Quiz #4 Study Guide

Stages of Labor

First stage

• begins with regular uterine contraction, ends with complete cervical effacement and dilation

  • latent phase

    • regular, painful uterine contractions that cause cervical change

  • active phase

    • period where greatest rate of cervical dilation occurs

  • care management

    • determine if patient is in true labor (not prodromal labor)

      • assess contractions, cervix, fetus

    • admission data

      • review prenatal data

      • assess for SROM and pink/bloody show

      • review for hx of sexual abuse

      • stress during labor

      • culture and father participation

    • physical examination

      • general systems assessment/vital signs

      • leopold maneuver (abdominal palpatiton)

      • assess FHR and pattern

      • assess contractions

        • frequency

        • intensity (mild, moderate, strong)

        • duration

        • resting tone

    • lab and diagnostic tests

      • urinalysis

      • CBC, HIV, type and screen

      • GBS

    • assess amniotic fluid/membranes

  • interventions

    • emotional support, physical care, comfort measures, advice

  Second stage

  • begins with full dilation (10 cm)

  • complete effacement

  • ends with infant birth

  • latent phase

    • aka delayed pushing, laboring down, passive descent

  • active phase

    • pushing/urge to bear down

    • ferguson reflex activated when presenting part presses on stretch receptors of pelvic floor

  • care management

    • monitor FHR and pattern

    • utilize valsalva maneuver

  Third stage

  • birth of baby until placenta expelled

  • shortest stage of labor

  • placental separation=lengthening of umbilical cord and gush of blood from vagina

  Fourth stage

  • begins with expulsion of placenta, lasts until woman stable usually within first hour of birth

  • care management

    • assess physiologic changes to pre-pregnancy status

    • assess for excess blood loss and alterations in vitals/consciousness

  Delivery process

  • mechanism of labor

    • turns/adjustments necessary in human birth process

  • 7 cardinal movements

    • engagement and descent

      • fetus moves through pelvic inlet to ischial spines

    • flexion

      • fetal chin presses against its chest

      • heads meets resistance from pelvic floor

    • internal rotation

      • shoulders rotate by 45 degrees

      • widest part of shoulders in line with widest part of pelvic inlet

    • extension

      • head emerges from vagina after fetal head passes under symphysis pubis

    • external rotation (restitution)

      • head external rotates so shoulders pass through pelvic outlet and under symphysis pubis

    • expulsion

      • anterior shoulder slips under symphysis pubis

Contraction Assessment

Safety Protocols

• wash hands before handling newborn

• given ID bands to both baby and parents at birth

• attach electronic security tag on baby to prevent abduction

• ensure bassinet has secure sides

• put hat on baby to prevent cold exposure

• place baby on back to sleep

• NO loose bedding or toys

Postpartum Priorities

Assessment

Follow the BUBBLE-HE mnemonic:

• Breasts – Assess for engorgement, nipple pain, or issues with breastfeeding

• Uterus – Check fundal height, firmness, and location (should be firm, midline, and descending)

• Bladder – Monitor adequate voiding, distention, or urinary retention

• Bowel – Assess for bowel movements, constipation, and hemorrhoids

• Lochia – Monitor vaginal bleeding (color, amount, clots, odor).

• Episiotomy/Laceration/C-section incision – Check for healing, signs of infection, and pain

• Homan’s sign – Assess for DVT

• Emotional state – Screen for postpartum blues, depression, and bonding with the newborn

Complications

• monitor for postpartum hemorrhage

  • cause

    • uterine atony, coagulopathy, retained placenta, laceration

  • management

    • assess fundus, especially if boggy

    • monitor lochia for heavy bleeding or large clots

  • medication

    • oxytocin

    • methergine

      • contraindicated with HTN

    • hemabate

      • contraindicated with asthma

    • misoprostol

• monitor for signs of infection

• prevent thromboembolism

  • early ambulation and compression devices

Breastfeeding

• encourage skin to skin contact

• provide lactation support

  • ensure baby’s mouth covers most of nipple and areola

• educate on formula feeding

Psychosocial

Discharge Planning

• educate on signs of complications/infection

• self-care instructions

  • ice pack for first 24 hrs

  • NSAIDs for pain

  • no lifting heavier than baby for 4-6 weeks

• contraception counseling

• newborn care

  • breastfeed every 2-3 hours, formula every 3-4 hours

  • anticipate 6-8 wet diapers

  • sleep 16-18 hrs/day

  • keep umbilical cord dry/exposed

  • sponge bath until cord falls off

Equipment

Resuscitation

• bulb syringe

  • suction mucus from nose/mouth

• wall suction/meconium aspirator

  • for thick meconium

• ETT/laryngoscope

  • for intubation

Thermoregulation

• radiant warmer

  • used immediately after birth to maintain body temp

• skin probe

  • placed on newborn to regulate heat

Newborn Care

Newborn physiologic adjustment tasks involve:

• establishing/maintaining respirations

• adjusting to circulatory changes

• regulating temperature

• ingesting nutrients

• eliminating waste

• regulating temperature

Newborn behavioral tasks include:

• establishing independence of mother (self-regulating arousal, changes in state, sleep)

• establish relationship with caregiver and environment

Care management

• calculate APGAR score at 1 min and 5 min

  • heart rate

  • respiratory rate

  • muscle tone

  • reflex irritability

  • generalized skin color

Newborn Screenings

• hyperbilirubinemia (jaundice)

  • newborns should be assessed for jaundice every 8 to 12 hours

  • prevented by adequate feeding

• universal newborn screening

  • mandated by U.S. law, this screening helps to detect genetic diseases that can cause severe health issues if not treated early.

• Newborn Hearing Screening is also a part of routine newborn care

Screening for Critical Congenital Heart Disease (CCHD) involves measuring oxygen levels in the right hand and either foot

Preeclampsia

• HTN and proteinuria after 20 weeks of gestation who previously had neither condition

• can also develop in postpartum period

• in absence of proteinuria, preeclampsia may be defined as HTN along with:

  • thrombocytopenia

  • renal sufficiency

  • impaired liver function

  • pulmonary edema

  • cerebral/visual symptoms (blinking stars/dots)

• risk factors include:

  • preeclampsia hx

  • multifetal gestation

  • chronic HTN

  • pregestational/gestational diabetes

  • SLE

  • obstructive sleep apnea

  • nulliparity

  • BMI >30

  • AMA

  • thrombophilia

  • assisted reproductive technology

• pathophysiology

  • placenta is root cause

  • begins to resolve after placenta expelled

  • spinal arteries fail to get larger and thicker

    • decreased placental perfusion and endothelial dysfunction= preeclampsia

  • placental ischemia=endothelial cell dysfunction

  • generalized vasospasm=poor tissue perfusion in organ system

• fetal changes

  • impaired uteroplacental blood flow can cause:

    • IUGR

    • oligohydramnios

    • placental abruption

    • nonreassuring fetal status

    • preterm labor

• preeclampsia with severe features

  • thrombocytopenia <100

  • renal insufficiency with elevated serum creatinine >1.1 mg/dl/doubling

  • pulmonary edema

  • headache unresponsive to medication

  • visual disturbances

  • systolic BP ≥160 or diastolic BP ≥110 at least twice 4 hrs apart

• gestational age

  • onset prior to 34 weeks is most often severe

    • manage at facility with resources for management of serious maternal/neonatal complications

  • induction at 37 weeks indicated for preeclampsia without severe features

• management

  • assess BP and edema

  • assess deep tendon reflex/hyperactive reflex (clonus)

  • assess PCR

  • evaluate for these s/s:

    • severe frontal headache

    • epigastric pain (heartburn)

    • right upper quadrant tenderness

    • visual disturbance

HELLP Syndrome

• can lead to:

  • liver hematoma/rupture

  • ARDS

  • sepsis

  • hypoxic encephalopathy

  • fetal/maternal death

  • preterm delivery

  • recurrent preeclampsia

• treatment

  • induction regardless of gestational age

  • monitor CBC and liver enzymes Q6H

  • magnesium infusion

  • BP control

  • early epidural placement