Maternal Nursing Exam 2 (labor, pain, FHR)

factors affecting labor

passengers, presentation, passageway, powers, position, psychological factors

passengers

fetus & placenta

-head size

—anterior fontanel = diamond, 3×2 cm

—posterior fontanel = triangle, 1×2 cm

—head must mold to fit through, goes back to normal w/in 3 days

-placenta previa = in front of head

presentation

which part of the fetus enters first

-cephalic = occipit (“vertex”)

-breech = sacrum (butt/feet)

-shoulder = scapula

factors determining fetal presentation

-lie = spine of fetus r/t mom’s spine: may be longitudinal, transverse (need C-section), or oblique

-attitude = relation of body parts (general flexion is normal)

-position = portion that overlies pelvis inlet

-station = relationship of presenting part to line between ischial spines (narrowest part of pelvis)

—measured in cm, (-) means above, (+) means below (+4 or +5 means birth is coming)

-engagement = largest diameter has passed the pelvic inlet (station = 0)

fetal position

where is the presenting part (what part of pelvis)

-R or L (determine by feeling fontanel)

-Occipit, Sacrum, Mentum/chin, or SCapula

-Anterior, Posterior, or Transverse

e.g. “RST” (baby’s sacrum is on mom’s right side & baby is facing the [left] side)

-OA is best (baby is facing the back)

fetal positions image

passageway

bony pelvis

-depends on subpubic angle, diameters, etc

-4 possible shapes/types of pelvis

soft tissues

-in labor, uterus becomes thick at top and thin at bottom, physiologic retraction ring separates

-cervix effaces (thins) and internal os dilates

—effacement at 100% feels paper-thin

—dilation goes 2-10 cm (10 = cannot feel cervis around baby’s head) *6-7 cm is more measuring what’s left around baby’s head

cervical exam

report dilation (in cm), effacement (%), station (-5 to +5)

powers

-primary = involuntary contractions (cause effacement, dilation, & descent)

—frequency = time from start of one to start of next

—duration = length

—intensity = peak strength

-secondary = bearing down (discourage Valsalva b/c holding breath is bad)

—involuntary urge to push, then voluntary pushing: to cause descent

process of labor

-true labor = contractions AND cervical change

-stages

1) onset to full dilation

2) dilation to birth

3) birth to placenta (3-4 contractions)

4) placenta to stability (1-2 hours)

7 cardinal movements of labor

*ready to deliver = head stays in place during contractions

-engagement = head in pelvic inlet

—asynclitism (head deflected) vs synclitism (parallel to AP plane of pelvis)

-descent (head moves through pelvis)

-flexion (of head)

-internal rotation (occipit rotates anterior)

-extension

-restitution and external rotation (after head is out)

-expulsion (after shoulders are out)

signs before labor*

-1st time: uterus moves down 2 weeks before term (lightening)

—multipara: after contractions

—less pressure on lungs, more on bladder (urinary frequency)

-low backache

-Braxton Hicks

-vaginal mucus increases (brownish red = bloody show)

-cervix softens/ripens

-1-3.5 lb weight loss

-energy burst

-membrane rupture

fetal adaptations to labor

-FHR normally 110-160, drops closer to term, then changes during labor

-fetal circulation compensates for stress of contractions

-fetal respirations:

—lung fluid clears

—decreased O2 concentration, CO2 increased

-blood pH lowers

-bicarb lowers

-respiratory movements decrease

maternal adaptations to labor

-CVS

—CO increases 12-31% d/t higher SV

—BP increases

—WBC increases

-maternal respirations: hyperventilation

-proteinuria 1+

-maternal integument stretches, maybe tears

-euphoria→seriousness→amnesia→elation or fatigue

-decreased pain threshold, sedation

pain

threshold = same for everyone

tolerance = what pt is willing to endure

pain in labor

visceral

-organ pain

-stages 1, 3, 4

-ischemia d/t low blood flow to uterus during contractions

-cervical stretching

-pressure on organs and nerves

-radiating pain

somatic

-skin/muscle

-stages 2, 4

-sharp/burning/localized

-d/t distention, pressure on bladder & rectum, stretching, lacerations

pain management

-do not assess w/ 0-10 scale; ask pt what she felt

-gate control theory: only a limited number of sensations can be felt at a time (i.e. distraction can block pain)

non-pharm pain control

-focal point

-breathing (slow at first, then lighter/faster)

—3:1 or 4:1 in-out/blow at 8 cm (use paper bag)

-wait to push till 8 cm

-effleurage = light stroking of abdomen

-counterpressure = circular movement/pressure on sacrum w/ fist

-TENS (on back, 1 min at a time)

water therapy 

-contra: FHR monitor on, fever, infection, bleeding, preterm

-never leave pt alone

-temp 96.8-99.5

ID water block: sterile H2O injection

-0.05-0.1 mL into 4 points on lower back

meds for pain

-implement early: first stage (late narcotics affect baby)

-sedatives: avoid (barbiturates, phenothiazines, benzos)

analgesics

-IM or IV

-opioids are limited

-risk of aspiration or low FHR/RR

-avoid meperidine/Demerol

-usually Nubain, Stadol, hydromorphone, morphine, maybe fentanyl or remifentanil

nerve block

-local perineal infiltration anesthesia

—for episiotomy or sutures

—lidocaine or chloroprocaine, plus EPI

-pudendal

—give late in stage 2 for episiotomy or operative vaginal birth, or stage 3 for stitches

-spinal anesthesia

—inj into subarachnoid space at L3-L5

—C-section: T6 down, vag: T10 down

—numbs to nipple line, works by gravity

—moves up for 5-20 mins, lasts 3 hr

reminders for spinal anesthesia

-AEs: hTN, low perfusion, ineffective breathing, HA (need blood patch)

-elevate head/shoulders/one hip

-assess VS, EFM, F&E q5min

-give bolus of LR or NS (500-1000 mL over 30 min) 15 min before to prevent hTN

-hTN

—decrease by 20%, SBP <100, FHR decrease

—turn laterally, increase IV rate, give O2 via nonrebreather mask at 10-12 L

-elevate legs, give vasopressor like ephedrine

epidural*

-catheter inserted (usually after)

-anesthetic or opioid

-L4-L5 (numb to belly line)

-least CNS depression

-C section: T8-S1, vag: T10-S5

-position pt lateral, rotate q1hr

-continuous or PCA

-pulse ox ON!

-contra: hemorrhage, coagulopathy, infection, IICP, heart conditions

-will feel pressure

-might be able to move after

other nerve blocks

-combined spinal-epidural: does not immobilize

-epidural & intrathecal

—no VS change

—can still push

—also used post-op

-contra: hemorrhage, hTN, bleeding disorder, blood thinners, infection, IICP, heart conditions

nitrous oxide

-AEs: N/V, dizzy

-rapid onset, no accumulation, self-admin

-pt is the only one allowed to hold mask

general anesthesia

-for regional contraindication or rapid birth

-risks: intubation difficulty, gastric content aspiration

-elevate one hip

-preoxygenate

-anesthetic given, then muscle relaxer, then ETT, then NO & O2, maybe amnesic

-may cause neonatal narcosis or hemorrhage

nursing management before epidural**

-signed consent

-bathroom

-IV fluid bolus

-sit on side of bed

-pulse ox on

after:

-stay at bedside for 20 mins

-watch for HR drop in mom and baby

methods of birth

-Lamaze: enjoy process, rely on support person

-Bradley: all decisions made before, partner is final decision-maker in the moment

-hypno-birthing: self-hypnotize, pt will not remember anything after

fetus during labor*

low O2

-low blood supply d/t mom’s BP change or low BV

-mom’s hemorrhage or anemia

-cord compression

-low blood flow to fetus from placenta

FHR changes d/t hypoxemia

FHR monitoring: intermittent auscultation

intermittent auscultation

-need special stethoscope or fetoscope or Doppler ultrasound

-palpate fetal position first

-compare to mom’s radial pulse

-count for 30-60 sec after contraction

-for low risk, no Pitocin

-contractions: intensity, duration, frequency, resting tone (soft or hard)

FHR monitoring: EFM

-to assess O2

-external (transducers on abdomen)

—no pressure measurement

—weak signal d/t obesity, anterior placenta, fetal movement

—elastic belt holds in place

—not always good for preterm

—mom cannot get up

-internal (electrode on fetus)

—requirements: ROM, cervix 2-3 cm, can access presenting part

—catheter (IUPC) inserted into fluid pocket to measure pressure

normal uterine activity during labor

-contraction frequency: 2-5 per 10 min

-contraction duration: 45-80 sec

-contraction strength: 40-80 mmHg

-resting tone: 10 mmHg

-relaxation time: >45-60 sec

FHR baseline*

average during 10 minute segment (rounded to closest 5 bpm)

—normal = 110-160

-accelerations normal, decelerations are not

-variability = irregular fluctuations in baseline of 2+ cycles per min

—absent = amplitude range not detectable, 0-2 bpm (not good)

—minimal = 3-5 bpm (monitor)

—moderate = 6-25 bpm (normal)

—marked = 26+ (monitor, usually during pushing)

—*number one indicator of fetal well-being

baseline tachycardia & bradycardia

-tachy = >160 for 10+ min

—early sign of low O2

—also d/t mom: fever/infection, anemia, meds, drugs, hyperthyroidism; fetus: movement, stress

—Rx: reposition, check temp, give antipyretics/antibiotics

-brady = <110 for 10+ min

—d/t head coming out, HF, virus, maternal hypoglycemia or hypothermia

periodic & episodic FHR changes*

periodic = w/ UCs, episodic = not

increase by 15+ bpm for 15+ sec

accelerations or decelerations

accelerations

—abrupt = <30 sec

—return w/in 2 min

—d/t compressed vein, movement, stimulation, breech, OP position, UCs

—normal, indicate good O2/neuro status

decelerations*

(>30 sec)

—early = beginning of UC (nadir aligns w/ UC peak)

—r/t UCs, CPD (benign)

-late = end of UC (nadir is after UC peak)

—d/t low O2 (less benign)

—give IVF/O2, reposition

-variable

—sudden, shaped like a V/U/W on monitor 

—d/t cord compression

—reposition, give amnioinfusion

-prolonged = 2+ min

variability image

periodic/episodic changes image*

non reassuring FHR patterns*

-baseline bradycardia or tachycardia

-absent or minimal variability

—d/t sleeping, sedation, or lack of O2

—prevent from getting worse

-variable or late decelerations

-prolonged decelerations

*may indicate hypoxemia or acidemia

EFM methods

-US transducer on upper abdomen, goes over baby’s back at heart level, measures FHR

-tocotransducer over uterus on hardest part of fundus, measures UCs

-evaluate baseline rate, baseline variability, accelerations, decelerations, changes, trends (indicate fetal O2)

assessment of fetus

-fetal scalp stimulation (tickle baby’s head) & vibroacoustic stimulation

—FHR should increase (indicates no acidemia)

—contra: decelerations or bradycardia

-cord acid-base testing

—test pH of placental artery & vein

—test P_CO2 & P_O2

-scalp blood sampling

interventions for fetus*

-amnioinfusion

—NS or LR bolus into uterus

—for deep or frequent variables, low amniotic fluid volume, or meconium-stained fluid

—relieves cord compression

-tocolytic therapy

—meds to inhibit UCs

—e.g. terbutaline

—used if position change, IVF, or stopping Pitocin fails

nursing care for abnormal FHR*

*standing orders (but call HCP after)

-intrauterine resuscitation

—reposition to side

—short-term O2 via nonrebreather mask at 10-15 L

-bolus of 500-1000 mL LR or NS

-turn off Pitocin or remove cervadil

-tocolytic meds

categorizing FHR

-category I (green): normal

—no acidemia, no risk

—no Rx needed

-category II (blue): indeterminate

—no central acidemia, no risk, low risk of progression to acidemia

—conservative management

-category II (yellow)

—intermittent hypoxia, no risk, moderate risk of progression

—conservative management w/ surveillance 

-category III (orange)

—potential decompensation, no risk, high progression risk

—conservative management w/ prep for delivery

-category IV (red): abnormal

—possible asphyxia, high risk, present risk of progression

—baby needs delivered immediately 

mnemonic for FHR*

V.E.A.L. C.H.O.P.

-Variable deceleration = Cord compression

-Early deceleration = Head pressure

-Acceleration = Okay

-Late deceleration = Placental insufficiency

fetal compensation*

HR drops to compensate for low BP or BV (opposite of adult)