273 Exam 2

true labor

1. progressive dilation and effacement

2. regular contractions

3. pain usually starts in the back, radiates to abdomen

only diagnosed if cervical change is made!

false labor

1. lack of cervical change

2. irregular contractions

3. contractions mainly in front of abdomen

4. can relieve pain

Critical factors in labor: 1st 5 P’s

1. passageway (birth canal)

2. passenger (fetus)

3. powers (contractions)

4. position

5. psychological response

passageway

1. maternal (immovable) pelvis

   • gynecoid and anthropoid are best

2. soft tissues (cervix, pelvic floor, vagina)

   • cervix dilates and effaces

   • vaginal canal distends

fetal head

• face and cranial base are fixed

• cranial vault, which has sutures, is moldable

• fontanelle: intersection of sutures

fetal lie

relationship of fetal spine to mother’s spine (cephalocaudal)

• longitudinal - vertical (parallel to maternal spine)

  • cephalic

  • breech

• transverse - horizontal

  • shoulder- always C/S

fetal attitude

• relation of fetal body parts to one another

• posture of fetus to conform to uterine cavity

• normal- general flexion

  • head flexed, chin on chest

  • arms crossed over chest

  • legs flexed at knee, thighs on abdomen

• abnormal- extension

fetal presentation

body part that enters the pelvis first

• normal

  • cephalic presentation (AKA vertex)

  • occiput presenting, head flexed

powers

1. primary force (contractions)

   • uterine muscular contractions, which cause cervical change through effacement and dilation

   • laboring down (waiting 1-2 hrs once 2nd stage begins b/c easier and less energy)

2. secondary force (pushing)

   • pushing during 2nd stage once 10 cm dilated

   • coordinate with primary force

position (fetal)

engagement: when the fetal presenting part is even (station 0) with the ischial spine, this is the start of the cardinal movements of labor

extension: fetal head has to get underneath the pubic bone

• LOA and ROA most favorable

fetal malposition: occiput posterior (OP) maternal risks and clinical therapy

maternal risks

• intense pain on small of back “back labor”

• prolonged labor

• increased risk of assisted vag delivery, perineal laceration, C/S

clinical therapy

• hands/knees position to allow fetal rotation

• vaginal or C/S

psychological factors in labor

1. birth experience factors

   1. locus of control

   2. pain/anxiety

   3. labor support (doulas)

   4. previous experience

2. preconceived ideas/expectations

3. readiness

4. cultural view

5. birth plan= wish list

maternal systemic responses to labor (CV, resp, GI)

CV

• HR increases 10-20 bpm

• BP increases during contractions

• BP decreases with epidural

RESPIRATORY

• oxygen demand increases at labor onset

GI

• decreased motility and gastric emptying- N/V

sterile vaginal exam evaluates 6 things

dilation/effacement/station

dilation: 0-10 cm

effacement: 0-100% or 4-0 cm

station: -5 to +4

• also evaluate:

  • fetal position (vertex vs. breech)

  • orientation (OA or OP)

  • membrane status

nursing care during admission: labor/fetal assessment (6)

1. uterine contractions

2. membranes/BOW

3. fetal movement

4. vaginal bleeding

5. EFM

6. SVE

nursing care during admission: maternal assessment (6)

1. VS

2. weight/weight gain

3. review prenatal record

4. psychosocial assessment

5. establish a positive relationship/rapport

6. patient education

3 ways to do EFM?

1. doppler

2. ultrasound

3. toco transducer

doppler or US

• on baby’s back

• assess fetal heart rate/tones

• baseline/normal FHTs 110-160

• variability

• accelerations (15 beats x 15 sec)

• decelerations

toco transducer

• on fundus

• assesses contractions

• determines start, end, and interval contractions

• cannot determine intensity

  • ask mom or palpate

what is a baseline?

10 min segment during non-event

• exclude accels/decels

• between UCs

• reported as a single number in 5 bpm increments

• normal is 110-160

possible influences on baseline changes (tachycardia >160)?

• early sign of hypoxia

• maternal medications, fever, dehydration

• fetal anemia

possible influences on baseline changes (bradycardia <110)?

• fetal hypoxia

• maternal medications (analgesics)

• maternal hypotension (position, epidural)

what is variability? what does it tell us?

how well is CNS functioning?

• fluctuations in FHR around the baseline

• exclude accels/decels

• between UCs

• NOT ASSESSED DURING AN “EVENT”

variability documentation

absent: undetectable or 0 bpm

minimal: 1-5 bpm

moderate: 6-25 bpm

marked: >25 bpm

what are accelerations?

an abrupt increase at least 15 bpm above baseline for at least 15 seconds, but less than 2 min

what may accelerations be associated with? what are they a sign of?

• fetal movement

• fetal well-being and adequate oxygenation

decelerations

onset

• gradual

• abrupt

shape

• mirrors UC or V/W/U

relationship to UC

• early, late, no relationship?

types of deceleration

• early

• late

• variable

• prolonged

internal monitoring: when are FSE and IUPC indicated? 4 criteria?

FSE: need instant, continuous recording. most accurate FHR tracing

IUPC: contraction intensity, uterine resting tone, very accurate timing

4 criteria

• ROM

• At least 2 cm

• Presenting fetal part low enough to allow placement of the scalp electrode

• Skilled practitioner available to insert spiral electrode

non-pharmacologic measures

• labor support

• water-birth/hydrotherapy

• ambulation/position changes

• birthing aids

• massage

• heat/cold

• visualization

• breathing techniques

pharmacologic measures

1. systemic analgesia

2. inhaled analgesics

3. regional analgesia/anesthesia

systemic analgesia

• medications DO cross placenta

  • fetal respiratory depression

• route: IV or IM, NOT PO

• safety: dizzy, fall risk

• not going to give if mom is delivering in next 4 hours because then the baby may be delivered w resp. depression

inhaled analgesics

• 50/50 nitrous oxide and oxygen “laughing gas”

• safe- no FHR abnormalities

regional analgesia/anesthesia

• local numbness

• pain relief, NOT pressure relief

• does NOT cross placenta

• types:

  • epidural

  • spinal

  • spinal + epidural

  • pudenal block

epidural MOA

injection of local anesthetic and analgesic into epidural space

• continuous block (catheter left in place)

epidural advantages

• most report relief

• pt is fully awake during labor and brith

• can be given any time

• dose can be adjusted during labor based on pt needs

• DO NOT CROSS PLACENTA

epidural disadvantages

• maternal hypotension

• skilled personnel required to administer

• costly- elective, insurance may not cover

• onset may take 30 min

• restricted in positions/movement during labor/birth

• may increase duration of 2nd stage

epidural and spinal contraindications

1. local or systemic infection (sepsis)

2. coagulation disorders/plt count <100,000

3. severe anatomic abnormalities of the spine/back surgery

4. uncorrected hypovolemia

epidural expected findings

relief from pain, not pressure

epidural and spinal priority interventions

• preload with IV fluid bolus

  • 500-1000 ml wide open

• monitor maternal vital signs, FHR

  • hypotension= corrective IV infusion prn

• EFM

• frequent bladder assessment

• pruritis assessment

• ensuring that mom avoids supine position to help minimize hypotension (HOB elevated or side lying)

• assist with pushing

• assess return of sensation prior to ambulation

epidural teachings

• movement/position changes will be restricted during labor

• might require straight or foley catheter

spinal block MOA

local anesthetic directly into spinal fluid in subarachnoid space

• typically with C/S

spinal block advantages

• immediate onset

• smaller drug volume

• can be given any time

spinal block disadvantages

• high incidence of hypotension

• short-acting (2-3 hrs)

• one dose only

• spinal headache= blood patch

pudenal block and local infiltration MOA

injected into pudenal nerves

SQ or IM

pudenal block and local infiltration advantages

• absence of maternal hypotension

• minimal medication used, none to fetus

pudenal block and local infiltration disadvantages

does not relieve contractions

pudenal block expected findings

provides pain relief in lower vagina, vulva, and perineum

pudenal block priority interventions

A pudendal block is used for the second stage of labor, an episiotomy, or an operative vaginal birth with outlet forceps or vacuum extractor.

It must be administered about 15 minutes before it would be needed to ensure its full effect.

pudenal block patient teachings

• numbs the local area, does not relieve pain from contractions

• no side effects

second stage comfort measures

• Cool washcloths to face/neck

• Pericare/change underpads

• Encourage rest between contractions

• Visualization techniques

• Support her legs/head

• Ice chips

• Position changes

third stage comfort measures

• Tremors common- heated blanket

• Provide food and fluids- general diet

• Encourage rest

• Assist with perineal care, ambulation

  • To bathroom to void or straight cath

  • Icepack, peripad, peri bottle

• Transfer to PP area when stable

signs of placental separation

• gush of dark blood

• “lengthening” cord protruding from vagina

• firmly contracting uterus

• bulge at perineum

• rise in fundus (back into abdomen)

degrees of lacerations

1st: skin

2nd: muscles of perineal body

3rd: anal sphincter muscle

4th: anterior rectal wall

what is a VBAC?

vaginal birth after C/S

• 50-70% success

VBAC contraindications

• prior classical uterine scar

• myomectomy

• inadequate staff/facility

• cervical ripening

VBAC risks

uterine rupture

VBAC nursing considerations

• fetal surveillance

• documentation

• readiness for emergent C/S

assisted vaginal delivery 4 criteria

1. ROM

2. 10 cm

3. vertex and engaged

4. adequate pelvic size

assisted vaginal delivery indications

• Prolonged second stage 

• Distressed FHR

• Failure of presenting part to fully rotate and descend

• Limited sensation and inability to push effectively due to anesthesia

• Presumed fetal jeopardy or fetal distress

• Maternal heart disease

• Acute pulmonary edema

• Intrapartum infection

• Maternal fatigue 

• Infection

assisted vaginal delivery risks

• perineal trauma (episiotomy, hematoma, etc.)

• vacuum: bruising, swelling, hematoma

• forceps: abrasions/marks, minor temporary facial nerve injury

C/S indications

• breech/transverse

• dystocia: doesn’t progress to full dilation

• fetal distress

• ECV unsuccessful

• placenta previa

• herpes lesions

C/S risks

• infection

• hemorrhage

• fetal injury/tachypnea

C/S nursing care

pre-op: labs, history, anesthesia

post-op: lochia, breastfeeding, pain management, assess incision, catheters

skin incision types

• transverse (pfannenstiel)

• vertical

skin and uterine incisions are not always in the same direction!!

uterine incision types

• transverse-lower uterine segment

  • can have vaginal birth next time

• classical-upper uterine segment

  • can’t have vaginal birth in the future due to risk of uterine rupture

cervix adaptations

• bruised

• edematous

• cervical os remains changed

• back to normal in 6 weeks

vagina adaptations

• mucous- edematous and relaxed after birth

  • thickens around 3 weeks

• localized dryness

• epithelium restored 6-8 weeks

perineum adaptations

• hemorrhoids

• edematous, bruising

• possible lacerations

ovulation/menstruation adaptations

• no breastfeeding= 6-11 weeks for ovulation, 7-9 weeks for menses

• breastfeeding= depends on how much; 3-18 months

cardiovascular adaptations

Cardiac Output:

• high first few days PP

• normal by 3 months

Blood Volume:

• drops rapidly after birth d/t blood loss

• normal by 4 weeks

Pulse and BP:

• 40-60 bpm first 2 weeks PP

• no big changes to BP, but observe for pre-eclampsia

Coagulation:

• hypercoagulable state/risk for clotting (DVTs)

Cellular:

• increased WBCs 4-6 days PP

urinary adaptations

GI adaptations

decreased peristalsis and fear leading to constipation

musculoskeletal adaptations

• Some women have separation of rectus abdominal muscles

• Changes in joints during pregnancy can cause feet to permanently increase 2 sizes

integumentary adaptations

• hair loss- temporary

• stretch marks

• night sweats (getting rid of fluid)

breastfeeding adaptations

Pituitary gland stimulated to release:

• Prolactin: synthesis and release of breast milk in the breast

• Oxytocin: contraction of the smooth muscle in the uterus and around the alveoli cells in the breast

PP discomforts

• Perineal discomfort

  • Promote good hygiene, wiping front to back

  • Peribottle

  • Ice for first 24 hours then warmth to help with circulation

  • Sitz bath

• Hemorrhoidal discomfort

  • Topical ointments, preparation H, tucks pads

• Abdominal incision if c-section

• Afterpains - uterine contractions that occur when the uterus is involuting

  • More severe for multigravida becuase body is working harder to get back to pre-pregnancy state

  • Premedicate before breast feeding or pumping session

• Immobility and muscle strain

  • Early ambulation

    • Decrease risk of DVTs

• Safety first

  • Make sure they can bear weight on legs and not dizzy

  • Dangling

  • Assisting them the first few times

breast discomforts

• Breast care

  • Plain water, no soap

    • Soap causes drying and difficult for baby to latch

  • Apply expressed breast milk for healing

• Nipples: assess if erect, flat or inverted; erythema, bruising, cracked, fissured, bleeding

• Breast engorgement

  • If breastfeeding: q 2-3 hour feeds

  • Non-breastfeeding mothers/weaning: lactation suppression efforts

    • Wear sports bra, tight bra, back to shower

    • Ice packs, ibuprofen

Rh and ABO incompatibility

• Rho GAM at 28 weeks; PP within 72 hours; other at-risk events (car accident, invasive procedures)

• type O mother with A, B, or AB fetus

  • less severe, no tx

male condom MOA

Thin sheath placed over an erect penis, blocking sperm

• 85% failure rate

• instruct on proper use

Oral contraception (progestin only/minipill)

Pill containing only progestin that thickens cervical mucus to prevent sperm from penetrating

• 9% failure rate

Oral contraception (progestin only/minipill) teaching

• can use while breastfeeding

• must be taken with meticulous accuracy

IUSs MOA

T-shaped device inserted into uterus that releases copper, progesterone, or levonorgestrel

• 0.2% failure rate

• No “user error”

IUSs teaching

Highly effective immediately after placement. May cause discomfort on insertion

vasectomy or tubal ligation MOA

Male:

• Sealing, tying, or cutting the vas deferens

• 0.15% failure rate

Female:

• Fallopian tubes are blocked to prevent conception

• 0.5% failure rate

vasectomy or tubal ligation teaching

permanent

lactational amenorrhea

• 98% effective

• baby must be <6 months

• no supplements/pacifiers: all infant nutrition from the breast (NOT pumping)

• no menses

placenta purpose

• acts as lungs and liver

• provides O2 and nutrients

• removes waste

umbilical cord purpose

• 2 arteries: transfer waste

• 1 vein transfers O2

shunts purpose

Ductus venosus

• Blood bypasses liver into inferior vena cava

Foramen ovale

• Blood flows from R atrium to L atrium

Ductus arteriosus

• Blood bypasses lungs into descending aorta

APGAR

Appearance (skin color)

Pulse (heart rate)

Grimace (reflex irritability)

Activity (muscle tone)

Respirations (respiratory effort)

• scored at 1, 5, and sometimes 10 min

• 8, 9, 10 - satisfactory adaptation

• 5, 6, 7 - required intervention

• Below 5- requires resuscitation 

  • rescore at 10 and 20 min

immediate newborn assessment

• within first 2 hours

• first assessment in birthing area

• vital signs q30 min x2 hours in the immediate period

• gestational age is determined using Ballard scale

  • physical maturity section within 2 hours

  • neuromuscular maturity section within 24 hours

newborn vital signs expected ranges

newborn measurements

weight: 5 lb 8 oz- 8 lb 14 oz

length: 17-22 in

HC: 13-15 in

prevention of heat loss

• Conduction: skin to skin; warm blanket on scale

• Convection: keep newborns away from drafts

• Evaporation: dry the newborn well

• Radiation: keep away from cold objects (ex. windows)

vitamin K (phytonadione)

• prevents hemorrhage

• absence of gut bacteria at birth, cannot produce vit k

• low prothrombin levels

• IM in vastus lateralis

erythromycin eye ointment

prophylactic for opthalmia neonatorum from G or C

• legally mandated

• instilled into lower conjuntival sac, OU

• may be delayed until 1 hour of life to facilitate bonding

expected lochia findings

rubra (days 1-3): red

serosa (days 3-10): pink/brown

alba (days 10-14): white/yellow

when should the fundus be midline (U/U)?

10-12 hours after delivery. should drop 1 cm below umbilicus (U/1) every day

3 unexpected uterine involution findings

firm fundus, bright red trickling: laceration

boggy fundus, red flowing: uterine atony

boggy fundus, dark red and clots: retained placenta

expected RR, BP, HR, temp in PP

RR: 12-20

BP: falls first 2 days, increases days 3-7, back to pre-pregnancy by 6 weeks

HR: 40-80 bpm

Temp: low/afebrile