M/B 2

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  1. FHR - baseline variability
    • refers to fluctuations in baseline FHR that are irregular in amplitude and frequency
    • cycles portray peak & trough of HR within it's baseline range over a minute
    • 4 types: Absent, minimum, average, and marked
  2. FHR baseline variability: absent
    • amplitude range undetectable
    • almost flat line
  3. FHR baseline variability: Minimum
    • Amplitude range is undetectable
    • ≤5 bpm
  4. FHR: baseline variability: Moderate
    • Amplitude from peak to trough 6 bpm to 25 bpm
    • Predicts a well-oxygenated fetus with normal acid-base balance at the time
  5. FHR: baseline variability: Marked
    Amplitude greater than 25 bpm
  6. FHR - periodic changes
    • accelerations or decelerations in the FHR that are in relation to uterine contractions and persist over time
    • Include: accelerations and 4 types of decelerations
  7. FHR - Episodic changes
    accelerations and deceleration patterns not associated with contractions
  8. FHR accelerations
    • visually abrupt, transient increases (onset to peak <30 sec) in the FHR above baseline
    • 15 beats above baseline and last from 15 sec to 2 mins
  9. FHR decelerations
    • transitory decreases in FHR baseline
    • 4 types: early, variable, late, and prolonged
    • Classified according to shape, timing, and duration in relationship to the contraction
  10. FHR decelerations - recurrent
    Defined as recurrent when they occur with at least 50% of UC's over 20 min period
  11. FHR decelerations - intermittent
    Defined as intermittent when they occur with fewer than 50% of UC's over 20 min period
  12. FHR early decelerations
    • Visually apparent, usually symmetrical, with gradual decrease and return associated with UC
    • Do not occur early or before contraction, thus the term is something of a misnomer
    • *When UC occurs, fetal head is subjected to pressure that stimulates the vagal nerve
    • Are benign and need no intervention; however, usually indicates pushing is near, so check mom
  13. Early decel's - nadir
    • the lowest point of the deceleration
    • occurs at the peak of contraction
    • Generally, the onset, nadir, and recovery mirror the contraction
  14. Variable deceleration
    • Visually apparent abrupt decrease in FHR
    • Most common decel's in labor
    • When persist over time, fetal tolerance is confirmed by presence of variability or accel's
    • Acceleration that precedes or follows is a "shoulder", is compensatory response to hypoxemia & increase in FHR of 20 bpm for <20 sec
  15. Characteristics of variable decel's
    • Can be periodic or episodic while varying in duration, nadir, and timing in relation to UC's
    • Decrease in FHR is ≥15 bpm lasting ≥15 sec's and < 2 mins
    • Shape can be U, W, or V
    • Caused by umbilical cord occlusion
  16. Characteristic of NORMAL variable decels
    • Duration of <60 sec
    • Rapid return to baseling
    • Accompanied by normal baseline and variability
  17. Characteristics of indeterminate or abnormal variable decels
    • Prolonged return to baseline
    • Persistence to less than 60 bpm and 60 sec
    • Presence of overshoots tachycardia
    • repetitive overshoots and absent variability
    • See text 250
  18. Late decels
    • visually apparent symmetrical gradual decrease in FHR associated with UC's
    • Can be sign of fetal intolerance to labor, which is assessed by evaluating baseline, presence of variability, and presence of accels
    • Onset is gradual with nadir ≥30 sec
    • Usually, onset, nadir, and recovery occurs AFTER onset, peak, and end of UC
    • See text 252
  19. What is High or low FHR
    • <110 or >160
    • fetal distress
  20. Prolonged deceleration
    • a visually apparent abrupt decrease in FHR below baseline that is ≥15bpm, lasting ≥2 mins, but <10 mins
    • Not recurrent; preceded and followed by normal baseline and moderate variability 
    • Episodic decels last >2 min and < 10
  21. Tachysystole
    • Also referred to as hyperstimulation
    • Excessive uterine activity which can contribute to fetal hypoxia
    • Should be treated regardless of fetal response
  22. Characteristics of tachysystole
    • More than 5 contractions in 10 mins
    • Contractions occurring within 1 min or each other and lasting 2 mins or longer
  23. Ischial spines
    part of the pelvis used to measure stations
  24. Fetal lie
    • relationship of long axis of fetus to long axis of mother
    • *Longitudinal - fetal spine is parallel to spine of mom
    • *Transverse - spine of fetus perpendicular to spine of mom
  25. Fetal attitude
    • relationship of fetal body parts to each other
    • Flexion is normal, where head is flexed so chin is on chest with arms crossed over chest, legs flexed at knee with thighs on abdomen
    • Deviations may cause difficulty with birth
  26. Fetal position
    the relationship of a specific part of fetus to the pelvic quarters of mom
  27. Fetal presentation
    • Part of baby coming first
    • We want cephalic (head first) vertex = head down, chin tucked
  28. Military presentation
    Head is neither flexed or extended
  29. Brow presentation
    Head partially extended, presenting occipital diameter
  30. Face presentation
    • head hyperextended and longest diameter
    • the submetrobregmatic presents
  31. Mentum presentation
    • chin first, presenting wides diameter
    • Can't be delivered vaginally
  32. Powers of Labor
    • 4 P's:
    • Passage - through pelvis, readiness of mother to deliver
    • Passenger - size and position of baby (fetal head molding)
    • Powers - uterine contractions and changes
    • Psyche - how is mom prepared - anxiety will slow labor
    • *5th power is position
  33. molding
    bones of baby skull overlap to fit through true pelvis
  34. Ferguson Reflex
    • natural trigger for maternal pushing 
    • involuntary urge to push
    • Can be diminished or eliminated by regional anesthesia
  35. Cervical changes
    • Effacement vs Dilation
    • Effacement: thinning of cervix
    • Dilatation: opening of cervical os
  36. Uterine contractions: Increment
    going up
  37. Uterine contractions: acme
    top of peak of contraction
  38. Uterine contraction: decrement
    going back down
  39. Uterine contraction: Frequency
    from onset of one contraction to onset of next
  40. Uterine contraction: Duration
    the beginning to the end of one contraction
  41. Uterine contraction: Intensity
    • the degree of tightness/firmness at peak
    • Mild, moderate, strong
  42. Uterine contraction: relaxation time
    • resting tone - pressure in uterus between contractions
    • measured by IUPC when internal fetal monitor is used
    • described as number of mmHg when uterus is not contraction
  43. influence of psyche on labor
    • high levels of anxiety prompt secretions of catecholamines, which may decrease frequency, duration, and intensity of contractions
    • important to have birth preparation, supportive family and experienced nurse
  44. True vs false labor
    • CERVICAL CHANGE is required for true labor
    • False labor involves irregular contractions with little or no cervical change
  45. False contractions
    • begin and remain irregular
    • often disappear with ambulation and sleep
    • do not increase in duration, frequency, or intensity
    • do not achieve cervical dilation
  46. True contractions
    • begin irregular but become reg and predictable
    • continue no matter womans activity level
    • increase in duration, frequency, intensity
    • achieve cervical dilatation
  47. Nitrazine
    • Bright yellow paper used to check for amniotic fluid
    • turns blue in presence of amniotic fluid
    • also turns blue in presence of blood and give false positive
  48. How many stages of labor?
    • duh
  49. Stage 1 of labor
    • onset of reg contractions to compete dilatation of cervix
    • 3 phases: latent, active, and transition
  50. Latent phase of labor
    • first phase of first stage
    • longest stage
    • from onset to 3-4 cm
  51. Active phase of labor
    • 2nd phase of 1st stage
    • from 4 cm to 7-8 cm
  52. Transition phase
    • third phase of 1st stage
    • from 7-8 cm to 10
  53. Stage 2 of labor
    from complete dilatation to birth of infant
  54. State 3 of labor
    • Birth to expulsion of placenta
    • Can take 5 to 30 mins
    • Involves lengthening of umbilical cord and sudden gush of vaginal blood
    • Change in shape of uterus
  55. State 4 of labor
    1-4 hr recovery period
  56. Ferning
    • gold standard to check for amniotic fluid
    • applied to slide, allowed to dry
    • causes a ferning pattern
  57. If pt has epidural and becomes nauseous, what should you check?
    • BP!! can cause hypotension and nausea
    • Give fluids! = IV bolus of 500 cc
  58. Other complications of epidural
    • Intravascular injection (into vein instead of where it should be)
    • Pt will taste metal, increased HR & BP, ringing in ears, Maternal Tachy or brady, dizziness or LOC
    • Give O2, meds, fluids... etc
  59. Leopolds maneuver
    • feeling back of baby by palpitation
    • Will feel flat back vs nobbes of arms & legs
  60. Apgar score
    • Assessment done on newborn at 1 and 5 mins after birth
    • A-Appearance
    • P-Pulse
    • G-Grimase
    • A-Activity
    • R-Respiratory effort
    • Most common 1 min is 8-9, usually losing points for color
    • Score of 0-3= severely depressed
    • Score of 4-6= moderately depressed
  61. Apgar: A
    • Appearance/color
    • 0- blue, pale
    • 1- Body pink, extremities blue
    • 2- Completely pink everywhere
  62. Apgar: P
    • Pulse/HR
    • 0 = Absent
    • 1 = Slow (below 100)
    • 2 = Over 100
  63. Apgar: G
    • Grimace - reflex response (ex: to catheter in nose)
    • 0= no response
    • 1= grimase
    • 2= crying, coughing, sneeze
  64. Apgar: A #2
    • Activity, muscle tone
    • 0= Flaccid (laying flat, arms out)
    • 1= some flexion of extremities
    • 2= Actual motion
  65. Apgar: R
    • Respiratory effort
    • 0= absent
    • 1= slow, irregular
    • 2= good, crying
  66. Gate control theory of pain
    • Proposes pain can be halted at 3 points:
    • Peripheral end terminals
    • synapse points in dorsal horn of spinal
    • point at which impulse is interpreted in brain
  67. Gate control theory of pain: peripheral terminals
    • Automatically reduced by production of endorphins and enkephalins
    • Or by irritating nerve fibers such as rubbing skin, heat and cold
  68. Gate control: interpreted in brain
    strategies such as breathing, focusing, visual, and auditory stimulation affect whether pain impulses reach levels of awareness
  69. Gate control: activities that tend to "close" pain gate
    • Application of pressure
    • Cutaneous stimulation such as effeurage
    • Heat/cold
    • breathing
    • aromatherapy
    • focusing
  70. Effeurage
    light massage
  71. nitrous oxide
    laughing gas
  72. Fentanyl
    • most commonly used narcotic
    • short acting
    • can be given Q1hr up to 8 cm
    • doesn't take away pain, just takes off the edge
  73. What are the World Health Organization and Lamaze International birth practices that promote and support normal physiologic birth.
    • Labor should begin on it's own
    • Women should be able to move about freely during labor
    • Women should receive continuous labor support
    • NO ROUTINE INTERVENTIONS
    • Spontaneous pushing- allowed to assume non-supine position for birth
    • Mom & baby together after birth :-)
  74. WHO recommendation to decrease maternal ketosis
    commonly treated by an intravenous infusion of glucose and fluid, as labor takes alot of energy and can cause hypoglycemic state from not eating.
  75. What is the most effective position for pushing in the second stage of labor?
    • An upright position - HOB at 45* or greater, squatting, kneeling, or standing
    • increases the pelvic outlet and better aligns the fetus with pelvic outlet
    • Squatting is best
  76. What is common position in US
    • lithotomy position, in bed
    • prefered by doctors as it allows better visibility and control
    • Doesn't help labor though, gravity can't help
  77. When using IV narcotics for pain relief in labor, what is the teaching to patients and what precautions must be taken to prevent respiratory depression in the infant at birth?
    • Important to realize systemic analgesics cross blood/brain barrier = reach infant
    • Drug of choice, dose, and timing must be considered or infant will be too sleepy to breath
    • MUST HAVE NARCAN CLOSE!
    • Given too soon can slow progress of labor,
  78. What are the essential nursing actions that must be taken prior to epidural placement?
    • Assess pain level
    • Educate pt and family about epidural, pros and cons
    • Assess and document baseline BP, HR, RR, temp
    • Assess FHR to confirm normal FHR pattern
    • Encourage pt to void prior
    • Administer IV bolus with epidural as can cause hypotension
  79. Non-pharmacologic method of pain relief: birth ball
    • facilitates upright position
    • Opens pelvis
    • Allows oman to roll or bounce as she deems necessary to manage contraction and pain
  80. Hydrotherapy
    • type of non-pharmacologic method of pain relief
    • Promotes relaxation and pain control
    • Releases endorphins, decrease muscle tension, promotes circultion
  81. What is dick-read method of delivery
    advocates birth w/o fear by education and environmental control and relaxation
  82. Lamaze
    promotes psychoprophylaxis with condition and breathing
  83. Bradley
    Husband-coached childbirth and support by working with and managing the pain rather than being destracted from it
  84. What are the procedures used to evaluate whether the membranes have ruptured?
    • A speculum exam, assessing for fluid in vaginal vault
    • Use nitrazine paper and ferning test
  85. Why is it important to know if rupture of membranes has occurred and what time it occurred?
    • It is important to know the time because once they rupture, the babies protective layer is gone and women should deliver within 24 hours!
    • Increased risk of prolapsed cord- not as much cushion now!
    • Increased risk for infection too.
  86. What is COAT related to ROM
    COAT: color, odor, amount, time!
  87. Procedures for giving oxytocin in labor
    • HIGH ALERT- 2 nurses must assess FHR strip
    • FHR must be good, no late decels
    • Low dose: start at 0.5 u/min, gradually increase 1-2 u/min every 30-60 min
    • Doc FHR
  88. Risks for oxytocin in labor
    • Tachysystole (fetus compromised)
    • Uterine hyperstimulation:
    • Contractions >90 sec, q2min
    • Resting tone >20mg
    • NRFHR = nonreassuring FHR
    • Montevideo units >200
  89. Nursing intervention for oxytocin which is causing hyperstimulation
    • Turn off oxytocin
    • Position on side
    • O2
    • Notify doc
    • bolus IV
    • administer tocolytics
  90. Benefits of giving oxytocin
    • able to plan induction
    • can hurry labor when fetus is compromised
  91. How will nurse know if proper amount of oxytocin is being given
    • Proper amount has been given when contractions increase, and mom and baby are still maintaining normal vitals.
    • Contractions should not exceed 3 per 10 mins, last no longer than 90 sec, and be to nighter than every 2 min
  92. What is the procedure for placing the tocodynamometer and the fetal heart rate ultrasound monitors during labor? What are the advantages and disadvantages of this type of monitoring?
    • Every woman in labor gets these placed
    • Easy to put on, noninvasive
    • Have to adjust often though, can't measure pressure/intensity
  93. What situation warrants a FSE (fetal scalp electrode?
    • Decision to place is based on need for continuous FHR tracing when troubleshooting methods do not alter quality of tracing
    • *Contraindicated when mom has HIV, active herpes, placenta previa, undx vag bleeding
  94. What situations warrant using IUPC
    • Intrauterine pressure catheter
    • Monitoring initiated based on clinical need for additional uterine activity
    • May be used when external monitoring is inadequate due to maternal obesity or lack of progress in labor when quantative analysis of uterine activity is needed for clinical decision making
  95. What does a category I FHR monitor strip look like
    • Good!-normal
    • baseline 110-160
    • moderate variability
    • late or variable decels absent
    • early decels absent or present
    • Accels absent or present
  96. What does a category II FHR monitor strip look like
    • Inteterminant: Any of the following:
    • bradycardia with veriability, tachycardia, absent variability w/o decels, marked variability, no accels after fetal stimulation, recurrent variable decels, prolonged decels, 
    • variable decels with slow return to baseline overshoots or shoulders
  97. What does a category III FHR strip look like
    • BAD! abnormal
    • Absent variability with recurrent late or variable decels
    • Bradycardia
    • sinusodial pattern
  98. Interventions for category III FHR strip
    • Discontinue oxy if being used
    • repositioning
    • IV bolus of 500 mL
    • O2
    • Amnioinfusion for repetitive variables
  99. Risks for ROM, whether spontaneous or artificially
    • Commits to delivery
    • Increased risk of infection
    • Prolapse of cord
    • Baby's head must be ingaged
    • Increases risk for C/S
  100. Assessments needed with ROM
    • Assess FHR beofre ROM (if artificcially ruptured) and immediately following 
    • Assess COAT
    • monitor contractions
    • assess maternal temp every 4 hours
    • Assess for needed pericare
  101. S/S of prolapsed cord
    • Obstetric emergency!!
    • Severe bradycardia or prolonged variable decelerations after ROM
  102. Nursing actions after prolapsed cord is identified
    • Call for help
    • Pt in knee chest position
    • lift fetal head off cord with gloved hand
    • Will be immediate C/S
  103. Know where to place the fetal ultrasound monitor for the fetal heart rate based on the babies’ position such ROA or LSA that you have determined by Leopold’s maneuvers
    • Right occiput anterior is the baby head down with spine on mothers right/front side
    • So monitors should be placed along back on right side, low on abdomen
    • LSA would be left sacral anterior, so breech position with back to left/front side of mom
  104. Precipitous labor
    expulsion of the fetus within less than 3 hours of commencement of regular contractions
  105. Nursing actions to support  woman who is experiencing precipitous labor and provider is not present to deliver baby
    • In hospital, call a code!
    • Stay in room & coach 
    • Assemble equipment for delivery and fetal resuscitation
    • Notify NICU if needed
  106. Nursing interventions for precipitous birth
    • STAY WITH WOMAN
    • wash hands & glove
    • Maintain head flexion with gentle pressure
    • After birth of head, wipe off, bulb suction: mouth first, then nose
    • Head down to deliver anterior shoulder, then upward to deliver posterior shoulder and body
  107. Dystocia in labor
    • dysfunctional labor related to cervical dilatation or descent of fetuw
    • Risk to mom: exhaustion and infection
    • Risk to baby: hypoxia, birth trauma, or death
    • Most common reason for primary C/S
  108. shoulder dystocia
    • difficulty encountered during delivery of shoulders 
    • Nurse should request assistance:
    • empty bladder
    • APPLY PRESSURE ABOVE PUBIC BONE or laterally to pubic bone to dislodge anterior shoulder
  109. Criteria for induction of labor
    • Preexisting maternal disease: PI hypertension, preeclampsia, diabetes, renal disease... etc)
    • SROM after 37 weeks w/o onset of labor
    • chorioamnionitis
    • Postterm preg
    • suspected fetal jeopardy
    • fetal death w/o onset of labor
    • h/o prior rapid delivery & live distance from hostpital
  110. Contraindication for labor in
    • Previous C/S with classical incision
    • Abnormalities that would preclude vaginal delivery
    • Placenta anomalies (abruptio, Previa)
    • Active herpes
    • cord prolapse

    • For fetal: abnormal lie - transverse or breech
    • fetal distress
  111. Risks and benefits of delivery by forceps or vacuum
    Baby: cephalohematoma, nerve injuries, skin lacs, skull fractures, intracranial hemorrhage

    Mom: vag or cervical lacs, extension of episiotomy, perineal hematoma, bladder trauma, infection, hemorrhage

    Benefits: prevent maternal exhaustion and/or fetal compromise
  112. What are the causes of meconium stained amniotic fluid and the nursing care for an infant born in it?
    • Meconium typically due to fetal asphyxia in utero causing relaxation of fetal anal sphincter
    • Big risk when baby breaths in meconium, can cause lower airway and inhibit surfactant action
    • Nursing: suction, O2, evaluate for respiratory distress
  113. What are the risk factors for an infant developing neonatal respiratory distress
    • Decreased surfactant levels
    • persistent hypoxemia and acidosis that leads to constriction of pulmonary arteries
  114. S/S of infant developing neonatal respiratory distress
    • Cyanosis
    • abnormal respiratory pattern: apnea or tachypnea
    • retractions of chest wall, grunting, flaring of nostrils or hypotonia (low muscle tone)
  115. Bishops score
    • used to score mom's coming in for induction, used mostly for first baby
    • scores based on dilation, effacement, station, cervical consistency and cervix position
    • Multip mom is favorable at 5, pimip at 9`
  116. If the woman does not have a ripe cervix, what are the medications and other methods for ripening the cervix?
    • Prostaglandin gel or suppository
    • Laminaria (seaweed sticks)
    • Cervidil (removed after 12 hrs)
    • Cytotect (ulcer med)
    • Stripping of membranes releases prostaglandins
  117. Indications for C/S: maternal factors
    • Active herpes or papilloma
    • AIDS or HIV
    • Cephalopelvic disproportion (head too big)
    • Disabling conditions: severe PIH, Heart disease
    • Failed induction/arrest of labor
    • Previous C/S with classical incision
    • Elective
  118. Indication for C/S: fetal
    • Fetal distress
    • extreme prematurity or low birth weight
    • transverse or breech position
    • multiple or conjoined twins
  119. Indication of C/S: placental
    • Placenta previa
    • Abruption
    • Umbilical cord prolapse
  120. Placenta succenturiata
    one of more lobes are in membranes a distance away from main placenta
  121. Placenta circumvallate
    ring around placenta btwn margin and middle made of a fold in amnion and chorion
  122. Battledore placenta
    • umbilical cord inserts in edge or margin
    • not stable, may detach
  123. Velamentous insertion of courd
    blood vessels of cord separate and leave cord before inserting into placenta
  124. Vasa previa
    • unprotected blood vessels,
    • covered only by amnion
  125. Placenta accreta
    placenta grows into myometrium of uterus through existing uterine scar
  126. What is a VBAC and when would it be appropriate to consider it?
    Vaginal birth after c-section! Women with low transverse incision are candidates for VBAC, 1 or 2 previous c-section with adequate pelvis and OR team available.

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Author:
jskunz
ID:
324012
Filename:
M/B 2
Updated:
2016-10-04 03:08:57
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Description:
mother/baby 2
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