Quiz 1 (introduction/orientation- FHR)

Antepartum

Before birth (delivery)

Intrapartum

During birth (labor and delivery)

Postpartum

After birth (delivery)

Queen Victoria

Influential queen who helped popularize medicated childbirth after using chloroform during the labor and delivery of one of her children

Ether

An early form of pharmacologic pain relief in childbirth

Puerperal (postpartum) fever

A serious infection that often killed new mothers after childbirth. Emphasized the importance of handwashing and infection prevention in healthcare (Semmelweis)

Twilight sleep

A childbirth pain relief method that combined morphine and scopolamine to provide relaxation to the mom in labor, but caused respiratory depression in babies

Dr. Robert A. Bradley

Known as the "Father of fathers" because he allowed fathers to come into the birthing room. Also developed the labor technique of deep breathing and relaxation

Kitzinger

Her method helped women use chest breathing, abdominal breathing, and their sensory memory (imagery) to help work through the birthing process.

Dr. Fernand Lamaze

Developed the labor technique of breathing and distraction for natural pain control

Cleansing breath

Relaxed breath in through nose and out through mouth with pursed lips. Used at the start and end of each contraction. (Watch for hyperventilation- have them focus on long deep breaths/breathe into a paper bag if needed)

HypnoBirthing

Method developed by Mongan that is a form of self hypnosis during delivery that produces a sense of peace and calm thereby reducing pain (most popular birthing technique now).

Psychoprophylactic method

a prepared childbirth technique used to encourage women to relax and concentrate on their breathing when a contraction occurs during labor to reduce the perception of pain

Analgesia

C-section

Assistive devices

The psychoprophylactic method may decrease the length of labor and decreased the incidence of what three things?

Grunting

Nasal flaring

Retractions

Tachypnea

See-saw respirations

Central cyanosis

Six signs of respiratory distress in a baby

Dilation

Baby delivery

Placenta delivery

Repair

4 stages of labor and delivery

Dilation (1st stage)

Which stage of labor is this: Dilation of cervix, Hypoxia or uterine muscles, Stretching of lower uterine segment, Pressure on adjacent structures

(Latent/early, active, transition)

Baby delivery (2nd stage)

Which stage of labor is this: 10cm dilated, able to start pushing, Hypoxia of uterine muscles, Distention of vagina and perineum, Nerve impulses (Pudendal nerve)

(Fully dilated-delivery)

Placenta delivery (3rd stage)

Which stage of labor is this: Uterine contraction and cervical dilation

(Birth of baby-placental delivery)

Repair (4th stage)

Which stage of labor is this: Repair of episiotomy/laceration

(Up to 4hrs after delivery)

Decreased gastric emptying can cause N/V

Why are PO meds typically not given during L&D

Systemic (IM/IV)

General anesthesia

regional anesthesia

Types of pain relief used during L&D (3)

Over required number of minutes

At beginning of contraction (Decreased circulation to the baby d/t vasoconstriction- decreased crossing of med into placenta)

How are IV medications given during L&D

30-60

Normal newborn RR. Can be affected by use of narcotic/opioid analgesics- decreased sucking/activity

Cross placenta

Cause respiratory depression

Can slow or stop labor

3 reasons narcotic analgesics should be given with caution during L&D

Fetal distress (C/S)- emergency

Depression of tetanic (hypertonic) contractions

Cesarean section (C/S) when cant use regional anesthesia

3 indications for the use of general anesthesia during L&D

Fetal depression

Uterine relaxation (can cause hemorrhage)

Supine hypotension

Nb respiratory depression

Maternal vomitting and aspiration (chemical pneumonitis/mendelsons syndrome- give antacids pre-op)

5 complications of general anesthesia during L&D

Regional anesthsia

Temporarily interrupts conduction of nerve impulses and blocks pathway to CNS (wont affect cognition, but wont be able to walk or get of out bed)

Ester (short-acting)- nesacaine

Amine (long-acting)- Marcaine

Opiate- morphine, fentanyl

3 local anesthetics that can be used in L&D

Pudendal block

Local anesthetic to pudendal nerve

Spinal block (C/S)

Regional anesthetic that goes into CSF in subarachnoid space

Epidural

Regional anesthetic that foes into the epidural space. Patient will arch their back (mad-cat position) and physician will inject between L3-L5 avoiding blood vessels and subarachnoid space. A test dose will often be done to determine reaction. **check coagulation times before procedure

Slows labor is given too soon

May decrease sensation to push

May decrease movement of baby downward into birth canal

3 disadvantages of an epidural during L&D

5-6 cm dilated and in active labor

When should an epidural be given if nullipara (first birth/never delivered before)

3-4 cm dilated and active labor

When should an epidural be given if multipara (multiple births)

Tingling and warmth (after injection)

Heavy feeling in lower extremities (after injection)

Shakes (common)

N/V (common)

What are four common side effects that can occur after injection of an epidural?

Hypotension (avoid by increase in fluid volume before injection)

Metallic taste

Vertigo and tinnitus (dizziness and ringing)

Confusion and muscle twitching

Convulsions (late effect)

Respiratory/cardiac arrest (late effect)

What are the 6 toxic side effects of an epidural?

BP x3 immediately after injection; then every 5 min x3

Use epinephrine

Prevent: pre-hydrate, give O2, monitor ECG and FHR

Hypotension measures for an epidural (3)

Stop local anesthetic infusion immediately

Call for help and activate LAST protocol

Airway management: 100% O2, prevent hypoxia/acidosis

Seizure control: benzodiazepines (avoid large doses of propofol)

4 immediate actions of LAST (local anesthetic system toxicity) management in epidural care

Immediate actions (4)

Bolus: 1.5 mL/kg IV over 1 minute

Infusion: 0.25 mL/kg/min (increase if unstable)

Max dose: 12 mL/kg in 30 minutes

Use small doses of epinephrine (

10 steps to LAST (local anesthetic system toxicity) management in epidural care

Uterine atony (relax uterus) with increased bleeding

Bladder atony (If bladder is full but not emptying it adds pressure to uterus causing it to relax even more- more bleeding)

Keep in place post C/S

Use duramorph/astromorph (morphine)

Post-epidural care (4)

FHR Doppler (U/S)

Internal monitor

Tocodynamometer (external monitor)

3 equipments that can be used to measure FHR

FHR Doppler

Ultrasound transducer used to measure FHR. Listen through entire contraction (every 5min for high risk, every 15-30 for low)

Internal monitor

Device used to measure FHR and monitor pressure of contraction (the only way to measure pressure of contraction) through telemetry

Tocodynamometer ("toco")

External monitor placed over the fundus to measure FHR

Baseline changes

Obtained between contractions for 10 minutes

110-160

Normal baseline FHR range

Tachycardia

>/= 160 bpm for at least 10 minutes

Severe tachycardia

>/= 180 bpm for at least 10 minutes

Bradycardia

Severe bradycardia

Wandering baseline

Baseline FHR in normal range but wandering in inconsistent ways

Variability (baseline variability)

The up and down pattern of the FHR

Long-term variability

One minute intervals (over 10 minutes)

Short-term variability

beat to beat variability (over 1 min). Obtained via an internal monitor

Check pH/O2 saturation monitor

Stimulate scalp of baby

Infant asleep?

Extreme prematurity?

Hypoxia or acidosis?

Medications/drugs? (CNS depressants)

What to check if there is absent variability (flat line) for FHR? (6)

Accelerations

Increase in FHR associated with movement. Can be seen with contractions and typically indicates fetal well being

True acceleration

increase of 15 beats for 15 seconds

Decelerations

Transient decrease in FHR

Early

Late

Variable

3 types of decelerations

Early deceleration

Type of deceleration that mirrors the contraction (as contraction starts deceleration starts; when contraction ends, deceleration ends). Usually benign

Head compression

cause of early decelerations

Late deceleration

Type of deceleration that starts after the contraction starts, and it is a "bad" sign (concerning)

Uteroplacental insufficiency

cause of late decelerations

Variable deceleration

Type of decelerations that vary as to when then begin. Occasional ones are typically benign, but repeatable/worsening ones are concerning. The deeper and wider, the more severe

Umbilical cord compression (Nuchal cord, short cord, prolapsed cord)

Cause of variable decelerations

Nuchal cord

Occurs when the umbilical cord is wrapped around the babies neck

Prolapsed cord

Occurs when the cord comes out before the baby. It is an emergency!

Have mom turn from side to side

Preform vaginal exam

If there is a suspected prolapsed cord, the priority is to get baby off the cord. What 2 things can be done to make this happen

Prolonged decelerations

Decreased FHR < baseline for >/= 2 minutes

Sinusoidal

Absent, short-term variability. Shows a wave pattern on ECG. Concerning if it is persistent

Vaginal exam if variable deceleration

Have mom turn to eft side, knee to chest, or trendelenberg position for prolapsed cord

Oxygen (not always first priority- baby can't revive oxygen if cord is compressed)

Increase fluids

Turn of pitocin (helps uterine contraction)

Check labs (decreased Hgb= decreased O2)

Fetal scalp pH (normal 7.25-7.35,

10 steps to treating decelerations

Monitor baby's response to labor

Oxygenation and perfusion of placenta and baby

Why do we check FHR (baseline, variability, accelerations, deceleration) (2)

Baseline WNL 110-160 BPM

Moderate FHR variability

No late or variable decelerations

Possible early decelerations

Category 1: normal FHR (4)

Tachy/bradycardia without absent variability

Minimal variability

Absent variability without recurrent decelerations

Marked variability

No accelerations after stimulation

Recurrent variable decelerations with minimum or moderate variability

Prolonged decelerations >/= 2 min,

Recurrent late decelerations with moderate variability

Variable decelerations and other signs

Category 2: indeterminate FHR (9)- needs evaluation

Sinusoidal pattern OR

Absent variability with recurrent late decelerations, recurrent variable decelerations, or bradycardia

Category 3: abnormal FHR (2)- needs action!

Find abdominal midline

Begin at pubic bone (point probe down)

Rock probe from side-side

(Baby's HR will be much faster than moms- who you know you've found it)

3 steps to finding FHR with a Doppler for an early pregnancy

Find abdominal midline

Begin at fundus and move down

2 steps to finding FHR with a Doppler for a mid to late pregnancy

Locate back of fetus (leopold's maneuver)

Place ultrasound transducer

"Toco" transducer placed over fundus

3 steps to finding FHR with external monitors

Shrill

High pitched cry (concerning)

Lusty

Strong and normal cry

Toward umbilicus

When taking a rectal temp on a baby (typically right after birth), you insert the probe in which direction

60-80/40-45

What is the normal BP of a newborn

32-28 cm (chest about 2 cm smaller0

Normal occipital frontal circumference (OFC)

Flat and soft

Normal fontal finding

Sunken fontanelles

Sign of dehydration in infants

Bulging fontanelles

Sign of increased intracranial pressure in infants.

Anyloglossia

Tongue tie. If it interferes with feeding it will be surgically cut

Palpate

If a baby has a wilms tumor on their kidneys, what normal thing can you NOT do during their PA

Patent urachus

Opening between the bladder and umbilicus; can cause urine to come out of umbilicus

Redness

Drainage

Bleeding

What three thigns should you assess after a circumcision (should decrease as time progresses)

Sucking

Babinski

Grasp

Moro

4 reflexes required for newborn PA

What is an abnormal BG for a newborn

Chronic hypertension (previous or before 20 weeks)

Gestational hypertension

Preeclampsia/eclampsia (add seizure)

3 hypertensive disorders in pregnancy

Nulliparous

BMI >30 Family history (mom or sister) Advanced maternal age

4 moderate risk factors for hypertensive disorders during pregnancy

HTN with previous pregnancy

Multiple gestation

Chronic HTN

Kidney disease

DM

Autoimmune conditions

6 high risk factors for hypertensive disorders during pregnancy

Cerebral hemorrhage

Leading cause of death in preeclamptic patients

Postpartum hemorrhage

>1000 mL of cumulative blood loss or ant amount of bleeding accompanied by S&S of hypovolemia within 24hrs of delivery, regardless of the route of delivery. 2nd most common cause of maternal mortality

Pitocin (oxytocin)

Methergine

Hemabate

Cytotec

TXA (only one used to treat hemorrhage d/t a thrombin issue)

5 medications used to prevent postpartum hemorrhage

Breast

Uterus

Bowel

Bladder

Lochia

Episiotomy

Hemorrhoids

Attachment

Emotional status

Postpartum assessment- BUBBLE HAE