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Interpartum

Childbearing

TermDefinition
Tocotransducer (Toco) External monitor for contractions, least invasive method; monitors frequency
IUPC; Intrauterine Pressure Catheter; Most accurate for intensity of contractions
Contraction Analysis Four characteristics: frequency, duration, intensity, and resting tone
Duration How long contraction lasts (beginning to end of contraction)
Frequency Range measured in minutes (ex:2-4)
Intensity Strength of contraction; use IUPC
Resting tone Return back to baseline before contraction; need for oxygen return to fetus
Contraction Decreased blood flow; has to last at least 30s
Tachysystole Could result if contracts too often, lack of resting tone; >5contractions/10minutes
If contractions too often Slow down Pitocin, give some oxygen, give fluid bolus, breathing
Baseline Fetal Heart Rate Average range between contractions; normal 110-160bpm
Tachycardia FHR 160< for at least 10min (moderate 160-179 & severe 180<)
Tachycardia Causes Elevated maternal temperature, dehydration, anxiety, breathing, fetal infection, hypoxic environment, prematurity
Bradycardia <110
Bradycardia Causes Maternal position (supine), epidural, hypotension
Baseline Variability Absent (undectectable) Minimal (0-5 bpm) Moderate 6-25 bpm Marked (25<); look at between contractions
Periodic changes Occur with contractions (accelerations or decelerations)
Nonperiodic changes Occur between contractions
Early Deceleration Should begin and end with contraction (signifies head compressing into pelvis) but resolves by end of contraction - good
Variable Deceleration Most common type; common during pushing, commonly U V or W shaped (cord compression) rapid drop rapid rise
Variable Deceleration First intervention is change her position
Late Deceleration Characteristic of uteroplacental insufficiency (drop begins after contraction peaks)
Late Decels Caused by Low/high maternal BP, Hyperstimulation (too frequent contractions, decreased maternal oxygenation, placental abnormalities (Ex: post-term)
Intrauterine Resuscitation Reposition/re-examine, readjust/remove oxytoxin/pitocin, rehydrate, re-oxygenate, report, record
Labor Triggers Decreased progesterone, increased estrogen, prostaglandins, and oxytocin, fetus' thyroid hormones
Impending Signs of Labor E surge, Braxton hicks, lightening (baby drops), cervical ripening, mucous discharge, bloody show, rupture of membranes, weight loss, GI changes (n&v, diarrhea)
Braxton Hick Primarily in back, goes away with activity, dilation or effacement (thinning)
Membrane Assessment Spontaneous Rupture of Membranes (SROM): Nitrizine test, ferning
AROM Artificial Rupture of Membranes
Nitrizine test Don't check cervix before test, blood or ky jelly can cause false+, amniotic fluid more alkaline so paper will turn blue if membrane ruptured
Ferning Swab fluid from cervix, if amniotic fluid will look like a fern
True Labor Back &Hip pain, increased intensity and duration, dilation, regular intervals (stronger, longer, and closer together over time)
When to go to the hospital Regular contractions, bright red vaginal bleeding, SROM, Decreased fetal movement
5 P's of Labor Powers, Passage, Passenger
Powers Primary Effacement & dilation, begins at fundus and follows contour of uterus, increased frequency, intensity, duration
Secondary Powers Voluntary - mom pushing
Passage Types of pelvis Gynecoid (most common, best,round) Platypeloid (least conducive, shaped like Playtypus bill), Android (heart shaped), Arthropoid (oval)
Passenger Fetus, membranes, and placenta (fetal sutures and fontanels allow molding of head) fetal attitude (head down/relation of fetal parts to one another) fetal line (look at maternal/fetal spines - longitudinal(horizontal), transverse (vertical), oblique)
Best positions for delivery Occipit anterior (head down) ROA Right Occipit interior LOP left occipit interior
Fetal Station Relationship of fetal head to mother's pelvis (more + number = closer into birth canal baby is) 0= ischial spine +3 best -3 above ischial spine
Order of Cardinal Movements Engagement, descent, flexion, internal rotation, extension, restitution/external rotation, expulsion
Engagement Stays in pelvis (doesn't ascend with ballotment)
Descent Descend into pelvis
Flexion Tucks chin to chest
Internal rotation Turn to align with mom's axis
Extension Extends head out
Restitution External rotation, turns to allow shoulders (position before internal rotation)
Expulsion Removal
Stages of Labor Stage 1 (0-10cm) Stage 2 10 cm - delivery Stage 3: delivery of baby to delivery of placenta Stage 4: first postpartum hour
Stage 1 Phase 1: Latent (0-3) Phase 2: Active (4-7) Phase 3: Transition (8-10)
Latent Phase Length Multigravida ~6h and primigravida ~9h
Latent Phase Alert, excited, anxious; effacement and dilation beginning, regular contractions are beginning, increasing intensity and frequency, cervix dilates 0-3cm
Active Phase Prim ~5h Multi ~2-3h; fear loss of control, increased anxiety, fetal descent into pelvis, dilates 4-7, intensity, frequency, duration, get epidural or IV narcotics, increase in bloody show
Transition Phase 100% effaced, primi~2h multi~1-2h, increased anxiety,fear, irritability, increased bloody show, contratcitons about q2 and last 40-60s, increased rectal pressure, n&v, involuntary shaking, 8-10cm
Prep for birth Cleanse perineum, position for birth, nurse washes hands, opens prep tray, sterile gloves, pushing with patient
Second Stage Feels powerless&sense of purpose, completely dilated, feel like BM needed, perineum begins to bulge, flatten, and move anteriorly
Ferguson's Reflex Urge to push
Third Stage Lengthening of cord and small gush of blood means placenta is ready to separate, will start bolus of oxytocin
Fourth Stage Euphoria and Bonding; increased P decreased BP, urine retention, massage fundus(should be firm), nonpalpable bladder, smooth&pink perineum w/o bruising or edema
Fourth Stage Comfort Measures Tremors common (heated blanket, warm drink) provide food and encourage rest
APGAR Score 1 minute (tells us about intrauterine life) 5minutes (tells us how baby is adapting to external uterine life) Monitor T, HR, R, skin color, tone Absent = 0
A Activity (muscle tone) 1- flexed arms and legs 2-active
P Pulse 1- <100 2- 100
G Grimace (ex: irritability) 1- Minimal response to stimuli 2- prompt response to stimuli
A Appearance (Skin color) 1- pink body blue extremities 2- pink
R Respiration 1-slow&irregular 2- vigorous cry
Non Pharm Pain Relief Comfort, gate control theory, imagery, breathing, position changes, hydrotherapy
Gate Control Theory Effleurage, counter pressure on sacrum, thermal stimulation (warm/cool compress) decreases pain stimuli
Systemic Analgesia Goal is to provide maximum pain relief with minimal risk
IV Opioids Nalbuphine (Nubain), Meperidine (Demerol), Butorphanol tartrate (Stadol)
Advantages of IV opioids RN administration, rapid onset, short duration
Disadvantages of IV opioids Decrease ctx frequency and intensity, crosses placenta, possible poor pain control
IV Opioid Antagonist Narcan
Lumbar Epidural Block Local anesthetic into epidural space; post-procedure head of bed 25 degrees, lateral uterine tilt, monitor q5-15min, continue fluid bolus
Spinal Block Immediate onset, risk for spinal headache (give lots of caffeine or blood patch)
General Anesthesia Impaired unconsciousness, common indications (perceived lack of time, contraindications to regional, failure to successfully insert regional, patient refusal)
Induction Post-term, medical necessity (ex: HELLP), PROM(Premature rupture of membranes), chorioamnionitis(Temp,WBCs, foul discharge), fetal jeopardy
Contraindications for Induction Previa (low lying placenta), Abnormal presentation (breech or transverse), CPD (cephalopelvic disproportion - bad pelvis type), Scarred upper uterus (previous abortions or surgery), gestational age less than 39 weeks, unless medically indicated
Cytotec Given orally or vaginally for induction by softening cervix in preparation for Pitocin introduction; synthetic prostaglandin, more effective than oxytocin, adverse outcomes in doses greater than 25mcg, prn q4h, don't give if contractions q3-4min
Cervidil Looks like tampon, helps ripen cervix by slowly releasing medicine over 12h period, removed 30mins before pitocin
Balloon Catheters Foley Cath (25-80ml balloon) ripens cervix by applying pressure
Bishop Scale Used for induction; less than 5 unfavorable for induction
Stripping Membranes Gloved hand, rotate 360 degrees twice; labor typically begins w/n 24-48h
Amniotomy Artificial rupture of membranes (AROM) Disadvantages: infection risk/prolapsed cord
Oxytocin Infusion Initiate uterine contractions (10-20u oxytocin & D5W) Risks (tachysystole of uterus/uterine rupture)
Pitocin given which stages 1 and 2 and post-partum
1st degree episitomy perineal skin and mucous membranes
2nd degree episiotomy also muscles of perineal body
3rd degree episiotomy Also involves anal sphincter
4th degree episiotomy Into rectum
Emergent indicaitons Abruption, umbilical cord prolapse, amniotic fluid embolus, non-reassuring fhr, uterine rupture
HnH, CBC, Platelet Count (100,000) Pre-op C section
Prophylatic/Cathetier Given Pre-op
TIME OUT Patient, procedure, time of antibiotics, fire risk, sedation scale, everyone present, allergies, everyone confirms they agree
Morphine Side Effects post c-section Pruritus (Bendaryl and Narcan), n&v, urinary retention,, respiratory depression
External cephalic version ECV) Fetus changed from breech, transverse, oblique; 36-37w
ECV Contraindications Intrauterine growth restriction, FHR abnormal, rupture of membranes, C-section indicated, amniotic fluid abnormalities
ECV Trendlenberg, physician turns baby, nurse uses ultrasound, routine toco
Vaginal Birth after Cesarean (VBAC) Low transverse incision, adqueate pelvis, no other uterine scards, in house staff
Operative Deliveries Forcep delivery (outlet - perineum, low 2+ or below) vacuum (at outlet)
Contraindications for operative deliveries Gestation <34, cephalopelvic disproportion, macrosomic,
Precipitous Labor Labor that lasts less than 3h from onset of labor to birth (hypertonic UC, rapid dilation)
Inadequate Expulsive Forces 2nd stage of labor when woman is not able to push or bear down (due to exhaustion, epidural)
Hypertonic Uterine Dysfunction Frequent contractions with decreased intensity and increased uterine tone (won't dilate or efface) prolongs labor
Hyotonic Uterine Dysfunction Infrequent contractions with decreased intensity (no dilation or effacement - prolonged labor) might give AROM and pitocin
Fetal Dystocia May be caused by excessive fetal size, malpresentation, multifetal pregnancy, fetal anomialies
Fetal Dystocia Complications Asphyxia, maternal lacerations, fetal injury, CPD
Fetal Dystocia Risk factors abnormal presentation, hydrocephalus, macrosomic over 4500g
Shoulder dystocia Difficulty encountered during delivery of shoulders after birth of head that may occur with macrosomia, prolonged 2nd stage
Prolapse of Umbilical Cord When cord lies below the presenting part of the fetus
Rupture of uterus when there is partial or complete tear in the uterine muscle (scar, tachysystole, eversion are causes) tearing sensation, late decels, loss of FHR
Disseminated Intravascular coagulation (DIC) Syndrome that occurs when the body is breaking down blood clots faster that it can forma a clot; quickly leads to hemorrhage (petechia,blood oozing, blood in urine) causes: fetal demis, uterine rupture, embolism, abruption
Anaphylactic Syndrome (Amniotic fluid embolism) Embolism forms when the amniotic fluid that contains fetal cells, lanugo, and vernix enters the maternal vascular system and results in cardio-respiratory collapse
Created by: TedMed