NUR 113 Exam 2

Intrapartum, Placenta Abruption, Placenta Previa, and Prenatal Loss

True labor contractions timing.

• Regular, becoming closer together

• 4-6 min apart

• lasting 30-60 seconds

False labor contraction timing

• Irregular

• Not occurring close together

True labor contraction strength

Become stronger with time, vaginal pressure is usually felt

False labor contraction strength

• Frequently weak

• Not getting stronger with time or alternating (strong on followed by weaker ones)

True labor contraction discomfort

Starts in the back and radiates around toward the front of the abdomen

False labor contraction discomfort

Usually felt in the front of the abdomen

Does activity change true contraction

Contraction continue no matter what positional changes are made

Does activity change false contraction

Contractions may stop or slow down with walking or making a position change

A patient should go to the hospital when contractions are…

• 5 minutes apart

• Last 45-60 sec

• Strong enough so that a conversation during one is not possible

A patient should stay home when contractions…

Diminish in intensity after drinking water and walking around

Onset of first stage of labor

Regular contractions

End of first stage of labor

• Full dilation (10 cm)

• Full effacement (100%)

Average duration of first stage of labor

12 hours

What is the most common type of deceleration?

Variable deceleration

______ deceleration is caused by cord compression.

Variable

What may help variable decelerations?

Amnioinfusion

What are the two decelerations that amnioinfusion will not help?

• Early (head compression)

• Late (caused by uteroplacental insufficiency)

What is the pattern like for variable decelerations?

No real pattern - can occur any time during the contraction

Category I: Normal FHR pattern

• Baseline 110-160

• Baseline variability moderate

• Present or absent accelerations

• Present or absent early decelerations

• No late or variable decelerations

• Can be monitored with intermittent auscultation during labor

• Predictive of normal fetal acid-base status

• No interventions required

Category II: Interminate FHR pattern

• Fetal tachycardia (>160 bpm) present

• Bradycardia (<110 bpm) not accompanied by absent baseline variability

• Absent baseline variability not accompanied by recurrent decelerations

• Minimal or marked variability

• Recurrent late decelerations with moderate baseline variability

• Recurrent variable decelerations accompanied by minimal or moderate baseline variability, overshoot, or shoulders

• Prolonged decelerations >2 min but <10 min

• Not predictive of abnormal fetal acid-base status

• Require evaluation

Category III: Abnormal FHR pattern

• Fetal bradycardia (<110 bpm)

• Recurrent late deceleration

• Recurrent variable decelerations - declining or absent

• Sinusoidal pattern (smooth, undulating baseline)

• Predictive of abnormal fetus acid-base status

• Require intervention

Nadir of deceleration matches peak of contraction during _____ deceleration

Early

What is acceleration?

A acme of 15 bpm above baseline with duration > 15 seconds but < 2 min

In what phase of labor do you administer a epidural?

Active

What can happen if an epidural is administered to early?

Stalled or prolonged labor

What are the cons of an epidural?

• Maternal hypotension (IVF before)

• Fetal bradycardia

• Possible spinal headache

Onset of the second stage of labor.

• Full cervical dilation

• Complete effacement

• Bloody show

• Rupture of amniotic sac

• Rectal pressure (like bowel movement) and flaring

• Bearing down with each contraction

• Appearance of head

End of the second stage of labor.

Birth

Average duration of the second stage of labor.

1 hour

What is the expected and normal appearance of amniotic fluid?

Clear

What does cloudy or foul smelling amniotic fluid mean?

Infection

What does green amniotic fluid mean?

Passed meconium from stress

What could cause stress to the baby?

• Hypoxia

• Cord compression

• Post-dates/ prolonged gestation

• IUGR
  Hypertension

• Diabetes

• Breech presentation (normal for this position)

What is augmentation/Induction

The stimulation of uterine contractions by medical or surgical means before the onset of spontaneous labor

What are the risk for induction?

• Hyperstimulation of uterine contractions (>120 seconds)

• Uterine tetany

• Compromised uteroplacental blood flow

• Amniotic fluid embolism

Induction indication

• Prolonged gestation (post-date) - by 42 weeks

• Premature prolonged rupture of membranes (PPROM)

• Gestational hypertension

• Cardiac disease

• Renal disease

• Chorio

• Shoulder dystocia

• IUFD

• Isoimmunization

• Diabetes

Cervical ripening prostaglandins

• Prepadil

• Cervidil

• Cytotec (only approved by FDA for cervical softening)

What does pitocin do?

Stimulates uterine contractions

How is pitocin given?

Piggy-back to IVF

What can pitocin cause?

Uterine hypertonicity

What medication requires continuous fetal monitoring after being administered?

Pitocin

What is a episiotomy?

A surgical cut made at the opening of the vagina during childbirth, to aid a difficult delivery and prevent rupture of tissue

Indications for cesarean section. (Life threating)

• Umbilical cord prolapse

• Fetal malpresentation

• Cephalopelvic disproportion (CPD)

• Placenta previa

• Placental abruption

Other possible indications for cesarean section.

• Non-reassuring fetal heart rate tracing

• Uterine rupture

• Severe preeclampsia

• Multiple gestation of 3 or more babies

• HIV if untreated or if high viral load

• Late-term or active genital herpes infection

• Uncontrolled diabetes

Onset of the third stage of labor.

Delivery of baby

End of the third stage of labor.

Expulsion of placenta

Average duration of the third stage of labor.

20 minutes

What is the criteria for internal monitoring?

• Amniotic membranes must be ruptures

• Cervix dilated 2 cm

• Presenting part down against the cervix

What are the two types of placenta previa?

• Previa

• Low-lying

What is previa?

When the placenta edges cover the internal os

What is a low-lying placenta previa?

Less than 2 cm from internal os but does not cover it

When is a placenta previa identified?

2nd or 3rd trimester

Risk factors for placenta previa.

• AMA >35

• Previous c-section

• Multiparity/Multifetal/Short birth spacing

• Uterine insult or injury/Surgery

• Cocaine use

• Previous D&C

• Prior previa

• Endometrial ablation

• Infertility treatment

• Hypertension

• Diabetes

Placenta previa complications

• Prenatal and Postpartum hemorrhage

• Perinatal mortality/Morbidity

• Abruption emergency c-section

• Hysterectomy

• Early/Premature delivery

• Miscarriage

• Hypovolemic shock/ Fetal hypoxia cerebral ischemia

• DIC
  IUGR

• Abnormal fetal presentation

How many weeks is a spontaneous abortion?

less than 20

How many weeks is considered a fetal demise?

More than 20

At how many days is a death considered neonatal death?

0-28

Why would you administer a bolus of IV fluids prior to an epidural?

Prevent hypotension

During the latent phase of labor vitals signs (BP, pulse, respirations) should be taken every _____ minutes.

30-60

During the active phase of labor vital signs (BP, pulse, respirations) should be taken every _____.

15-30 minutes

During the latent and active phase of labor temperature should be taken every _____ hours.

4; More frequently if membranes are ruptured

Once the membrane has ruptured temperature is taken every ____ hours.

2

During the latent phase of labor contractions (frequency, duration, intensity) should be assessed every ____ minutes.

30-60 by palpation or continuously by EFM

During the active phase of labor contractions (frequency, duration, intensity) should be assessed every ____ minutes.

15-30 by palpation or continuously by EFM

During the latent phase of labor FHR should be assessed every _____ by doppler or continuously by EFM.

Hour

During the active phase of labor FHR should be assessed every _____ minutes by palpation or continuously by EFM.

15-30

During the second stage of labor vitals signs are assessed every _____ minutes.

5-15

During the second stage of labor FHR is assessed every _____.

5-15 minutes by Doppler or continuously by EFM

How many contractions do you palpate during the second stage of labor.

Every one

During the third and fourth stage of labor vital signs (BP, pulse, respirations) are assessed every _____ minutes.

15

During the third stage of labor FHR is assessed using the apgar scoring at _____ minutes.

1 and 5

What is assessed during the fourth stage of labor.

• Newborn head-to-toe

• Vital signs every 15 minutes until stable

During the fourth stage of labor you should palpate for firmness and position of the uterus every _____.

15 minutes for the first hour

During the fourth stage of labor you should assess vaginal discharge every ______.

15 minutes with fundus firmness

First stage of labor

• From 0-10 cm dilation

• Consists of two phases

What are the two phases of the first stage of labor?

• Latent

• Active

Latent phase cervical dilation

0-6 cm

Latent phase cervical effacement

0% to 40%

Latent phase contraction frequency

5-10 minutes

Latent phase contraction duration

30-45 seconds

Active phase cervical dilation

6-10 cm

Active phase of labor cervical effacement

40% to 100%

Active phase of labor contraction frequency

2-5 minutes

Active phase of labor contraction duration

45-60 seconds

Second stage of labor

From complete dilation (10 cm) to birth of the newborn; may last up to 3 hours

What are the two phases of the second stage of labor?

• Pelvic phase

• Perineal phase

What is the pelvic phase?

Period of fetal descent

What is the perineal phase?

Period of active pushing

Perineal phase contraction frequency.

2-3 minutes

Perineal phase contraction duration.

60-90 seconds

How long does it take for the placenta to be delivered?

Usually 5-10 minutes, but could take up to 30 minutes

Signs that the placenta is ready to deliver.

• The uterus rises upward

• The umbilical cord lengthens

• A sudden trickle of blood is released from the vaginal opening

• The uterus changes its shape to globular

Normal blood loss is approximately _____ for a vaginal birth.

500 mL

Normal blood loss is approximately _____ for cesarean birth.

1000 mL

How are braxton hicks contractions described?

Tightening or pulling sensation of the top of the uterus

Where do braxton hicks contractions occur?

Abdomen and groin and gradually spread downward before relaxing

Cervical softening/Effacement and possible dilation can occur _____ or _____ before labor.

• 1 month

• 1 hour

When does lightening occur?

When the fetal presenting part begins to descend into the true pelvis

Your patient tells you that she is breathing much easier, has a decrease in gastric reflux and noticed an increase in vaginal discharge and urination. What can you suspected has occurred?

Lightening

What might your patient complain of once lightening occurs?

• Increased pelvic pressure

• Leg cramping

• Dependent edema in the lower legs

• Lower back discomfort