maternity exam 1

second stage of labor

-full dilation of the cervix to birth

1. latent phase (relatively calm with passive descent of baby through birth canal)

2. descent phase (active pushing and urges to bear down)

active stage of labor

-in first stage of labor

- 4-7cm of dilation

crowning

-fetal head remain visible at vaginal opening between contractions

-indicated birth is imminent

postpartum lochia

-normal postbirth uterine discharge

-lochia rubra (blood and other debris for 3-4 days)

-lochia serosa (old blood, leukocytes for 22-27 days, pink-brown)

-lochia alba (mucus, bacteria, serum, 2-6 weeks post birth, whiteish)

normal vs abnormal lochia

-normal: earthy/fleshy odor, gradual decrease in amount

-abnormal: foul odor, large clots, heavy bleeding, return to bright red after it lightened

delivery of placenta

-third stage of labor

signs placenta is ready to be delivered:

-lengthening of umbillical cord

-sudden gush of blood

-firm, globular uterus

-fundus rises in abdomen

management of postpartum hemorrhage

-FIRST massage fundus

-THEN

--empty bladder

--continue massage

--administer uterotonic meds

--increase IV fluids if indicated

--notify provider

--monitor VS and blood loss

causes of postpatum hemorrhage

Tone (uterine atony)

Tissue (retained placenta)

Trauma (lacerations)

Thrombin (clotting problem)

uterine atony

-uterus fails to contract after delivery, causing blood vessels where placenta detached to stay open --> excessive bleeding

-most common cause of postpartum hemorrhage

-is a boggy fundus (NOT FIRM)

perineal lacerations

-tissue tear during vaginal birth

-first degree (skin only)

-second degree (skin and perineal muscles, most common)

-third degree (extends to external anal sphincter)

-fourth degree (extends to rectal mucosa

epidural interventions

after epidural monitor:

-BP, RR, O2 sat

-pain relief

-level of sensory block

-fetal heart rate

epidural block

-provides pain relief from T10-S5

-mother remains awake

epidural block side effects

-maternal hypotension (most common SE) bc epidural causes vasodilation (fetal monitor may show late decels)

-decreased mobility

-difficulty urinating

-itching and shivering

five p's

1. Passenger (fetus and placenta)

2. Passageway (birth canal)

3. Powers (contractions)

4. Position of mother

5. Psychologic response

passageway

-includes maternal pelvis, cervix, pelvic floor, and soft tissues

gynecoid is the most common and easiest pelvis

3 main fetal presentations

1. cephalic (head first) -- vertex, military, brow, and face

2. breech (buttocks, feet, or both first)

3. shoulder

fetal attitude

refers to the posturing of the joints and relationship of fetal parts to one another

fetal lie

refers to the relations of the long axis (spine) of the fetus to the long axis of the mother

physiological p of labor

- stress and anxiety can increase catecholamine release which slows labor, increases pain, and affect fetal oxygenation

pharmacological pain management for labor

-sedatives (barbituates, phenothiazines, benzodiazepines)

-systemic analgesia (opioid agonist and antagonist analgesics)

-nerve block analgesia and anesthesia (pudendal nerve block, spinal anesthesia, epidural, combined spinal-epidural, local perineal infiltration)

-nitrous oxide

-general anesthesia

pharmacologic pain management for postpartum

--uterotonic meds (used for pph)

-oxytocin (pitocin)(first-line)

-methergine

-hemabate

-misoprostol

nonpharmacologic pain management for labor and postpartum

-relaxation and breathing techniques

-effleurage and counterpressure

-touch and massage

-application of heat and cold

-changing positions

-acupressure and acupuncture

-transcutaneous electrical nerve stimulation

-water therapy

-intradermal water block

-aromatherapy

-music

-hypnosis

-biofeedback

maternal adaptation

as women progress through labor, various body system adaptations cause her to exhibit symptoms

-cardiovascular changes

-renal changes

-respiratory changes

-integumentary changes

-musculoskeletal changes

-neurologic changes

-gastrointestinal changes

-endocrine changes

maternal assessments in labor

-BP, HR, RR, Temp, Pain

-contraction pattern

-bladder status

-emotional status

newborn anatomy

-head is large compared to body

-chest circumference is slightly smaller than head circ

-abdomen is round and soft

-skin may have vernix, lanugo, and acrocyanosis after birth

newborn skull

-largest and least compressible structures

sutures

-allow for overlapping and changes in shape (molding)

-help identify position of fetal head

-lambdoid, sagittal, coronal, frontal

fontanels

-intersections of sutures

-help in identifying position of fetal head and in molding

-posterior (smaller and closes 2-3months)

-anterior (larger and closes 12-18months)

four stages of labor

1. first stage - onset of contractions to full dilation of cervix

2. second stage - full dilation to birth

3. third stage - birth of fetus until delivery of placenta (5-30min)

4. fourth stage - 2 hours postdelivery of placenta (assess every 15min)

first stage of labor (phases)

1. latent -- mild contractions cervix 0-3cm

2. active -- stronger, longer, frequent contractions, cervix 4-7cm

3. transition -- most difficult phase, 8-10cm

triage of labor (is pt in actual labor?)

assess:

-gestational age

-contraction frequency

-membrane status

-vaginal bleeding

-fetal heart rate

-maternal VS

-cervical dilation

-pain

bonding

emotional connection that develops FROM the parent TOWARD the infant and usually begins immediatly after birth

promoted by:

-skin to skin contact, talking to baby, feeding, eye contact

APGAR

-performed at 1 and 5min (10 if needed)

Appearance (color)

Pulse

Grimace (reflex irritability)

Activity (muscle tone)

Respirations

-evaluates how well baby is adapting post-birth, does not predict long-term outcomes

therapeutic communication

-use open-ended questions

-listen actively

-validate feelings

-encourage parents to express concerns

-avoid false reassurance

-respect cultural beliefs and practices

medications for induction

-misprostol (cytotec)

-dinoprostone (cervidil)

-oxytocin (pitocin) --> most used to induce and augment labor (can also prevent PP hemorrhage)

vaginal examination

- performed to assess cervical dilation, effacement, station, fetal presentation, and membrane status

hormones in postpartum period

-after placenta is delivered, there is a decrease in estrogen and progesterone

--allows for uterine involution, lactation, and return to ovulation

involution of the uterus

the return of the uterus to a nonpregnant state after birth

(returns to nonpregnant state by 6 weeks post)

(at 2 weeks post uterus is no longer palpable abdominally)

fundal assessment

-should be firm and midline

complications of displaced uterus

prevents effective uterine contraction, increasing the risk of hemorrhage

causes of displaced uterus

-is when uterus is high and deviated (usually right)

-usually due to full bladder

interventions of displaced uterus

-encourage pt to void

-if unable to void insert catheter

-after emptied --> reassess fundus

infant abduction

hospital safety:

-identification bands for mother and baby

-electronic security tags

-matching identification before baby leaves room

-staff identification badges

parent education:

-never leave baby alone

-never give baby to someone without proper id

-call nurse if unsure about someone entering room

discharge teaching

-gradualling crease activity and rest when possible

-eat balanced diet and have adequate fluids

-continue prenatal vit if recommended

-perineal care (change pad frequently, wipe front to back, monitor for infection)

-know when to call provider (ex. heavy bleeding, fever, foul lochia)

-sexual activity and contraception

-medications

-follow up after discharge (routine care, home visits, telephone follow-up, support groups)

lab values for postpartum mother

-h/h: may decrease after delivery --> large decrease suggests hemorrhage

-WBC: often elevated postpartum (normal unless other symptoms indicating infection)

-platelets: may fluctuate but normal

rhogam

-given to rh-negative mother who delivers rh-positive baby

-prevents maternal sensitization to rh-positive blood cells, reducing the risk of RH isoummunization in future pregnancies

intrapartum care

mother:

-VS, pain

-contractions

-empty bladder

-emotional status and support

-reposition

-encourage hydration

baby:

-fetal HR

-variability

-accels and decels

labor progress

-cervical dilation

-effacement and station

-membrane status

postpartum care

-assist mother with rest and recovery post birth

-assessment of physiologic and psychologic adaptation

-prevention of complications

-education regarding self-management and infant care

-support of mother and her partner during transition to parenthood

different types of anesthesia for emergency c section

-epidural (used only if already functioning)

-spinal block (rapid onset and common)

-general anesthesia (only when needed immediatly and regional anesthesia did not work or contraindicated)

SROM

spontaneous rupture of membrane (occurs naturally)

AROM

artificial rupture of membrane (performed by provider)

PROM

premature rupture of membrane (ruptured before labor begins)

-concern of infection

interventions for low BP

-FIRST: turn mother onto left side

-THEN:

--increase IV fluids

--apply O2

--notify provider

--administer vasopressor if ordered

--continue fetal monitoring

breast care for breastfeeding mother

encourage:

-frequent feeds

-proper latch

-alternate breasts

-assess nipples for trauma

-observe infant swallowing

breastfeeding benefits

for infant:

-passive immunity

-ideal nutrition

-easier digestion

for mother:

-promotes uterine contraction

-may reduce postpartum bleeding

-enhances bonding

sitz bath

purpose:

-increase circulation

-reduce swelling

-promote healing

-provide comfort

breastfeeding mother

-early: colostrum

-later: mature milk production

-breasts become: fuller, warmer, and heavier as milk 'comes in'

bottle-feeding mother

-milk production still occurs bc of hormones

-nursing care

--wear supportive bra

--avoid breast stimulation

--use cold packs for discomfort

--take analgesics as prescribed

pelvic floor (kegel) exercises

-strengthen pelvic floor muscles

--helps improve muscle tone, prevent urinary incontinence, and support pelvic organs

diaphoresis in postpartum

-common postpartum finding bc body eliminated excess fluid created during pregnancy

immediate newborn care

-maintain airway

-dry infant

-maintain body temp

-assess respirations

-assess heart rate

-identify infant correctly

-administer routine meds (vit k, erythromycin)

-promote skin-to-skin contact

postpartum depression

-onset (anytime during 1st year post)

-duration (persists or worsens)

-symptoms (persistent sadness, hopelessness, loss of interest)

-infant care (may struggle to care for self or infant)

-treatment (professional evaluation and treatment)

postpartum blues

-onset (usually 2-3 days post)

-duration (resolves within 2 weeks)

-symptoms (tearfulness, mood swings, irritability)

-infant care (still able to care for baby)

-treatment (support and reassurance)

mother newborn attachment

-relationship that develops BETWEEN the infant and caregiver over time

-normal behaviors

--responding to crying

--naming baby

--talking to baby

--holding baby

intrauterine resucitation

applied during labor to reverse fetal hypoxia and acidosis by improving placental blood flow and fetal oxygenation

1. left lateral position

2. stop pitocin

3. increase IV fluids

4. oxygen

5. notify provider

primary powers

-effacement and dilation of cervix with involuntary contractions

- mother has NO control over this

secondary powers

-bearing down efforts (pushing fetus)

-mother CAN control