l&d exam 2

what are some signs that labor may be beginning? (6)

*does not mean you are in labor, but uterus is getting ready

• lightening → baby “drops” into pelvis between 36-40 weeks

• mucus plug is expelled as cervix softens and dilates

• nesting → burst of energy preceding labor

• cervical ripening (“softening”)

• rupture of membranes → “water broke”; may occur before or during labor

• bloody show → light, red tinged bleeding as cervix begins to dilate

labor officially begins with…

uterine contractions that cause cervical change

dilation

opening of the cervix from 0-10cm

effacement

thinning of the cervix measured as a percentage

→ 0% = thick

→ 100% = paper thin

what needs to come first? dilation or effacement?

effacement!

the cervix needs to thin and soften before it dilates

labor: fetal presentation

ideally, you want the baby’s head to be down towards the vagina (cephalic position).

sometimes, the baby is flipped (breech) or their shoulder is in the way of the birth canal

labor: fetal position

labor: fetal attitude

relationship of the fetal head to the spine

we want the baby’s head to be flexed, with their chin tucked in (“vertex”)

we do not want the baby’s head to be extended, with their face coming out first

labor: fetal station

fetal position within the maternal pelvis, rated from -5 to +5

• negative station = baby is high and not engaged

• 0 station = baby is engaged in maternal pelvis

• positive station = baby is low, coming out of the pelvic outlet

we want the baby to be a positive station when they are being delivered!

“-5 is up in canada and +4 is on the floor”

T or F: patients should be continuously moving while in labor

true!

changing positions is great for labor for many reasons. it helps mom with coping through pain and it keeps baby awake and stimulated

T or F: stress hormones are not good for labor

true!

therefore, it is important to keep mom as relaxed as possible during the labor process. lower cortisol = easier labor that progresses faster

how can you determine labor contractions are real/true?

• contractions start in lower back/abdomen

• may feel pressure in pelvis

• may feel like intense menstrual cramps

• contractions get closer together and stronger

• these contractions cause cervical change!

how can you determine if contractions are false?

• may feel like mild menstural cramps that are uncomfortable but not painful

• contractions stop with rest

• contractions don’t effect mom’s ability to walk, talk, and progress with normal activities

• these contractions do not cause cervical change!

how does mom adapt physiologically during labor?

• increased HR during contractions, WBCs increase, increased oxygen demands

• decreased gastric emptying (why moms feel nauseous)

• oxytocin levels rise

T or F: labor is stressful to baby

true!

why is labor stressful to baby?

transient hypoxia!

during contractions, blood flow from the placenta is pushed away from baby

4 stages of labor

1 - begins with onset of contractions causing cervical change. can be considered active or latent. the first phase of labor persists until the patient is 10 cm dilated

2 - begins when mom is 10 cm dilated and pushing

3 - begins when baby is born. “birth” of the placenta happens in this phase

4 - recovery period after placenta is delivered until about 2 hours after delivery

first stage of labor: active vs latent phases

latent phase → characterized by irregular contractions, effacement progress, and dilation from 0-4 cm

active phase → characterized by regular contractions, decent of fetus into birth canal, and dilation of the cervix from 4-10 cm

which phase of the first stage of labor takes longer? active or latent?

latent

T or F: the duration of labor varies, especially depending on parity

true

first time moms typically have much longer labors compared to moms with multiple children

when a mom first comes in to the ED in suspected labor, what is apart of the initial assessment? (5)

• vitals

• fetal monitoring (at least 20 mins)

• monitoring contractions

• cervical exam

• review prenatal history

what are some ways a nurse can assess contractions? (3)

palpation

• belly will feel hard during contractions

external monitoring - “belly bands” called a TOCO

• non-invasive; uses a pressure sensor at the top of the fundus

• does not measure strength of contractions accurately

• most commonly used

internal monitoring - using a device called IUPC

• invasive; catheter is inserted in uterus to accurately measure the strength of contractions

• membranes must be ruptured

• can dislodge the placenta

what factors do nurses measure when measuring contractions? (4)

• frequency - 2-5 in 10 minutes

• duration - lasts about 90 seconds

• strength - varies

• resting tone - uterus is soft in between contractions

T or F: its okay for contractions to occur every minute during the first stage of labor

FALSE

we want adequate rest time for baby in between contractions. when they’re being squeezed, they’re receiving little to no blood flow.

contractions become closer together (about every minute or two) when mom is ready to push

what is fetal monitoring? how do we monitor a baby?

fetal monitoring (FHR) monitors the baby’s heart rate and oxygenation alongside contractions.

intermittent auscultation - auscultation of baby’s HR with a doppler. used for low risk clients after fetal wellbeing is established after admission

electronic fetal monitoring - recommended upon admission and used at all times in high risk clients. can be done externally or internally.

what are the steps when interpreting FHR? (4)

1. establish a HR baseline (roughly, what is the average of the baby’s HR?)

2. establish variability

3. are any accelerations present?

4. are any decelerations present?

what is a normal HR range for FHR?

110-160 bpm

FHR: variability

fluctuations/variations in baby’s heart rate. when interpreting a baby’s variability, do not include accels/decels

four types: absent (bad), minimal (can be okay), moderate (YES), marked (can be okay)

why do we want baby’s HR to fluctuate or be variable?

FHR variability is a good sign that suggests the baby’s neurological system is mature and intact.

the baby’s heart rate SHOULD vary based on changes in its environment, such as contractions, sleeping, etc.

FHR: absent variability

FHR: minimal variability

FHR: moderate variability

FHR: marked variability

FHR: what are accelerations?

increases in fetal heart rate from baseline

needs to rise at least 15 beats above baseline to be considered an acceleration and needs to last for at least 15 seconds → “15 by 15”

accelerations are good! they show fetal wellbeing and solid neurological function

FHR: what are decelerations?

decreases in fetal heart rate from baseline

some decelerations are expected, some are more dangerous

FHR: early decelerations

gradual decreases in fetal heart rate that match contractions

caused by fetal head compression

shaped like a “U” on FHR/contraction strip

“contraction goes up, fetal heart rate goes down”

FHR: variable decelerations

an abrupt decrease in fetal heart rate

may occur with or without contractions and are caused by umbilical cord compression

shaped like a “V”

FHR: late decelerations

gradual decrease in fetal heart rate that occurs after the peak of a contraction

associated with placental insufficiency

shaped like a “U”

ex) my mom when she had me :)

VEAL CHOP pnemonic for FHR accels/decels

FHR: prolonged decelerations

any deceleration that lasts longer than 2 mins but less than 10 minutes

this is very very bad

FHR: sinusoidal pattern

smooth, undulating wave-like pattern lasting greater than 20 mins

rare, but emergent → emergent birth necessary

associated with fetal anemia

FHR: bradycardia (FHR <110bpm) and tachycardia (FHR>160bpm) for more than 10 minutes

both not reassuring

bradycardia → associated with hypoxia, cord compression, cord prolapse, placental abruption, or uterine rupture

tachycardia → maternal fever (sepsis!), dehydration, fetal distress, and hypoxia

FHR: category 1

• baseline 110-160bpm

• moderate variability

• no late or variable decels

• early decels are present or absent

• accels present or absent

this is the NORMAL category!

FHR: category 3

• recurrent late/variable decels and absent variability

• bradycardia and absent variability

• sinusoidal pattern

BAD BAD BAD

“we should never see a cat. 3 FHR unless they come in emergently”

FHR: category 2

somewhere in between categories 1 and 3

• moderate variability with recurrent late or variable decels

• minimal variability

• absent variability without recurrent decels

• prolonged, variable, or late decels

intrauterine resuscitation

means…. “what should i do if I don’t like this baby’s FHR?”

• maternal repositioning

• increasing IV fluids especially if BP is low or placenta is insufficient

• supplemental oxygen

• amnioinfusion → putting amniotic fluid back in to mom

if FHR patterns do not improve or worsen, anticipate emergency birth

visceral pain

pain originating from organs or nerves

during birth, this type of pain originates from…

• uterine contractions

• cervical dilation

somatic pain

pain felt in muscles, joints, and bones

during birth, this type of pain originates from…

• pressure from fetal head

• stretching pelvic muscles and perineal tissue

during the first phase of labor, ___________ pain is felt the most

visceral

during the second phase of labor, __________ pain is felt the most

somatic

what factors influence a mom’s pain perception? (5)

• length of labor

• comfort measures in place

• anxiety

• physical pain

• preparation for labor

is the 0-10 scale a beneficial tool when assessing labor pain?

NO

coping/not coping pain scale

Instead of asking a laboring person to rate the intensity of their physical pain on a number scale, care teams evaluate how well the person is managing or coping with the sensations of labor

what are some non-pharmacological pain management interventions for moms in labor? (8)

• relaxation and breathing → lamaze technique

• positioning

• touch and massage → effleurage, counterpressure

• acupressure and acupuncture (needs extra training)

• heat/cold therapy → baths, hot/cold packs

• aromatherapy

• water therapy

• music

effluerage

a massage technique that focuses on…

• gentle or deep pressure in circular or linear motions

• performed on the mom’s back, abdomen, hands, or forearms

counterpressure

a massage technique that is most helpful with back pain during contractions

a second person applies pressure to a spot on mom’s back or both hips during contractions to provide counterpressure for contractions

what are some pharmacological pain management interventions for moms in labor?(6)

• opioid analgesia (fentanyl, morphine, meperidine, oxycodone, tramadol)

• opioid agonist-antagonist (nalbuphine)

• perineal infiltration

• pudendal nerve block

• spinal/epidural

what opioid analgesics can be used for moms in labor? what route are they given and what are some complications?

meperidine (demerol), oxycodone, tramadol, fentanyl, morphine

route: IV

comps: can cross placenta and make baby sleepy, so watch for bradycardia and absent variability. for this reason, avoid within 1 hour of birth (8 cm dilated)

there is a medication that can be used for pain management that actually is associated with decreased respiratory depression. what medication is this?

nalbuphine (nubain)

this medication is an opioid agonist/antagonist

labor pain management: perineal infiltration

numbing skin used for episiotomy or repairs

labor pain management: pudendal nerve block

local anesthesia injected into the pudendal nerve

more effective than perineal skin infiltration

labor pain management: spinal anesthesia

a single injection into the subarachnoid space (goes deeper than epidural)

most commonly used before c-sections

lasts about 2 hours

PATIENT CANNOT MOVE AROUND AT ALL

labor pain management: epidural anesthesia

a continuous infusion of pain medication given via a catheter that remains in the epidural space for the duration of labor

most commonly used for labor/natural vaginal births

PATIENT CAN MOVE IN BED, BUT CANNOT GET UP

what are some contraindications that would stop an individual from getting an epidural? (3)

• coagulopathy → conditions that affect blood clotting, such as HELLP syndrome and elevated platelet levels

• spinal anomalies → conditions that affect normal spine curvature, such as scoliosis

• infection around epidural site

what are some complications of an epidural? (4)

• infection

• hematoma

• severe headache (“spinal headache”) that is worse when sitting up; caused by accidental puncture of CSF sack, causing a CSF leak

• hypotension caused by vasodilation from epidural meds

to prevent hypotension from an epidural, what can the nurse do to intervene? (2)

• give a fluid bolus before epidural placement

• q. 5 mins BP checks

T or F: epidural may interfere with pushing

true!

the epidural decreases sensation and can dull the natural reflex to bear down, especially if the medication rate is too high

what are some different birthing locations and why would they be chosen over others?

home

• relaxing environment, recommended for low risk births

birth center

• recommended for safe birth outcomes, less invasive than hospitals, usually staffed by midwives, recommended for low risk births

hospital

• recommended for safest birth outcomes

• emergency care available for high risk births

• more options for pain mgmt

T or F: evidence shows that having a doula reduces maternal morbidity and mortality

true

differences between midwives and OBGYNs

midwives (certified nurse midwife)

• licensed and certified in low risk pregnancies

OBGYNs

• licensed and certified in high risk pregnancies, trained in surgery

when a mom is actively pushing the baby out, what should you be assessing as the nurse? (3)

• exhaustion/pain levels

• coping/not coping

• monitor pushing efforts and give feedback → good pushing = baby is moving down!

a mom has been pushing for three hours and is physically and mentally exhausted. what is a great option for next steps?

• “labor down” → for 1-2 hours, stop physically pushing and let baby do the work

labor: cardinal movements

“twists and turns the baby is doing”

includes multiple steps:

1. pre-engagement (before labor, cervix is closed)

2. engagement

3. descent

4. neck flexion

5. internal rotation

6. extension

7. external rotation

8. expulsion

labor: crowning

when the baby’s head is visible on the perineum

during the birth of the baby’s head, the mom should push _______ to prevent tearing

slower

labor: nuchal cord

umbilical cord wrapped around baby’s neck

can potentially be very very bad!!!

provider is trained to assess if the cord is wrapped around baby’s neck and what to do afterwards

labor: perineal lacerations

tearing of the tissue of the perineum due to stretching during birth, typically when baby’s head and shoulders are coming out

four degrees:

• 1st - skin is lightly torn, like a mark

• 2nd - most common; perineal muscles are torn but the anal sphincter is intact

• 3rd - anal sphincter is torn

• 4th - skin tear from vagina to anus, completely tearing the anal sphincter. this type of laceration typically needs surgical removal to fix

episiotomy

perineal incision done by the provider during birth with the intention of opening the pelvic outlet for baby to easily move through

decreases the length of the 2nd stage of labor due to fetal distress

mom should be locally anesthetized before episiotomy

why would a natural tear heal easier than an episiotomy?

“jagged edges reattach easier than straight, floppy edges”

after the baby is delivered, the placenta needs to be expelled from the uterus. what are some signs of placental separation? (2)

• bleeding

• umbilical cord lengthening

the placenta can be delivered two ways: actively and passively. what is the difference?

passive - allowing maternal body to expel placenta on its own

active - typically the standard of care in the hospital setting; controlled cord traction by provider and uterotonic medication

• pitocin given so uterus contracts, which clamps bleeding and speeds up the birth of the placenta

• decreased risk of postpartum hemorrhage

APGAR

basic assessment of a newborn’s physiologic status immediately after it comes out of the womb (1 min and 5 mins)

the APGAR tool assesses HR, breathing effort, muscle tone, reflex irritability, and color

what two body systems are extremely important to assess in a freshly newborn baby?

temperature regulation

• newborns are extremely sensitive to temperature differences, especially cold. They have a high risk of heat loss because their skin is thin and fragile

• interventions: put baby skin-to-skin with mom or dad, have them wear a hat, warm blankets, infant warmer

respiratory status

• assess respiratory rate (normal = 30-60), strength of cry

• coarse respiratory sounds are expected since their lungs are still full of fluid

• abnormal signs = nasal flaring, grunting, retractions

how do babies lose heat? (4)

evaporation: occurs when the newborn is wet

conduction: occurs when a newborn comes in contact with a cold object

convection: occurs when the newborn is in a cold environment

radiation: occurs when the newborn is placed near a cold object or environment, such as a crib next to a window

what is the PRIORITY assessment for a freshly postpartum mom?

monitor for postpartum hemorrhage!!

to watch for this, vitals should be done q. 15 mins for the first two hours

fundal assessment - why is it done?

a fundal assessment is done to ensure the uterus is shrinking quickly after birth to prevent excessive bleeding. the uterus should feel firm.

if the uterus feels boggy → massage the fundus to stimulate contractions!

lochia

vaginal discharge following birth consisting of uterine tissue, blood, and mucus

three types: lochia rubra (bright red), serosa (dark brown), and alba (clearish/white). lochia should lighten as the “dinner plate” heals

how should you measure a mom’s output of lochia?

by weight!

1g = 1 mL of blood

how much bleeding is considered ‘too much’ after birth?

soaking a peri pad in 15 minutes or less is considered concerning, especially when this is accompanied by…

• boggy fundus

• hypotension

• tachycardia

• passage of large blood clots

what are the three most important medications to give to a newborn after birth? why is this?

eye prophylactic abx - prevents neonatal ophthalmia, caused by gonorrhea. if left untreated, this can cause eye blindness.

vitamin K - newborns lack clotting factors at birth, so babies get an extra boost of vitamin K to stimulate production of clotting factors

hep B vaccine - since hep B can easily be transmitted from mom to baby during birth, the hep B vaccine is given to decrease the risk of transmission

birth complications: preterm labor and birth

(patho, etiology, S/S, diagnostics)

patho:

• onset of regular uterine contractions that cause cervical change in moms who are 37 wks or less

• preterm labor does NOT always result in birth!

etiology:

• not well understood, but associated with multiple risk factors, including GI/U infections, trauma, acute illness, dehydration, hx of preterm birth, SDOH, and lack of support

S/S:

• regular uterine contractions that cause cervical change

• PPROM

diagnostics:

• cervical checks, fetal monitoring, additional labs to RO infection, fFN lab testing (protein found in amniotic fluid after water broke)

tocolysis

a fancy word for “stopping contractions” and delaying preterm birth. done with multiple medications including:

• terbutaline → acts on smooth muscles of uterus to relax them

• nifedipine → CCB that lowers BP

• mag sulfate → neuroprotection

what are some contraindications to tocolysis? (5)

(aka, why would we not want to keep baby cooking?)

• fetal demise

• non-reassuring FHR (category 2 or 3)

• hemodynamic instability in mom

• severe preeclampsia

• frank bleeding

why can corticosteroids be used for preterm labor/birth?

corticosteroids improve neonatal respiratory outcomes

that being said, corticosteroids need at least 48 hours in mom’s system for effectiveness

birth complications: PPROM

(patho, etiology, S/S, diagnostics)

PPROM = preterm/prelabor rupture of membranes

patho

• membranes rupture before 37 weeks, creating a risk for infection!

etiology:

• not fully understood

• increased risk with acute infection, trauma, preterm labor, amniocentesis

S/S:

• gush/trickle of fluid from vagina

diagnostics:

• no single definitive test; mostly centers around assessments and infection prevention

what is the most important assessment to do for a mom with PPROM?

ASSESS FOR INFECTION!!

• foul smelling/discolored discharge or fluid from vagina

• elevated temp, WBC count, tachycardia in mom or baby

• uterine tenderness

what is the treatment for PPROM?

depends on gestational age, but usually mimicks the treatment for preterm labor (expectant mgmt, tocolysis, corticosteroids, mag sulfate, abx)

why are abx given to moms with PPROM?

for prophylactic coverage to prevent chorioamnionitis and sepsis in mom and baby

birth complications: chorioamnionitis

(patho, etiology, S/S, diagnostics)

patho:

• infection of the amniotic fluid, placenta, uterus, or membranes that typically begins as an ascending GU infection

etiology:

• can be caused by any pathogen, including bacteria, viruses, fungi, and STIs

S/S:

• fever, uterine tenderness, maternal and fetal tachy, elevated WBC

diagnostics:

• amniotic fluid culture

• placental pathology culture is definitive!

what is the main treatment for chorioamnionitis?

antibiotics!