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Healthy people 2010 on maternal health
- reduce maternal deaths and reduce maternal illness and complications due to pregnancy
- increase the proportion of pregnant women who attend prepared childbirth classes
When doing a vaginal examination when should you use
an antiseptic lubricant as opposed to using water?
Once the membrane has ruptured
Steps to vaginal exam
- Don sterile gloves
- inserts index and middle fingers into the vaginal introitus
- palpate to assess dilation, effacement, and postion
- if cervix is open to any degree, assess for presenting fetal part, fetal position, station, and presence of molding
- membranes should be described as intact, bulging, or ruptured
- Discuss with patient and document
Cervical dilation and effacement
- palpate cervix with index finger
- width of cervical opening determines dilation
- length of cervix determines effacement
Assessing fetal descent and presenting part
- use index finger to palpate the fetal skull
- ischial spines are blunt prominences at the midpelvis; they are the zero station
- centimeters above (-) and below (+) are used to denote station
- fetal descent of (-5 to +4) is the expected norm during labor
Describe intact membranes.
felt as a soft bulge that is more prominent during a contraction
What does priority assessment become once the membranes have been ruptured?
fetal heart rate (FHR) to identify a deceleration, which might indicate cord compression secondary to cord prolapse
If a women comes to the hospital with ruptured memranes, what should you assess for and why?
- When rupture occured (how long has it been since)
- maternal fever
- fetal and maternal tachycardia
- foul odor of vaginal dicharge
- increase in white blood cell count
With ruptured membrane there is an increased risk for infection
How do you confirm if the membrane has ruptured?
- take a sample of fluid from the vagina and test it with Nitrazine paper to determine the fluid's pH.
- Vaginal fluid is acidic
- Amniotic fluid is alkaline and turns Natrazine paper blue
When would a Natrazine paper test give a false positive?
When a women is experiencing a large amount of bloody show; blood is alkaline
A Natrazine paper test tape that remains yellow to olive green and shows a pH of between 5 and 6 indicates what?
that the membrane is still intact
What test besides the natrazine paper test can be administered to see if the membrane is still intact? and how is it administered?
the fern test; a sample of amniotic fluid is taken and put on a microscope slide and allowed to dry; the sample is then examined for a characteristic fern pattern that indicates the presence of amniotic fluid.
Uterine contractions with an intensity of ______ mm Hg or greateer are needed to initiatecervical dilation.
30 mm Hg
palpation of the fundus for contraction intensity includes?
- place pads of your fingers on the fundus and describe how it feels
- tip of the nose ( mild)
- like the chin (moderate)
- like the forehead (strong)
In recent research findings, a cervical length of less than 25 mm is predictive of what?
preterm birth in all populations
What are Leopold's maneuvers?
a method for determining the presentation, position, and lie of the fetus through the use of four specific steps.
What would green amniotic fluid indicate?
the fetus has passed meconium secondary to transient hypoxia
When is the best time to listen to fetal heart rate to assess for decelerations?
at the end of the contraction (not after one)
To establish a fetal heart rate baseline, ausculatat for a full minute after a contraction.
Where is the fetal heart rate most clearly heard?
at the fetal back
What action should you take to make sure you do not confuse the maternal heart rate with that of the fetus?
palpate the client's radial pulse simultaneously while the FHR is being auscultated through the abdomen
National professional organizations have provided general guidelines for the frequency of assessments of FHR that includes:
- Initial 10 to 20 minute continuous FHR assessment on entry into labor/birth area
- Completion of a prenatal and labor risk assessment on all clients
- intermittent auscultation every 30 minutes during acitve labor for a low-risk woman and every 15 minutes for a high risk woman
- During the second stage of labor , every 15 minutes for the low risk woman and every 5 minutes for the high risk woman and during the pushing stage.
What does baseline fetal heart rate refer to?
the average FHR that occurs during a 10 minute segment that excludes periodic or episodic rate changes, such as tachycardia or bradycardia; it is assessed when the woman has no contractions and the fetus is not experiencing episodic FHR changes.
What is considered the normal baseline FHR?
110 to 160 beats per minute
What is considered fetal bradycardia?
below 110 bpm and lasts 10 minutes or longer
What are causes of fetal bradycardia?
- fetal hypoxia
- prolonged maternal hypoglycemia
- fetal acidosis
- administration of drugs to the mother
- maternal hypotension
- prolonged unbilical cord compression
- fetal congenital heart block
What is considered fetal tachycardia?
baseline FHR greater than 160 bpm that lasts for 10 minutes or longer
Causes of fetal tachycardia?
- fetal hypoxia
- maternal fever
- maternal dehydration
- maternal hyperthyroidism
- maternal anxiety
- fetal anemia
- fetal heart failure
- fetal arrhythmias
Definition of baseline variability
- normal physiologic variations in the time intervals that elapse between each fetal hearbeat observed along the baseline in the absence of contractions, decelerations, and accelerations
- It is one the most important characteristics of the FHR ; its presence implies that both branches of the autonomic nervous system are functioning and recieving enough oxygen
Variability is described in three ways: minimal or absent, moderate, and marked.
What is the cause and interventions of a minimal or absent variability?
Caused by uteroplacental insufficiency, cord compression, maternal hypotension, uterine hyperstimulation, abruptio placentae, or a fetal dysrhythmia.
- lateral positioning of mother to improve uteroplacental blood flow and perfusion through the umbilical cord
- increas the IV fluid rate to improve maternal circulation
- administering oxygen at 8 to 10 L/min by mask
- internal fetal monitoring
- document findings
- possible preparation for surgical birth
Causes and interventions of a moderate variability?
No cause or interventions; is considered a good sign of fetal well being
Cause and interventions of a marked variability?
- occurs when there are more 25 beats of fluctuation in FHR baseline.
- Causes include:
cord prolapse or compression, maternal hypotension, uterine hyperstimulation, and abruptio placentae
- determine cause if possible
- lateral positioning
- increase IV fluid rate
- administer oxygen at 8 to 10 L/min by mask
- discontinue oxytocin infusion
- observe for changes in tracings
- internal fetal monitor
- report abnormal pattern to provider
- prepare for surgical birth
Definition of periodic baseline changes
temporary recurrent changes made in response to a stimulus such as a contraction.
transitory increases in FHR above the baseline associated with sympathetic nervous stimulation; usually 15 bpm above baseline with duration less than 2 minutes are considered reassuring
transient fall in FHR caused by stimulation of the parasympathetic nervous system; described by their shape and association to uterine contraction ; classified as early, late, variable, and prolonged
Early decelerations are not indicative of fetal distress and do not require intervention.
Repetitive late decelerations and late decelerations with decreaseing baseline variability are nonreassuring signs. Interventions include:
- notify health care provider
- reduce or d/c oxytocin
- provide reassurance that interventions are being done
- Turn client on left side to increase placental perfusion
- administer oxygen
- increase IV fluid rate
- assess for underlying contributing causes
Variable decelerations are associated with cord compression. They are nonreassuring when FHR is less than 60 bpm and persists for at least 60 seconds and is repetitive. They are visually apparent abrupt decreases with unpredictable shape.
Prolonged decelerations are abrupt FHR declines of at elast 15 bpm that last longer than 2 minutes but less than 10 minutes; can be remedied by identifying cause and correcting it.
Fetal Scalp sampling
- measures pH of blood
- woman must ruptured membranes
- cervical dilation of at least 3 to 5 cm
- vertex presentation at -1 station
- pH should be between 7.25 to 7.35
- pH below 7.15 indicates acidosis
Fetal Pulse Oximetry
- normal oxygen saturation of a healthy fetus is 30 to 70%
- used for singleton term futus in a vertex presentation
- at -2 station or below
- with a nonreassuring FHR pattern
- membranes must be ruptured
- cervix dilated at least 2 cm
- a soft sensor is placed on cheek, forehead, or temple of the fetus
- notify doctor if O2 becomes less than 30 % between contractions in conjuction with a nonreassuring FHR
- performed to promote fetal movement with the hope that FHR accelerations will accompany movement
- a vibroacoustic stimulator (artificial larynx) applied to lower abdomen and turned on for a few seconds to produce sound and vibrations or by tactile stimulation via pelvic examination and stimulation of fetal scalp with gloved fingers
- a well oxygenated fetus will have an accelertion of 15 bpm above the baseline HR that lasts at least 15 seconds and this reflects a pH of more than 7 with a intact nervous system
- Do not perform stimualtion if the fetus is preterm, the woman has an intrauterine infection , a diagnosis of placenta previa or a fever.
Appalachian women believe doing what will reduce pain during childbirth?
placing a hatchet or knife under their bed
Asian, Latino, and Orthodox Jewish women will request that who attend their birthing process?
Their own mothers and will not allow their husbands in the room.
Nonpharmacologic pain management
- continuous labor support
- ambulation and postition changes
- acupuncture and acupressure
- attention focusing and imagery
- therapeutic touch and massage
- breathing techniques
- woman immerses herself in warm water for relaxation and relief of discomfort
- woman should be in active labor ( more than 5 cm dilated) to prevent slowing of labor contractions
- membranes can be intact or ruptured
- temp should not exceed body temp
- and time is limited to 1 to 2 hours
Supine and sitting positions should be avoided since they may interfere with labor progress and can cause compression of the vena cava and decrease blood return to the heart.
Contraindications for Therapeutic touch or massage includes
- skin rashes
- varicose veins
What is effleurage?
a light, stroking, superficial touch of the abdomen, in rhythm with breathing during contractions
Three levels of breathing technique
- first pattern- slow paced breathing; inhales slowly through nose and exhales through persed lips; 6-9 bpm
- second pattern- shallow or modified paced breathing; inhale and exhale through mouth at rate of 4 breaths every 5 seconds; can be 2 breaths per second
- Third pattern- pattern paced breathing- similar to modified paced but punctuated every few breaths by a forceful exhalation through pursed lips
What is neuraxial analgesia/anesthesia?
administration of analgesic (opioids) or anesthitic (medication capable of producing a loss of sensation in an area of the body) agents, either continuously or intermittently, into the epidural or intrathecal space to relieve pain.
Drug categories that may be used for systemic analgesia:
- opioids, such as butorphanol (Stadol), nalbuphine (Nubain), meperidine (Demerol), or fentanyl (Sublimaze)
- Ataractics, such as hydroxyzine (Vistaril) or promethazine (Phenergan)
- Benzodiazepines, such as diazepam (Valium) or midazolam (Versed)
- Barbiturates, such as secobarbital (Seconal)or pentobarbital (Nembutal)
The use of opioids during labor are associated with what problems in the newborn?
- respiratory depression
- decreased alertness
- inhibited sucking
- delay in effective feeding
To reduce incidence of newborn depression with administration of opioids how soon should birth occur after administration and what is the reasoning?
birth should occur within 1 hour or after 4 hours of administration to prevent the fetus from receiving the peak concentration of opioid
Ataractics are used in combination with an opioid to decrease what?
nausea and vomiting and lessen anxiety
Morphine 2-5 mg IV
- may be given IV, intrathecally, or epidurally
- rapidly crosses the placenta
- can cause maternal and neonatal CNS depression
- decreases uterine contractions
Meperidine (Demerol) 25-50 mg IV
- may be given IV or epidurally with maximal fetal uptake 2-3 hours after administration
- can cause CNS depression
- decreases fetal variability
Opioid-- Butophanol (Stadol) 1 mg IV q3-4h
- is given IV
- Is rapidly transferred across the placenta
- causes neonatal respiratory depression
Opioid-- Nalbuphine (Nubain) 10 mg IV
- is given IV
- causes less maternal nausea and vomiting
- causes decreaesed FHR variability, fetal bradycardia and respiratory depression
Opioid -- Fentanyl (Sublimaze) 25 to 50 mcg IV
- is given IV or epidurally
- can cause maternal hypotension, maternal and fetal respiratory depression
- rapidly crosses placenta
Ataractics--Hydroxyzine (Vistaril) 50 mg IM
- does not relieve pain but reduces anxiety and potentiates opioid analgesics
- is used to decrease nausea and vomiting
Ataractics -- Promethazine (Phenergan) 25 mg IV
- is used for antiemetic effect when combined with opioids
- causes sedation and reduces apprehension
- may contribute to maternal hypotension and neonatal depression
Diazepam (Valium) 2-5 mg IV
- is given to enhance pain relief of opioid and cause sedation
- may be used to stop eclamptic seizures
- decreases nausea and vomiting
- can cause newborn depression; lowest possible dose should be used
Benzodiazepines -- Midazolam (Versed) 1-5 mg IV
- is not used for analgesic but amnesia effect
- issued as adjunct for anesthesia
- is excreted in breast milk
Barbiturates-- Secobarbital (Seconal) 100 mg PO/IM
- causes sedation
- is used in very early labor to alter a dysfunctional pattern
Barbiturates-- Pentobarbital ( Nembutal) 100 mg PO/IM
- Is not used for pain relief in active labor
- crosses placenta and is secreted in breast milk
Obstetric regional analgesia generally refers to a partial or complete loss of pain sensation below what level of the spinal cord?
T8 to T10
What are the routes for regional pain relief?
- epidural block
- combined spinal-epidural block
- local infiltration
- pudendal block
- intrathecal (spinal) analgesia/anesthesia
- Local and pudendal routes for episiotomies
- epidural and intrathecal routes during active labor and birth
How and where is the epidural block given?
- In the epidural space, located outside the dura mater between the dura and the spinal cord
- entered through third and fourth lumbar vertebrae with a needle
- catheter threaded into place and needle removed
At what point during labor can an epidural block be given?
- after labor well established
- cervical dilation greater than 5 cm
Epidural is contraindicate for women with history of.......?
- spinal surgery or spinal abnormalities
- coagulation defects
- woman recieving anticoagulation therapy
Complications of epidural include:
- nausea and vomiting
- intravascular injection
- respiratory depression
Effects of epidural on fetus during labor are......?
fetal distress secondary to maternal hypotension
encourage woman to avoid supine position to help minimize hypotension
How is the combined spinal-epidural analgesia used?
- insert epidural needle into the epidural space and then inserting a small gauge spinal needle through the epidural needle into the subarachnoid space
- an opioid without local anesthetic is injected into space
- needle then removed
- catheter inserted for later use
- rapid onset of pain relief (within 3-5 min)
What are the possible complications of a combined spinal-epidural analgesia?
- maternal hypotension
- intravascular injection
- accidental intrathecal blockade
- postdural puncture headache
- inadequate or failed block
Hypotension and FHR changes are managed with maternal positioning (semi-fowler's position), intravenous hydration, and supplemental oxygen)
What is local infiltration?
injection of local anesthetic, such as lidocaine, into the superficial perineal nerves to numb the perineal area (before episiotomy)
What is the pudendal nerve block?
- injection of a local anesthetic agent into the pudendal nerves near each ischial spine
- pain relief in lower vagina, vulva, and perineum
- used for second stage of labor, episiotomy, or operative vaginal birth with outlet forceps or vacuum extractor
- must be administered 15 min before needed
What is the primary complication of general anesthesia?
- fetal depression
- uterine relaxation and potential maternal vomiting and aspiration
Nursing interventions for general anesthesia for a woman in labor are...?
- ensure patient is NPO
- patent IV
- administer a non-particulate (clear) oral antacid or a proton pump inhiboitor (Protonix) as ordered to reduce gastric acidity
- assess with placement of wedge under woman's right hip to displace the gravid uterus and prevent vena cava compression in the supine position
- Once the newborn removed from uterus, assist the perinatal team in providing supportive care
Key nursing interventions during the first stage of labor:
- Identify the estimated date of birth from the client and the prenatal chart
- prenatal history to determine fetal risk status
- leopold's maneuvers to determine fetal position, lie, and presentation
- Check FHR
- vaginal examination to evaluate effacement and dilation progress
- intruct client about monitoring techiniques and equipment
- assess fetal response and FHR to contractions and recovery time
- interpret fetal monitor strips
- check FHR baseline for accelerations, variability, and decels
- reposition the client to obtain and optimal FHR pattern
- Recognizing FHR problems and initiating corrective measures
- check amniotic fluid for meconium, staining, color, and amount
- comfort client
- assess support system and coping status frequently
Questions to ask during a phone assessment.
- estimated date of birth, term or preterm
- fetal movement in past few days
- other premonitory signs of labor
- parity, gravida, and previous childbirth experience
- time from start of labor to birth in previous labors
- frequency, duration, and intensity of contractions
- appearance of any bloody show
- ruptured or intact membrane
- presence of supportive adult in household or if she is alone