Exam 1 Woman's Health (perspective of maternal care, antepartum, labor)

Premonitory Signs of Labor

• Lightening (baby drops lower into the pelvis, often reducing pressure on the diagphram)

• Increased Braxton Hicks contractions

• Cervical changes (softening and dilation of the cervix)

• Bloody show (release of mucus plug)

• nesting instinct (desire to prepare for baby)

• diarrhea or loose stools (due to hormonal changes)

• lower back pain

• water breaking (rupture of membranes; artificial or spontaneous)

What are the three stages of labor?

• First stage: Dilation

• Second stage: Expulsion

• Third stage: Placental

• Fourth stage: Recovery

First stage of Labor: Dilation

• Latent Phase:

  • Duration: Can last hours to days

  • Events: Cervix softens, effaces, and dilates to 3-4 cm

  • Contractions may be mild and irregular

• Active Phase:

  • Duration: Usually 4-8 hours

  • Events: Cervix dilates from 4 cm to 7-8 cm

  • Contractions become stronger, regular, and more frequent

• Transition Phase:

  • Duration: Usually 30 minutes to 1 hour

  • Events: Cervix dilates from 8 cm to 10 cm

  • Contractions are intense and may be accompanied by nausea, shaking, or feeling overwhelmed

Second stage of Labor: Expulsion

• Duration: Can last 20 minutes to 2 hours or more

• Events: Full cervical dilation (10 cm) to delivery of the baby

• Characterized by the urge to push (Ferguson's reflex)

• Pushing efforts to deliver the baby

Third stage of Labor: Placental

• Duration: Usually 5-30 minutes

• Events: Delivery of the baby to delivery of the placenta

• Contractions continue to expel the placenta

Fourth stage of Labor: Recovery

• Duration: About 1-2 hours after placental delivery

• Events: Delivery of the placenta to maternal stabilization

• Focus on monitoring maternal vital signs, uterine tone, and bleeding

• Initiation of bonding and breastfeeding

Rupture of Membranes: T

Time: Record the exact time when the membranes ruptured. This is crucial for monitoring the duration of labor and assessing infection risk.

Rupture of Membranes: A

Amount: Note the quantity of amniotic fluid released. It can range from a gush to a slow trickle

Rupture of Membranes: C

Color: Observe and document the color of the amniotic fluid. Normal fluid is clear with a mild, musty odor. Greenish fluid may indicate meconium, while cloudy or yellow fluid could suggest infection

Rupture of Membranes: O

Odor: Assess the smell of the fluid. A foul or strong odor may indicate chorioamnionitis, an infection of the amniotic sac

Rupture of Membranes: Normal

• Time: Typically occurs near the onset of labor, but can happen earlier

• Amount: Usually 500-1000 mL total, often released as a sudden gush

• Color: Clear, sometimes with bits of vernix (white, creamy substance)

• Odor: Mild, slightly musty smell

What are the five P’s in the labor process?

• Power

• Passage

• Passenger

• Position

• Psyche

Power

The uterine contractions and maternal pushing efforts that propel the fetus through the birth canal

• Contractions: 3-5 in 10 minutes during active labor

• Duration: 60-80 seconds

• Intensity: Moderate to strong

Passenger

The fetus, including its size, position, and presentation

• Fetal size: Appropriate for gestational age

• Position: Vertex (head-down)

• Presentation: Cephalic (head first)

Passage

The birth canal, including the pelvis, cervix, and vagina

• Pelvis: Adequate size and shape for vaginal delivery

• Cervix: Dilates to 10 cm

• Vagina: Stretches to accommodate fetus

Psyche

The mother's psychological state and emotional readiness for labor and birth

• Positive attitude

• Reduced anxiety and fear

• Sense of control and mastery over labor

Position

The mother's position during labor and delivery, which can affect the progress of labor

• Varies throughout labor

• Upright positions often encouraged during active labor

• Lithotomy or semi-reclined for delivery

What is Leopopold’s Maneuver?

This maneuver helps healthcare providers assess fetal lie, position, and presentation without using electronic fetal monitoring. It's particularly useful before placing external monitors to ensure optimal positioning for detecting the fetal heart rate

How do you perform Leopopold’s Maneuver?

1. Fundal grip: Palpate the fundus to determine which fetal part occupies the fundus.

2. Lateral grip: Place hands on either side of the abdomen to feel for the fetal back and small parts.

3. Pawlik's grip: Use one hand just above the symphysis pubis to identify the presenting part.

4. Pelvic grip: Face the mother's feet and use both hands to palpate the lower uterine segment, determining how deeply the presenting part has descended into the pelvis.

How do you define contractions?

1. Frequency: The number of contractions in a 10-minute period, averaged over 30 minutes. Normal uterine activity is ≤5 contractions in 10 minutes.

2. Duration: The length of each contraction, typically expressed in seconds. Normal duration is 60-80 seconds during active labor.

3. Intensity: Described as mild, moderate, or strong when assessed by palpation.

How can contractions be measure?

• Palpation: The nurse feels the abdomen to assess contraction strength and frequency

• Electronic Fetal Monitoring (EFM): Provides a visual representation of contraction patterns

What is resting tone?

refers to the level of tension or firmness in the uterus between contractions during labor

What is a Normal resting tone?

by palpation, the uterus should fully relax between contractions, allowing for optimal blood flow to the placenta and fetus. This relaxation period is crucial for fetal oxygenation and well-being

What is being assessed during a vaginal exam for labor?

1. Assess cervical dilation and effacement

2. Determine fetal station and position

3. Evaluate membrane status (intact or ruptured)

4. Monitor labor progress

5. Guide clinical decision-making for labor management

6. Detect potential complications (e.g., cord prolapse)

7. Determine timing for interventions or delivery

Why are vaginal exams during labor minimized?

• limited to minimize infection risk

• performed when there are changes in labor patterns (increased contraction intensity or the urge to push)

• Sterile technique is crucial to prevent introducing microorganisms into the uterus

Dilation

• Measured in centimeters from 0 to 10 cm

• Refers to the opening of the cervix

• 10 cm is considered fully dilated

Effacement

• Measured as a percentage from 0% to 100%

• Describes the thinning and shortening of the cervix

• 100% is fully effaced

Station

• Measured from -5 to +5

• Indicates the position of the presenting part in relation to the ischial spines

• 0 station means the presenting part is at the level of the ischial spines

What are the mechanisms of labor?

• Engagement (fetal presenting part enters the pelvic inlet)

• Descent (fetus moves downward through the birth canal)

• Flexion (the fetal chin tucks toward the chest, reducing the diameter of the presenting part

• Internal Rotation: fetus rates to align its widest diameter with the widest diameter to the pelvis

• Extension (fetal head extends backward as it passes under the pubic arch

• External Rotation (Restitution) (fetal head rotates to realign with the body

• Expulsion (shoulders and body of the fetus are born

What is the difference of true labor and false labor?

1. Contractions:

   • True labor: Regular, increasing in frequency and intensity

   • False labor: Irregular, no consistent pattern

2. Discomfort:

   • True labor: Pain often starts in the back and moves to the front

   • False labor: Pain usually felt in the front

3. Cervical change:

   • True labor: Progressive cervical effacement and dilation

   • False labor: No cervical change

4. Effect of movement:

   • True labor: Contractions continue regardless of activity

   • False labor: Contractions may stop with walking or position change

5. Duration:

   • True labor: Contractions become longer and stronger over time

   • False labor: Contractions remain inconsistent

What is the frequency of assessments in the 4th stage of labor?

• Every 15 minutes for the first hour

• Every 30 minutes for the second hour

• Every hour for the next two hours

What is being monitored during the vaginal examines during labor (4th stage)?

1. Uterine firmness and position

2. Vaginal bleeding (lochia)

3. Vital signs (blood pressure, pulse, temperature)

4. Bladder fullness

5. Perineal condition

6. Overall maternal well-being

Why are there frequent vaginal assessments in the 4th stage?

for early detection and prevention of postpartum complications, particularly postpartum hemorrhage. The nurse should be alert for signs of a soft (boggy) uterus, excessive bleeding, or other indicators that might necessitate immediate intervention

Sources of Pain: First stage

• Uterine contractions

• Cervical dilation and effacement

• Stretching of the lower uterine segment

• Pressure on surrounding structures (bladder, rectum)

Sources of Pain: Second stage

• Continued uterine contractions

• Stretching of the vagina and perineum

• Pressure on pelvic floor muscles

• Stretching of the vulva and perineum as the fetus descends

Sources of Pain: Third stage

• Milder uterine contractions for placental separation and expulsion

• Cramping sensations

Sources of Pain: Fourth stage

• Afterpains (uterine contractions)

• Perineal discomfort from tears or episiotomy

• Breast discomfort as lactation begins

What is Effleurage?

• gentle massage technique used during labor to promote relaxation and pain relief

• light, circular stroking movements typically applied to the abdomen or lower back

• performed by the laboring mother herself, her partner, or a healthcare provider

Key points about effleurage:

1. Method: Use fingertips or palms to make soft, rhythmic, circular motions

2. Areas: Commonly applied to abdomen, lower back, or thighs

3. Benefits:

   • Reduces pain perception

   • Promotes relaxation

   • Provides a focal point during contractions

   • Enhances blood circulation

4. Timing: Can be used throughout labor, especially during contractions

5. Variations: Can be combined with breathing techniques or visualization

When should sedatives NOT be given to a laboring mother?

• Late stages of labor (Especially during the second stage (pushing phase), as they may interfere with the mother's ability to push effectively)

• Imminent delivery (When birth is expected within the next 1-2 hours)

• Compromised fetal status (If there are signs of fetal distress or decreased fetal heart rate variability)

• Maternal respiratory depression (In cases where the mother has pre-existing respiratory issues or is at risk for respiratory depression)

• History of adverse reactions (If the mother has previously experienced negative side effects from sedatives)

• Severe preeclampsia or eclampsia (As sedatives may mask neurological symptoms)

• Impaired liver or kidney function (Which could affect the metabolism and excretion of the sedative)

• High-risk pregnancies (Where constant monitoring and quick responses may be necessary)

• When natural labor progression is desired (As sedatives may slow down labor)

• If the mother prefers non-pharmacological pain management (Respecting her birth plan when medically appropriate)

Why should sedatives NOT be given to a laboring mother?

• Interference with labor progression (Sedatives can slow down contractions and potentially prolong labor)

• Reduced maternal participation (They may impair the mother's ability to push effectively during the second stage of labor)

• Fetal effects (Sedatives can cross the placenta and affect the fetus, potentially leading to respiratory depression in the newborn)

• Masking of symptoms (They may obscure important clinical signs of complications, such as preeclampsia)

• Impaired maternal-infant bonding (Sedation can interfere with early bonding and initiation of breastfeeding immediately after birth)

• Respiratory depression (There's a risk of maternal respiratory depression, especially if combined with other pain medications)

• Altered mental status (Sedatives can affect the mother's ability to make informed decisions about her care)

• Interference with natural oxytocin release (This can potentially impact the natural progression of labor and postpartum uterine contractions)

• Risk of aspiration (Sedation increases the risk of aspiration if emergency surgery becomes necessary)

• Difficulty in assessment (It becomes challenging for healthcare providers to accurately assess the mother's condition and labor progress)

When are opioids used most in labor?

• used most during the early to mid stages of labor (active phase of the first stage)

• administered to manage moderate to severe pain when the contractions are becoming more intense and frequent

• BEFORE the second stage (pushing phase) begins

• the goal is to provide pain relief while allowing the mother to remain alert and participate in the labor process

Key points about opioid use in labor:

1. Timing: Often given in the active phase of the first stage

2. Purpose: To manage moderate to severe pain

3. Administration: Available in IV and oral preparations

4. Duration: Short-acting forms provide relief for about 4 hours

5. Dosing: Often prescribed as needed (prn) with range orders

6. Considerations:

   • Must be timed carefully to reduce risk of neonatal respiratory depression

   • Not typically used close to delivery due to potential fetal effects

   • Individualized dosing based on patient response and circumstances

What is an Epidural?

• Medication is injected into the epidural space, which is outside the dura mater

• A catheter is placed, allowing for continuous or intermittent medication administration

• Provides analgesia and anesthesia for both vaginal and cesarean births

• Typically placed at the L3-L4 interspace

• Onset of pain relief is gradual

• Can be used for extended periods during labor

What is a Spinal (Subarachnoid Block)?

• Medication is injected directly into the subarachnoid space, which contains cerebrospinal fluid

• Single injection, no catheter placement

• Provides rapid and intense anesthesia

• Typically used for shorter procedures or cesarean sections

• Faster onset of action compared to epidurals

• Limited duration of effect

What is the difference between an Epidural and Spinal?

1. Location of injection

2. Presence of catheter (epidural) vs. single injection (spinal)

3. Duration of effect

4. Speed of onset

5. Intensity of anesthesia

Adverse Effects of Epidural

1. Hypotension

2. Inadequate pain relief

3. Dural puncture headache

4. Maternal fever

5. Prolonged labor

6. Urinary retention

Nursing Actions of Epidural

• Monitor blood pressure every 3-5 minutes for 15-30 minutes after initial injection

• Assess fetal heart rate continuously

• Reposition client to avoid aortocaval compression

• Increase IV fluid rate if hypotension occurs

• Administer phenylephrine or ephedrine per protocol for significant hypotension

• Reassess blood pressure every 15 minutes when stable

Adverse Effects of Spinal

1. Rapid onset hypotension

2. Nausea and vomiting

3. High spinal block

4. Post-dural puncture headache

5. Respiratory depression

Nursing Actions for Spinal

• Assess vital signs every 5 minutes for 30 minutes or per facility guidelines

• Monitor for signs of high spinal block (difficulty breathing, nausea)

• Ensure adequate IV hydration prior to SAB initiation

• Assist anesthesia provider in administering prophylactic vasopressors

• During cesarean birth, assess vital signs every 5 minutes until end of surgery

• Monitor for post-dural puncture headache in the days following the procedure

What is Pudendal Block?

• Purpose: Anesthetizes the lower vagina and part of the perineum

• Uses: Often employed for episiotomies and vaginal births, especially those requiring low forceps

• Procedure: Local anesthetic is injected near each ischial spine to block the pudendal nerves

• Additional step: Perineum is infiltrated with local anesthetic for complete numbness

• Effect: Does not block pain from uterine contractions; patient still feels pressure

• Onset: Brief delay between injection and numbness

• Limitations: Does not provide pain relief for uterine contractions

What are the possible complications of Pudendal Block?

1. Toxic reaction to the anesthetic

2. Rectal puncture

3. Hematoma formation

4. Sciatic nerve block

When is General Anesthesia used?

• Emergency cesarean sections (When there's no time to administer or wait for regional anesthesia to take effect)

• Inadequate regional anesthesia (If an epidural or spinal block proves insufficient for surgical anesthesia during a cesarean)

• Patient refusal or contraindications (When a patient declines regional anesthesia or has medical conditions that make it unsafe)

• Unexpected complications (For emergency procedures at any stage of pregnancy, such as:

  • Trauma repair from accidents or domestic violence)

  • Acute surgical emergencies (e.g., appendectomy)

  • Severe fetal distress requiring immediate intervention

• High-risk pregnancies (Some complex cases may require general anesthesia for optimal management)

• Coagulation disorders (Patients with bleeding disorders may not be candidates for regional anesthesia)

What are the potential effects for General Anesthesia?

• Respiratory depression

• Aspiration risk

• Delayed emergence

• Neonatal respiratory depression

• Uterine atony

• Postoperative nausea and vomiting

What are the nursing interventions for General Anesthesia?

1. Preoperative:

   • Restrict oral intake as ordered

   • Administer ordered medications (e.g., sodium citrate, famotidine)

   • Assist with cricoid pressure (Sellick's maneuver) if required

2. Intraoperative:

   • Monitor vital signs closely

   • Assist anesthesia team with airway management

   • Be prepared for potential failed intubation (10 times higher risk in pregnancy)

3. Postoperative:

   • Monitor oxygen saturation using pulse oximetry

   • Assess vital signs every 15 minutes until stable

   • Observe for pallor or cyanosis

   • Encourage deep breathing to eliminate anesthetics

   • Ensure suction equipment and Ambu bag are immediately available

   • Administer oxygen until client is fully awake and alert

   • Monitor for signs of aspiration or respiratory complications

4. Neonatal care:

   • Be prepared for potential neonatal respiratory depression

   • Ensure neonatal resuscitation equipment is readily available

5. Pain management:

   • Assess and manage postoperative pain according to facility protocol

6. Education:

   • Provide clear postoperative instructions to the patient and family

Antepartum Fetal Assessment

• Fetal movement counting

• Non-stress tests

• Biophysical profiles

• Doppler studies

Intrapartum Fetal Assessment

• Intermittent auscultation

• Electronic fetal monitoring (EFM)

Prenatal Testing

• Genetic screening

• Structural anomaly scans

Physical Examination

• Fundal height measurements

• Leopold's maneuvers

What are you looking for during a fetal assessment?

• Verify fetal life

• Assess fetal size, growth, and position

• Evaluate amniotic fluid volume

• Screen for genetic, structural, and chromosomal anomalies

• Monitor fetal oxygenation status

• Detect potential complications early

How often do you monitor a low risk labor baby?

• First stage (latent phase): Every 30-60 minutes

• First stage (active phase): Every 15-30 minutes

• Second stage: Every 5-15 minutes or after each contraction

Fetal Baseline

• Temperature: 97.7°F to 99.5°F

• Respiratory rate: 30 to 60 breaths per minute

• Heart rate (pulse): 110 to 160 bpm

• Blood pressure:

  • Systolic: 65 to 95 mm Hg

  • Diastolic: 30 to 60 mm Hg

Classification of FHR

• Absent

• Minimal

• Moderate

• Marked

Absent FHR

amplitude range undetectable

Minimal

amplitude range ≤5 bpm

Moderate

amplitude range 6-25 bpm (good)

Marked

amplitude range >25 bpm

What is an acceleration? (32 weeks gestation)

• The FHR must reach a peak at least 15 beats per minute (bpm) above the baseline

• The entire acceleration must last a minimum of 15 seconds but less than 2 minutes

• This is often referred to as the "15 x 15" rule

• reassuring signs of fetal well-being, indicating adequate oxygenation and normal acid-base balance at the time of observation

• visually apparent increase in the fetal heart rate (FHR) that occurs abruptly

What is an deceleration?

visually apparent decrease in the fetal heart rate (FHR) from the baseline

Early Deceleration

• Gradual decrease, taking 30 seconds or more from onset to nadir

• Mirror the shape of uterine contractions

• Generally considered benign

Late Deceleration

• Gradual decrease, taking 30 seconds or more from onset to nadir

• Onset, nadir, and recovery occur after the beginning, peak, and end of a contraction

• May indicate fetal hypoxemia

Variable Deceleration

• Abrupt decrease (less than 30 seconds from onset to nadir)

• Drop at least 15 bpm below baseline

• Last 15 seconds to 2 minutes

• Often associated with umbilical cord compression

Prolonged Deceleration

Decrease in FHR lasting 2-10 minutes from onset to return to baseline

Fetal Bradycardia

• Definition: FHR baseline less than 110 beats per minute (bpm)

• Duration: Lasting 10 minutes or longer

• Potential causes: Fetal hypoxia, cord compression, maternal hypotension, or medication effects

Fetal Tachycardia

• Definition: FHR baseline greater than 160 bpm

• Duration: Lasting 10 minutes or longer

• Potential causes: Fetal hypoxia, maternal fever, dehydration, or medications

Assessments/Interventions for Brady/Tachy

• Reposition the mother

• Administer oxygen

• Increase IV fluids

• Discontinue oxytocin if in use

• Prepare for possible emergency delivery if condition persists or worsens

Variable Decelerations Reasoning

• Caused by umbilical cord compression

• Interrupts oxygenation at the cord level

• Often related to low amniotic fluid volume

Early Decelerations Reasoning

• Thought to be a vagal response during fetal head compression

• Represent a fetal autonomic response to changes in intracranial pressure or cerebral blood flow

• Clinically benign with no known relationship to fetal oxygenation

Late Decelerations Reasoning

• Represent fetal reflex response to transient hypoxemia during contractions

• Result from decreased oxygenated blood delivery to the intervillous space

• Caused by uteroplacental vessel compression during uterine activity

VEAL

• Variable Deceleration

• Early Deceleration

• Acceleration

• Late Acceleration

CHOP

• Cord Compression

• Head Compression

• Okay

• Placental Insufficiency

V/C/P

• Variable Acceleration

• Cord Compression

• Position change mom and amnio fusion

E/H/O

• Early Acceleration

• Head Compression

• OKAY; vaginal examination

A/O/O

• Acceleration

• OKAY

• OKAY

L/P/S

• Late Acceleration

• Placental Insufficiency

• S: all the interventions

  • turn mom

  • turn on oxygen

  • turn off Pitocin

  • IV Bolos

  • If intervention do not work, call provider

What could cause decreased acceleration?

• Fetal sleep cycles

• Prematurity

• Medications given to the mother, such as:

  • Opioids

  • Magnesium sulfate

  • Other analgesics

• Congenital anomalies

• Fetal anemia

• Fetal cardiac arrhythmias

• Infection

• Preexisting antepartum neurologic injury

• Fetal hypoxia or acidosis

Nursing Care by Stages of Labor: Stage One

• Assessment: Monitor contractions, cervical dilation, effacement, and fetal heart rate (FHR)

• Intervention: Provide comfort measures, encourage position changes, and ensure adequate hydration

Nursing Care by Stages of Labor: Stage Two

• Assessment: Evaluate pushing efforts, descent of fetal head, and maternal exhaustion

• Intervention: Coach pushing, assist with positioning, and prepare for delivery.

Nursing Care by Stages of Labor: Stage Three

• Assessment: Monitor for signs of placental separation and blood loss

• Intervention: Administer oxytocin as ordered, apply controlled cord traction, and assess uterine tone.

Nursing Care by Stages of Labor: Stage Four

• Assessment: Check vital signs, uterine tone, and bleeding

• Intervention: Promote bonding, initiate breastfeeding if desired, and monitor for complications

External Cephalic Version

• Definition: Procedure to manually turn a fetus from breech to vertex position

• Indication: Breech presentation near term

• Nursing considerations: Monitor FHR, prepare for emergency C-section, administer tocolytics if ordered

Bishop Score

• Definition: Scoring system to assess cervical readiness for labor

• Indication: Determine likelihood of successful induction

• Nursing considerations: Accurately assess cervical status, communicate findings to provider

Cervical Ripening

• Definition: Process to soften and prepare the cervix for labor

• Indication: Unfavorable cervix prior to induction

• Nursing considerations: Administer prostaglandins or place mechanical dilators, monitor for onset of labor

Induction of Labor

• Definition: Artificially initiating labor

• Indication: Medical or obstetric reasons to deliver before spontaneous labor

• Nursing considerations: Administer oxytocin as ordered, monitor contractions and FHR, assess labor progress

Amniotomy

• Definition: Artificial rupture of membranes

• Indication: Induce or augment labor

• Nursing considerations: Assist with procedure, note time and characteristics of amniotic fluid, monitor FHR

Amnioinfusion

• Definition: Infusion of saline into the amniotic cavity

• Indication: Reduce variable decelerations, manage oligohydramnios

• Nursing considerations: Assist with infusion, monitor intrauterine pressure and FHR

Vaccum/Forceps

• Definition: Assisted vaginal delivery using vacuum or forceps devices

• Indication: Prolonged second stage, fetal distress, maternal exhaustion

• Nursing considerations: Prepare equipment, assist with procedure, monitor for complications

Episiotomy

• Definition: Surgical incision of the perineum during delivery

• Indication: To facilitate delivery or prevent severe lacerations

• Nursing considerations: Prepare for procedure, assist with repair, provide postpartum perineal care

C-Section

• Definition: Surgical delivery of the fetus through abdominal and uterine incisions

• Indication: Various maternal or fetal indications

• Nursing considerations: Prepare for surgery, assist with positioning, monitor vital signs and bleeding

VBAC (Vaginal Birth After Cesarean)

• Definition: Vaginal delivery following a previous cesarean birth

• Indication: Client desire, absence of contraindications

• Nursing considerations: Provide continuous electronic fetal monitoring, ensure immediate access to OR, support vaginal birth