATI
    • - uterine contractions
    • - fetal monitoring
  3. Vaginal Examination
    • Performed digitally by primary care provider or qualified nurse for:
    • - cervical dilation
    • - descent of the fetus through the birth canal by fetal station in centimeters
    • - fetal position
    • - membranes- intact or ruptured (once u suspect u want to make sure and keep vaginal exams at a minium)
    • (u can feel the membrane- u can palpate and it feels like a bulge
  4. Rupture of Amniotic Fluid Membranes
    • SROM/AROM
    • maybe be a sudden gush of trickle. fluid should be clear
    • Assessment
    •   - time, odor (identifies infection), color (yellow/green represent meconium) - tells u how stress the baby is
    •   - meconium stained fluid may indicate fetal hypoxia

    • AROM 
    •  - Amniotomy (a disposable plastic hook Amnihook is used to perforate the amniotic fluid
    •  - done by NP, MD
    •  - assess time, odor, color

    Maternal temp is taken every hour once rupture happens

    • if the water breaks and the baby is very high- the cord can slip out
    • also along with the other assessments u should monitor the fetal heart rate (esp if u have a rupture of membranes) it should not be bradycardia
  5. Assessment of Amniotic fluid Membrane rupture
    • Assessment to verify rupture of membranes: sample taken from vagina using speculum for examine
    • - nitrazine paper: determines fluids PH
    •      * Turns blue: alkaline PH 6.5-7.5
    •      * may have a false positive if this is bloody show present
    • - Fern testing
    •   * fluid added to the slide, allow to dry, viewed under the microscope
    •   * fern pattern is a characteristic of amniotic fluid

    when identify rupture membrane it is important assess fetal heart tones
  6. Fetal Heart Rate
    put them on a fetal monitor the top part is the fetal heart rate the bottom portion is contraction
  7. Contractions
    • Rhythmic tightening of the  uterus (muscle) that occurs intermittently (gets really tight)
    • involuntary thins and dilates cervix (mom doesn't control this)
    • Assess 3 parameters TOCO uterus in latin:
    • Durations: how long the contractions last
    • Intensity: the strength of the contraction (u can feel this would ur own hand- or u can tell with intrauterine cathter)
    • Frequency: how often the contractions occurs (it is the beginning on one contraction to the beggining of the next)
    • Resting tone: tone of muscle between resting (how we tell is where does it rest on the paper)
    • DIF resting tone
    • think about the stress these contractions are putting on the newborn
  8. External Assessment of contractions
    • Palpating contractions:
    • Feels like the tip of nose- mild

    Feels like chin- moderate

    Feels like forehead- strong
  9. Continuous Fetal Electronic Monitoring
    External fetal monitor

    • - identify baseline fetal heart rates
    • - identify fetal well being (how is baby doing)
    • - identifies signs that indicate if fetal is compromise
  10. Assessing Fetal Heart rate: external
    • Establish fetal heart rate baseline
    • - normal is 110-160
    • - average FHR that occurs during a 10 minute segment that excludes periodic and episodic rate changes such as tachycardia and bradycardia

    Fetal bradycardia is a baseline FHR below 110 bpm and last 10 mins or longer

    Fetal tachycardia is a baseline FHR greater than 160 bpm and last 10 mins or longer

    • Bold red lines 1 mins
    • each block going across is a sec
    • and 10 up
    • if mom has a fever we may notice the baby's heart increase
  11. monitoring contractions and fetal heart rate
    external monitoring mom will have one at the top of her uterus and one at the bottom monitoring fetal heart 

    • Internal leads- one on top of the baby's head (use this if u aren't able to monitor the baby well)
    • Intrauterine cather- picks up the pressure inside of the uterus
    • mom maybe heavy or mom all over the place
    • mom is a risk for infection
    • if mom has hep or HIV u would not use it
  12. locating fetal heart sounds by fetal position for external fetal monitoring
    • the best place to hear over the shoulder
    • if they are vertex (u can hear under the belly button

    if u hear it above the belly button u can tell the baby is a breech baby
  13. Fetal Heart rate patterns: variability
    • one of the most important characteristics of the FHR indicating fetal well being 
    • description: miminal, moderate, marked
    • beat the heart goes
    • beats flutuations
    • ex- baseline is 140 heart is going to go up and down and so forth. this tells u about the CNS. best indicator 
    • how we get variability: heart rate goes up (sympathetic and it goes does parasymp) we than know these things are intact and the baby is doing well
    • means the fetus is recieving enough o2.
  14. Variability cont
    Short term
    long term
    Short term variability: most accurately assessed with internal lead (this is how u can get the beat to beat)

    Long term: external lead- changes in the FHR over long period such as 1 minute
  15. Variability Moderate
    6-25 beats- so u can go and down this many beats- fluctuations occurs between the baseline

    • this is what we want
    • shows the autonomic and CNS- means baby is well oxygenated 

    • Nurse:
    • FHR stable, monitor continuously
  16. Variability absent/minimal
    absent: no detectable variation around the baseline

    minimal: < 5 of fluctuation in the FHR baseline

    sympathetic and parasymp is not working

    • Nursing intervention:
    • improve uteroplacental blood flow and perfusion- prevent acidiosis and fetal hypoxia
    • - see why this could have happened. did u give pt any meds? identify cause if related to drug than u have to wait
    • - change maternal position- to incre placental and umibical blood flow
    • - increase the IV fluid 
    • - oxygen
    • - consider internal fetal monitoring (for accuracy)
    • - discontinue oxytocin (pitocin) 
    • - document findings 
    • - report to the health care provider
    • - possible preparation for surgical removal if interventions don't work

    if mom bp drops it can cause this too, move her increase IV fluids.
  17. Variability Marked
    • if u have too much variability and the baby isn't moving.
    • CNS is all over the place
    • occurs when there is more than 25 beats in fluctuation in the FHR baseline
    • cause: cord prolapse/compression, maternal hypotension, unterine hyperstimulation, and abruptio placenta

    • Nursing intervention
    • - identify cause
    • - change position
    • - increase IV
    • - Give O2
    • - consider internal fetal monitoring
    • - discontinue oxytocin (pitocin)
    • - document findings
    • - notify MD
    • - get prepared for surgical removal if interventions don't work
  18. FHR: Periodic baseline changes
    • Are temporary recurrent changes made in response to a stimulus such as a contraction (movement)
    •  
    • Fetal Accelerations: elevations of FHR of more than 15 bpm above baseline 

    fetal decelerations: classified as early, variable, and prolonged
  19. FHR periodic changes accelerations
    • Up 15 beats over 15 seconds 
    • associated with the sympathetic nervous system 
    • tells us when that baby moves the placenta is able to give it enough oxygen
    • denotes fetal movement and well being and are the basis of non stress testing
    •  Nursing
    • no intervention
    • continue to monitor
  20. FHR periodic Deceleration
    Early (contractions)
    They come at the beginning of an contraction and once the contraction is over it goes back to baseline

    Cause: Head compression- baby has some pressure on its partial as it moves thru the pelvis- as the contraction comes the baby gets moved in pelvis and there is pressure on the baby

    • Nurse:
    • monitor strip
    • document findings: early decels 
    • might want to do some changes in position and check bladder
    • continue to monitor
    • consider benign
  21. FHR periodic changes decel
    Late (contractions)
    • it has to do with where it starts on the contractions
    • at the peak of the contraction (fetus feels most pressure) then the heart rate starts to drop (follows slop right down and it comes back up). it occurs late in contraction
    • has to do with uteroplacental flow (insufficiency) not enough oxygen reserve to give baby an extra kick to keep heart rate going. at the end of the contraction they start to recover again

    • Nursing intervention
    • - turn them 
    • - oxygen
    • - increase IV 
    • - shut/reduce of pitocin 
    • - assess client for any underlying contributing cause
    • - notify HCP about pattern
    • - obtain further orders
    • - document all intervention and their efforts on the FHR pattern
  22. FHR periodic decel
    Variable decel
    Prolonged decels ( greater than 15 beats longer than 2 mins less than 10mins)
    it can occur at any place they can be w's, u, little deep

    Cause by cord compression- oliogohydraminos

    • Nursing
    • - change position to help get baby off cord all types of positions
    • -  administer oxygen
    • - increase fluids
    • - assess for any underlying contributing causes
    • - reduce/discontinue pitocin
    • - notify HCP about patterns
    • - obtain further orders
    • - document all interventins and their efforts
  23. VEAL CHOP
    • V- variable C- cord compression
    • E- early      H- head compression
    • A- accel      O- ok
    • L- late         P- placenta insuffiency (uteroplacental insufficiency) placenta old

    • so nurse doesn't say late/early etc they put in categories
    • Category 1 
    • normal everything looks presents/absence of early decel

    • Category 2
    • bradycardia, tachycardia, a little concern, absent variability, but not accompany with decel, minimal/marked u would treat with movement, incre IV, oxygen

    • Category 3
    • bradycardia, reccurrent late decel, u can't get rid of them, recurrent varables decel, wave pattern (brain damage), turn oxygen, iv fluids, espc left
  24. Nursing management of reassuring fetal heart rate patterns
    • Position client to the left
    • administer oxygen
    • increase IV fluid
    • assessing client for any underlying contributing causes
    • reduce/discontinue oxytocin/pitocin
    • notify HCP about pattern
    • document all interventions and there effects on the FHR pattern
    • if having decel modify the pushing 
    • prepare for surgical birth
  25. cephalic disporportions
    the head doesn't fit in pelvic area
  26. monitoring uterine contractions internal untrauterine pressure catheter IUPC
    • Used on people we want accuracy
    • we can zero it
    • it is the pressure inside the uterus
    • MVU- greater than 200
    • add up 4 contractions and duratuib 

    no worries
  27. external fetal monitoring advantages/disadvantages
    • Advantages
    • non invasive

    • Disadvantages
    • can restrict the mother's movement
    • cannot detect short term variability
    • signal disruptions can occur due to maternal obesity, fetal malpresentation, and fetal movement as well as by artifact. 
    • does not measure intensity of contraction
  28. internal fetal monitoring advantages/disadvantages
    • Advantages
    • more accurate
    • shows beat to beat short term variability
    • indicated for women/fetus that are high risk
    • maternal position does not disrupt signal
    • measures intensity of contractions with MVU

    • Disadvantages
    • invasive
    • should not be used for women who have HIV, herpes, active herpes lesion
  29. Internal Monitoring criteria
    Four specific criteria must be met for this type of monitoring to be used:

    • Ruptured membranes
    • cervical dilation at least 2cm
    • presenting fetal part low enough to allow placement of the scalp electrode
    • skilled practitioner available to insert spiral electrode
  30. Other fetal assessment methods
    • fetal oxygen saturation monitoring (fetal pulse oximetry)
    • - u can get blood from vaginal examine (sample of the blood)
    • - provides real time recording of fetal oxygen sat (only providers)
    • acidic baby represent hypoxia
    • Fetal stimulation
    • scratch the top of baby
    • if u have decre variability 
    • u want to wake baby up to have an accel
    • if u scratch head and then u get an accel u can figure baby may be sleeping and continue to monitor

    • vibro acoustic stimulation
    • to help wake them up
    • it is buzzer and the kid kicks.
  31. true v false labor
    how do u teach mom she is in labor

    true labor- contractions will start and they will be in a nice rhyme and they will get closer together

    False- contraction will be irregular, weak pressure, 

    true labor- starts in back and radiates up to the front

    False- starts under the belly bc of the cervix open

    true- if u get up and walk it will get worst (same with shower)

    false- it may improve pain (same with shower)

    • Stay home until contractions are 5 mins apart lasting 45-60 sec
    • drink lots of fluid

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