NU301 exam 2

anterior fontanel

diamond shaped

3x2 cm

closed by 18 months

general flexion attitude

chin to chest, back rounded, arms and legs flexed toward trunk

fetal position

best for vaginal delivery

puts the smallest part of the back of the head coming out 1st

military attitude (sinciput)

looking straight ahead, large diameter enters pelvic inlet 1st

Brow attitude

marked extension, largest diameter enters pelvis first

fetal station

relationship between presenting fetal part and maternal ischial spine

measurement of fetal descent in cm above or below spine

what station number is engagement

0

what station number is crowning

+ 4 or 5

which pelvis shapes are compatible with vaginal delivery

C section

gynecoid, anthropoid

android, platypelloid

effacement

thinning and shortening of the cervix

full dilation marks the end of stage ___ of labor

1

secondary powers

voluntary, bearing-down

which hormone allows for cervical cervical ripening

prostaglandins

stage of labor

1. onset of contractions to full dilation (varies the most)

2. dilation to birth

3. birth until placenta (30 min max)

4. begins with delivery of the placenta to postpartum

visceral origin of labor pain

uterine body and cervix

1st stage due to stretching of uterus

vague location, dell, achy

T10-T12, L1 spinal nerve

somatic origin of labor pain

pundendal nerve

2nd stage of labor

intense, sharp, burning, well localized

S2-S4

when is general anesthesia used in labor

Emergency situations, rapid delivery required, lack of time to administer regional anesthesia, contraindications, failure to place region, severe pt anxiety, ascending spinal block

what is the rocking or walking epidural

combined spinal-epidural anesthesia

less, leads to leg weakening

minimal variability

Fluctuations of

Marked variability

fluctuations >25 bpm

Fetal tachycardia

baseline FHR >160 bpm for at least 10 min

causes: early sign of fetal hypoxemia, cardiac rhythm abnormalities, maternal infection, medication, maternal hyperthyroidism, fetal anemia, illicit drug use

acceleration

abrupt increase in FHR above baseline

onset to peak

Variable decelerations

cord compression

abrupt onset < 30 s

decrease 15 bpm for at least 15 s

cause: maternal position, cord knot, cord prolapse, cord wrap around neck

Prolonged deceleration

decrease for at least 15 bpm for more than 2 min but less than 10 min

true labor

contractions are regular and become stronger, longer, and closer together

felt in lower back and abdomen

cervix thinning, effacement, dilation

amniotomy

AROM

PROM

premature rupture of membranes

water breaks before the onset of labor, risk for infection

PPROM

preterm premature rupture of membranes

prolonged PROM

water breaking before 37 w and onset of labor, risk for infection

occurs from weakened amniotic membranes due to inflammation of pressure from contraction

perineal trauma risk factors

nulliparity, light skin, maternal nutritional status, birth position, pelvic anatomy, macrosomic neonate, assisted vaginal delivery, rapid delivery, prolonged 2nd stage

preterm risk factors

Hx of genital tract infection, african american, bleeding from unknown source, Hx of previous abortion, Hx of preterm birth, uterine anomaly, use of assisted reproductive technology, multifetal gestation, smoking or substance abuse, extreme prepregnancy weight, periodontal disease (leads to inflammation which impacts placenta), limited education, low socioeconomic status, late prenatal care, high levels of stress, COVID

-anything that puts strain on placental attachment

preterm labor interventions

activity restriction

avoid intercourse

tocoytics (buy time)

antenatal glucocorticoids (promote fetal lung maturity)

in preterm birth is inevitable (24-32 w) ___ is given for neuroprotection

mag sulfate

Precipitous labor

labor that lasts 3 hrs or less

from hypertonic contractions

associated with placental abruption, uterine tachysystole, and cocaine use

when would an amnioinfusion be indicated

Variable decelerations -more fluid can float baby off of cord to reduce compression

bishop score

how ripe the cervix is

higher the better

uterine rupture risk factors

previously scarred uterus, common during TOLAC or VBAC, prior trauma, abortion, grand multiparity (5 or more pregnancies), uterine overdistention (multiple fetuses or polyhydramnios), uterine window (not a hole yet but it is so thin that you can see through it)

Biggest sign: rapid onset of intense abdominal pain

What are the 5 P's affecting labor?

Passenger

Passageway

Powers

Position

Psychology

passenger

fetus and placenta

size of fetal head, fetal presentation, fetal life, fetal attitude, fetal position

true or false: palpation of the fontanels and sutures are during a sterile vaginal exam

true

posterior fontanel

triangular shape

1x2 cm

closes 6-8 weeks after birth

fetal presentation

part that lies closest to the cervical os (what comes first)

cephalic, breech (butt or feet), shoulder

fetal lie

relation of the spine of the fetus to the spine of the mother

vertex: longitudinal

transverse: horizontal or oblique

fetal attitude

relation of fetal body parts to one another (chin)

Face attitude

full extension of head

fetal position

relationship between the presenting part of the 4 quadrants of the mother's pelvis

BASED OFF POSTERIOR FONTANELLE

left or right, Occiput (head)/Sacrum/Menum (chin) /Scapula, anterior/posterior/transverse

what is the hardest fetal position to deliver

OP (sunny side up)

if the anterior fontanelle is felt rather than the posterior where is the posterior located?

diagonal

passageway

birth canal

bony pelvis, cervix, pelvic floor, vagina, introitus (opening of vagina)

bony pelvis is the biggest factor and most problematic

pelvis shapes

gynecoid

android

anthropoid

platypelloid

round

heart shaped, pubic arch sits really low

oval long ways

oval flat ways

powers

contractions

primary powers

involuntary

contractions originate in upper uterine segment, proceed downward in wave like pattern

categorized by frequency, duration, intensity

ferguson reflex

results in dilation and effacement of the cervix

what if the cervix is not felt

completely dilated and 100% effaced, same with uterine wall

labor signs

uterus descends down and forward (lightening)

stronger Braxton Hicks

bloody show: caused by cervix preparing for delivery, softening, and seperating from vaginal wall -> capillaries break

cervical ripening: soft, ready to change

ROM

slight weight loss

burst of energy (nesting)

increase in prostaglandins, estogen, oxytocin

decrease in progesteron

7 cardinal movements of labor

Engagement: head in line or not in line with body

Descent

Flexion

Internal rotation

Extension

External rotation: realign head with shoulder

Expulsion: birth

maternal physiological adaptation

increased CO, HR, BP, RR, WBC

proteinuria due to strenuous effort and muscle tissue breakdown

decreased gastric motility and glucose

referred labor pain

occurs during active labor

radiates to lower back, hips, shoulders

factors that effect perception of pain

Hx of painful experiences

coping skills

culture

fatigue

gate-control theory

Pain pathways are a one way highway, if you are in pain u can overload the pathway with different sensations to override the nerves

Nonpharmacologic Pain Management interventions

counterpressure (referred pain)

water therapy, massage, movement, aromatherapy, focal points, breathing, biofeedback, imagery

1st stage pain management

Opioids -ineffective, Epidural block analgesia, Combined spinal epidural analgesia -walking epidural, lighter and allows movement, Nitrous oxide (Safe and effective for altering perception of pain, Administered via face mask for rapid decrease in pain, Self administered, Increasing in popularity, mild sedative)

2nd stage pain management

Nerve block, Pudendal block, Spinal block, Epidural block, CSE, Nitrous oxide

sedatives as labor pain management

relieve anxiety, help mom sleep in 1st stage of labor

easily cross placenta, cause neonate respiratory depression and effects thermoregulation

do not give in active labor and monitor FHR

opioids as labor pain management

limited efficacy

maternal hypotension, bradycardia, respiratory depression-> baby gets less

cross placenta

epidural anesthesia

catheter left in epidural space

most effective

between 4th and 5th

gravity plays a part in how the epidural moves

watch for urinary retention, hypotension, and spinal headache

Pudendal nerve block

used right before delivery or if tore bad

lasts for 10-20 min

spinal anesthesia

no ideal for vaginal birth

used in C section

lasts 1-3 hours

spinal headache

epidural poke dura in spinal cord and fluid begins to leak, leading the brain to sag on skull OUCH

positional, caffeine and Tylenol help

blood patch!

interventions for hypotension caused by epidrual

IV fluid bolus, vasoconstriction meds, left side lying, oxygen

pt is to have an amniotomy to include labor. the nurse recognizes that the priority intervention after the amniotomy is to do which of the following

a. apply clean linens under the woman

b. take vital signs

c. perform vaginal exam

d. assess the FHR

d

biggest risk is prolapsed cord, sudden drop

why do we monitor FHR

differentiate reassuring patterns from nonreassuring patterns to determine fetal wellbeing

fetal oxygen!

Intermittent auscultation (IA)

listens to FHR at set intervals during labor

low risk women not on oxytocin

time period closer as it gets closer to delivery

higher risk for missing fetal distress

Electronic Fetal Monitoring (EFM)

allows for continuous assessment of fetal oxygenation and rapid intervention if needed

External EFM

ultrasound transducer and toco

shows when contraction occurs and FHR

Internal EFM

spiral electrode applied to fetal scalp and assess uterine activity/resting tone

monitors frequency, duration, and intensity of contraction

in MVU

components of uterine activity

frequency, duration, strength, resting tone, relax time, MVUs

components of FHR tracing

baseline, variability, accelerations, decelerations, changes over time

baseline HR

average rate during 10 min segment of monitoring

round to closest 5 bpm interval

sympatheric response accel

parasympathetic response decel

baseline variability

change in amplitude

fluctuation in baseline FHR of 2 cycles/min or greater

does not include acels or decels

measured from peak to trough within a single cycle

Absent variability

non detectable

caused by fetal hypoxia, metabolic acidemia, sleep cycles, tachycardia, prematurity, medications, pre-existing neurological deficits

moderate variability

flucuations 6-25 bpm from baseline

GOOD

sinusoidal pattern

abnormal pattern

sign of eminent doom and severe fetal anemia

pseudo-sinusoidal pattern

HR converts intermittenly to look like sinusoidal

may indicate chorioamnionitis, fetal sepsis, or maternal opiod analgesic

Fetal bradycardia

FHR

episodic

periodic

not related with uterine contraction timing

occur with uterine contractions

how long does it take to change the baseline FHR

10 min

Early decelerations

head compression

gradual onset, > 30 s return

normal

mirrors contraction pattern

Late decelerations

placental insufficiency

onset < 30 s return to baseline

begins after contraction has started

category 1 FHR

baseline 110-160

moderate variability

no lat or variable decels

Category 3 FHR

absent variability, recurrent late decels, recurrent variable decels, or bradycardia

sinusoidal pattern

r/t hypoxemia

intrauterine resuscitation

interventions for concerning decels patterns that increase uteroplacental blood flow and increase maternal oxygenation

Poison interventions

position change

oxytocin off

IV fluids

sterile vaginal exam

oxygen

notify provider

intrapartum

during labor and delivery

false labor

braxton hicks

felt above umbilicus

no cervical change

Nitrazine test

swabs vagina for pH to see if amniotic fluid is present or not

Ferning test

Swab vaginal area, rub on slide, under microscope it should look like a fern; positive indicates ROM

when does the 2nd stage of labor start

full dilation and effacement

preventing perineal trauma

perineal massage in 3rd trimester, warm compress, side lying position, slow passing of head

most common lacerations

perineal accompanied by tears on labia minora surrounding the urethra or extending to the clitoris\significant bleeding

1st degree

2nd degree

3rd degree

4th degree tear

-through skin and superficial muscles

-through muscles

-through anal sphincter

-completely through anal sphincter and rectal mucosa

3rd stage of labor

delivery of the placenta

fundal massage following placental expulsion and oxytocin, constricts bv's

4th stage of labor

time for baby bonding, recovery, and stabilization