NCLEX: Mark Klimek - Lecture 10 (Labor and Delivery)

How do you determine the estimated date of delivery?

Naegele's Rule:

- Take first day of LAST menstrual period (LMP)

- Add 7 days, subtract 3 months

If a patient's mentrual period lasted 5 days and ended Feb 10, what is the estimated date of delivery of her newborn?

November 12

If the last menstrual period of a pt was between June 10 and 15, what is the estimated date of delivery of her newborn?

March 17

During the 1st trimester (12 weeks), the patient is expected to gain how many lbs?

1 lb per month = total of 3 lbs.

During the 2nd trimester, the patient is expected to gain how many lbs (weeks 13-26)?

Add 1 lb every week

During the 3rd trimester, the patient is expected to gain how many lbs (weeks 27+)?

Add lb every week

What is the ideal weight gained during pregnancy?

28 lbs, plus or minus 3

So, between 25 to 31.

If weight gained during pregnancy is within +/- 1 to 2 lbs of the ideal weight for the gestational week, what should happen?

Nothing. Within normal limits (WNL)

If weight gained during pregnancy is within +/- 3 lbs of the ideal weight for the gestational week, what should happen?

Assess her.

If weight gained during pregnancy is within +/- 4 lbs or more of the ideal weight for the gestational week, what should happen?

There is trouble. Perform a biophysical profile (BPP) on fetus.

What is an alternative method to come up with the ideal weight gained during pregnancy?

Take the number of weeks gestation minus 9.

A woman is in her 28th week gestation. She gained 22 lbs, what is your impression?

1st trimester = 3lbs

2nd/3rd trimester = 16lbs

Total should be = 19lbs

Alternative method: 28-9 = 19lbs

Patient is 3lbs heavier than ideal weight = assess her.

A pregnant woman at 31 weeks gestation gained 15 lbs. What is your impression?

1st trimester = 3lbs

2nd/3rd trimester = 19lbs

Ideal weight = 22 lbs

Should be at 22lbs, but pt only gained 15lbs.

This is trouble. Get a biophysical profile (BBP) for fetus.

When can you start palpating the fundal height in a pregnancy?

Week 12

Where should the fundal height be at week 12-14?

Right above the pubic symphysis

Where should the fundal height be at week 16?

Midway between the umbilicus and pubic symphysis

Where should the fundal height be at week 20-22?

At the umbilicus (belly button)

What is the significance of being able to palpable fundal height?

The examiner should be able to determine in what trimester the pregnancy is, in case pt is unconscious or there is a diagnostic significance like a molar pregnancy (bigger than normal fundus).

What are the positive signs of pregnancy?

- Fetal skeleton on x-ray

- Presence of fetus on ultrasound

- Auscultation of fetal heart rate (Doppler)

- EXAMINER palpates fetal movement (outline)

When can the fetal heart rate be first heard?

8 to 12 weeks gestation

When can quickening may be first felt?

16 to 20 weeks gestation

What are "maybe" signs of pregnancy?

- Positive urine/blood hCG tests (could be cancer)

- Chadwick sign (cervical color change to cyanosis - Cs)

- Goodell sign (good and softening of cervix)

- Hegar sign (softening of lower uterine segment)

- They occur in alphabetical order!!

What should you teach patient about prenatal visits?

Go for prenatal visits as follows:

- Once a month until week 28

- Every other week at 28-36

- Once a week at 36+

- At 42+ weeks, delivery can be induced or C-section

If a woman comes in for her 12th week prenatal checkup, when is her next prenatal visit?

16 weeks

During the 1st trimester, a pregnant woman's hemoglobin (hgb) can fall to what range?

11 g/dL

During the 2nd trimester, a pregnant woman's hemoglobin (hgb) can fall to what range?

10.5

During the 3rd trimester, a pregnant woman's hemoglobin (hgb) can fall to what range?

10

How do you treat morning sickness in pregnancy?

Usually seen during 1st trimester

- Eat dry carbs before getting out of bed

How do you deal with urinary incontinence in pregnancy?

Usually seen in 1st and 3rd trimesters

- Void every 2 HOURS from the day she gets pregnant until 6 weeks postpartum (PP).

A pregnant pt complains of difficulty breathing. What should you advise her to do?

Usually seen during 2nd and 3rd trimesters

- Tripod position: Lean forward with hands on knees

A pregnant pt complains of back pain. What should you advise her to do?

Usually seen during 2nd and 3rd trimesters

- Pelvic tilt exercises (Glute bridge)

What is the truest, most valid sign of being in labor?

Onset of regular/progressive contractions

What does dilation mean in pregnancy?

Opening of the cervix from 0 to 10 cm

What does effacement mean in pregnancy?

Thinning of the cervix. Goes from thick to 100% efface (thin like paper)

What does station mean in pregnancy?

The relation between fetal presenting part and mother's ischial spines; the narrowest part of the pelvis

- Positive numbers = Positive news. Baby made it through the tight squeeze.

- If a baby stays at -3, -2, -1, it can't get through vaginally. C-section is needed.

What does engagement mean in pregnancy?

Station 0 - the fetal presenting part is at the ischial spines

What does estrogen do during pregnancy?

Increasing levels make the uterus more sensitive to oxytocin

What does oxytocin do during pregnancy?

Signals the uterus to contract

What do prostaglandins do during pregnancy?

Causes the cervix to soften or "ripen," allowing it to stretch open

What does relaxin do during pregnancy?

Relaxes the pubic symphysis and helps dilate the uterine cervix to facilitate delivery

What lie and presentation of the baby is most common?

- Vertical lie is compatible with vaginal birth

- Right Occiput Anterior or Left Occiput Anterior

- Pick ROA before LOA

What is the first stage of labor?

Cervical dilation and effacement:

Latent (Phase 1):

- Cervical dilation from 0-4 cm

- Contractions are 5-30 mins apart

- Lasts 15-30 secs with MILD intensity

Active (Phase 2): Remember this one!

- Cervical dilation from 5-7 cm

- Contractions are 3-5 mins apart

- Lasts 30-60 secs with MODERATE intensity

Transition (Phase 3):

- Cervical dilation from 8-10 cm

- Contractions are 2-3 mins apart

- Lasts 60-90 secs with STRONG intensity

A pregnant woman comes in to L&D (labor and delivery). She is 5 cm dilated, with contraction 5 minutes apart, lasting 45 seconds. What phase of labor is the pt in?

ACTIVE phase!

What is the second stage of labor?

Delivery of the baby

What is the third stage of labor?

Delivery of the placenta

What is the fourth stage of labor?

Recovery; 2 hours until bleeding stops

What is purpose of uterine contraction in first stage?

Dilation and effacement of the cervix

What is the purpose in 2nd stage?

Delivery of baby

What is the purpose 3rd stage?

Delivery of placenta

What is the purpose of 4th stage?

Stop bleeding

When does postpartum technically begin?

2 hours after delivery of placenta

What is the #1 priority of the second phase of labor?

Pain management

What is the #1 priority of the second stage of labor?

Clearing baby's airway

What is the #1 priority of third phase?

Checking cervical dilation

Helping mother with breathing and pain mgmt

What is the #1 priority of third stage?

Assess placenta for smoothness and intactness

Assess 3-vessel (not 2) umbilical cord is present

Uterine contractions should be no longer than ___ seconds and no closer than ___ minutes.

90 secs; 2 mins

SUPER IMPORTANT TO KNOW.

What is a sign of uterine tetany?

Contractions longer than 90 seconds and/or closer than 2 minutes.

What parameters regarding uterine contraction would make you stop Pitocin?

Contractions longer than 90 seconds and/or closer than 2 minutes.

What is uterine hyperstimulation?

Contractions longer than 90 seconds and/or closer than 2 minutes.

Frequency of contraction is measured from the...

beginning of one contraction to the beginning of the next contraction.

Duration of contraction is measured from the...

beginning of one contraction to the end of it.

Intensity of labor is measured by...

the patient. It is purely subjective.

Teach patient how to palpate with one hand over the fundus with the pads of the fingers

How would you treat painful back pain during pregnancy?

"OP" = Oh, Pain!!

Position, then push.

Knee-Chest position

Push with fist into sacrum to use counter pressure

How would you treat prolapsed cord during pregnancy?

Push head up and off the cord

Position mother in knee-chest

Prep for C-section

How would you treat most complications in pregnancy?

"LION"

Left side position

Increase IV

Oxygen

Notify HCP

In an OB crisis, if Pitocin is running, the first thing to do is....

STOP THE PITOCIN, then LION

When do you administer systemic pain medications during pregnancy?

Just DON'T administer pain med to a woman in labor if the baby is likely to be born when the med is at its peak.

You have a primigravida (first timer) at 5-cm dilated who wants her IV push pain med. What is the nursing intervention?

IV peak: 15-30 mins

Is it likely baby will be delivered by then?

No, so you can give pain med.

You have a multigravida at 8 cm wants her IM pain med. What is the nursing intervention?

IM peak: 30-60 mins

Is it likely baby will be delivered by then?

Yes, so you can NOT give pain med.

What does primigravida mean?

A woman who is pregnant for the first time

What does multigravida mean?

A woman who has been pregnant more than once

What does nulliparous mean?

Never given birth to a viable (20+ weeks gestation) child

What does multiparous mean?

Has given birth to more than one viable (20+ weeks gestation) child

What does viability mean?

Ability to live outside the uterus, 20 weeks

What does para or parity mean?

The number of completed pregnancies beyond 20 weeks gestation (whether viable or nonviable). The number of fetuses delivered does not determine the parity.

What does GTPAL stand for?

Gravida, Term, Preterm, Abortion, Living

Gravida: # of times pregnant, regardless of outcome

Term: # of pregnancies delivered at 37+ wks

Preterm: # of pregnancies delivered from 20-36 wks

Abortion: # of pregnancies ending before 20 wks

Living: # of currently living children (including in womb)