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HGTC OB Test 2

QuestionAnswer
Engagement The largest diameter of the presenting part reaches or passes through the pelvic inlet
Process of engagement in cephalic presentation. Floating The fetal head is directed down toward the pelvis but can still easily move away from the inlet.
Process of engagement in cephalic presentation. Dipping. The fetal head dips into the inlet but can be moved away by exerting pressure on the fetus.
Process of engagement in cephalic presentation. Engaged The biparietal diameter (BPD) of the fetal head is in the inlet of the pelvis. In most instances the presenting part (occiput) is at the level of the ischial spines (zero station).
Powers of Labor:Primary force Uterine muscular contractions --Causes complete effacement of cervix --Causes dilatation of cervix
Powers of Labor: Secondary force --Abdominal muscles --Used to push during second stage of labor
Signs of Labor: Preliminary (Also termed premonitory or prodromal)Signs Preceding Labor Lightening; Surge of energy; braxton hicks; ripening of cervix; rupture of membrane; bloody show
Lightening Fetus drops: Uterus sinks downward and forward--Occurs about 2 wks before term (Mulitparous: May be after contractions established)
Surge of energy 24 – 48 hrs before labor--Energy to clean and put things in order--Caution not to overexert
Braxton-Hicks Frequent but irregular and intermittent -Become stronger -Abd and groin pain
Ripening of cervix Cervix becomes soft (ripens) -Increase in water -May begin to dilate
Rupture of membranes Membranes may rupture spontaneously --Labor within 12-24 hrs
Bloody show Mucus plug expelled - Brownish or blood-tinged cervical mucus - Labor in 24-48 hrs
Other Signs Preceding Labor : Less common occurrence Diarrhea --N/V --Indigestion - Loss of weight: 1 to 3 lb; loss of water
Actual signs of labor Changes in maternal uterus - Changes in cervix, pituitary gland - Aging of placenta -Increased intrauterine pressure - Effacement - Dilation
Actual signs of labor: Uterine contractions change Regular, progressive - Increase in frequency, duration and intensity - Pain in back and radiated around abdomen
Actual signs of labor: Effacement Thinning of cervix - Muscles of the upper uterine segment shorten -- Drawing upward of the internal os and cervical canal
Actual signs of labor:Dilation Progressive enlargement or widening of cervical opening and canal - Due to fetal axis pressure and hydrostatic pressure of fetal membranes - Diameter increases: < 1 to 10cm - Completely dilated cervix= no longer palpable
Stages of Labor: First Stage Begins with onset of regular contractions (mild) - Ends with full dilation of cervix --Longer than 2nd & 3rd stages
First Stage of Labor consists of 3 phases: Early(latent)- Active - Transition
First Stage consists of 3 phases: Phase 1Early (latent) Progressive effacement of cervix - Little increase in descent - Excited and anxious
First Stage consists of 3 phases: Phase 2 Active Contractions resume - Dilates 3-4 cm to 7 cm - Bearing down efforts by woman - Fetal station is advancing - Anxiety increases – Employ coping strategies
First Stage consists of 3 phases: Phase 3 Transition Contractions more frequent, longer, and stronger-rapid dilation of cervix 8–10cm--Rectal pressure, low backache, belching, nausea or vomiting- Beads of perspiration on lip or brow --Apprehensive, irritable, angry, withdrawn
Stages of Labor: Second Stage Lasts from the time cervix is completely dilated to birth of fetus - Avg 20 min for multip (30min) - Avg 50 min for nulliparous (3hr) - Crowning occurs when birth is imminent -- Head encircled by vaginal introitus - Sense of purpose -- Burning sensation
Stages of Labor: Third Stage From birth of fetus - Until placenta is delivered - Placenta normally separates with 3rd or 4th contraction after fetus is born - Length from 3-5 min to 1 hr -Risk of hemorrhage increases as length of stage increases
Stages of Labor: Fourth Stage Recovery 1-4 hours after delivery of placenta -- Avg 2 hr after birth - Period of immediate recovery, homeostasis -- Observe for complications: Abnormal bleeding
Types of deliveries: SVD Spontaneous Vaginal Delivery:(Cephalic (vertex) most common)
Types of deliveries: FAVD Forceps Assisted Birth (Instrumental or operative vaginal delivery)
Types of deliveries: FAVD : Outlet forceps FAVD: fetal skull reached perineum
Types of deliveries: FAVD : Low forceps FAVD: presenting part at station +2
Types of deliveries: FAVD : Midforceps FAVD: fetal head is engaged
Indications for FAVD (Forceps Assisted Birth) Threat to mother or fetus --History of Heart disease - Pulmonary edema - exhaustion
Conditions for forceps use Cervix completely dilated -ROM (ruptured membranes), engagement - Vertex or face presentation - Bladder empty - CPD ruled out
FAVD Risks: Newborn Ecchymosis and/or edema of face - Lacerations - Caput or cephalhematoma -- Hyperbilirubinemia - Transient paralysis -Cerebral hemorrhage
FAVD Risks: Maternal Lacerations of birth canal -- 3rd of 4th degree extension of episiotomy - Bleeding, bruising, edema
FAVD Nursing Care: Decrease need for operative vaginal birth Correct labor dystocia PRN: Encourage position changes, ambulation -- Empty client bladder frequently / Correct FHR decelerations: Assist with maternal position changes -- Apply oxygen PRN - Increase fluid intake
FAVD Nursing Care: Assist with ID of contactions - Reinforce pushing with traction - Assess newborn for edema, bruising, caput, cephalhematoma - Assess mother for REEDA -- Hematoma, infection
REEDA redness, edema, ecchymosis, drainage, approximation
Types of deliveries: VVD (Vacuum Assisted Birth) Vacuum extractor used to apply suction to fetal head: Traction applied during contractions - Descent should be seen with first two pulls
VVD – Vacuum Assisted Birth: Risk cephalhematoma of newborn
VVD – Vacuum Assisted Birth: Nursing care Keep family informed; Assess FHR -- Reassure that caput will disappear within 3 days -Assess newborn for intracerebral hemorrhage, jaundice
Types of deliveries: Cesarean Birth--C-section Birth of infant through an abdominal and uterine incision: Repeat C/S - Elective C/C --Preservation of pelvic floor
Types of deliveries: VBAC Vaginal Birth After Cesarean
Perineal Episiotomy Surgical incision in perineum to enlarge vaginal outlet
Perineal Episiotomy: 1st degree Extends through the skin
Perineal Episiotomy: 2nd degree Extends though skin and muscle
Perineal Episiotomy: 3rd degree Extends though skin/muscle/anal sphincter
Perineal Episiotomy:4th degree Extends though skin/muscle/anal sphincter/ anal wall
Risks for episiotomy Primigravida - Macrosomia LGA - Forceps or vacuum assisted delivery - Shoulder dystocia
Episiotomy: Health Care Provider (HCP) initiated risks Lithotomy positions -- Breath-holding during pushing -Limited time for 2nd stage
Episiotomy:Describe site and direction of incision: Median (midline) Most common in U.S. -- Effective, easy to repair; Generally, least painful - Extension to or through anal sphincter more likely
Episiotomy:Describe site and direction of incision: Mediolateral Need for posterior extension; 3rd degree lac may occur - Blood loss is greater; Difficult to repair -- More painful
Episiotomy Prevention Prenatal Kegel exercises; Perineal massage; Natural pushing; Sidelying pushing position; Warm compresses; Counterpressure
Care of episiotomy Assist with distraction and discomfort during repair (episiorrhaphy) - Apply ice 20 to 30 minutes - Inspect every 15min x 4 - REEDA
Complications Associated with Episiotomy Blood loss, Infection, pain, perineal discomfort, painful intercourse
Need for Mobility - Physiology of contractions: Influence of hormones Progesterone: causes relaxation of smooth muscle tissue / Estrogen: causes stimulation of uterine muscle = contractions
Need for Mobility - Physiology of contractions:Muscle fibers shorten with contractions; Pushes fetus downward - Pulls lower uterus upward, causing dilation and effacement
Uterine contractions: Frequency Beginning of one contraction to beginning of next
Uterine contractions: Duration Time between the beginning of a contraction to the end of the same contraction
Uterine contractions: Intensity Strength of contraction at peak (acme) -Fundus palpated for indentability - Measured accurately with Intrauterine Pressure Catheter (IUPC)
Uterine contractions: Resting tone Tone of muscle in between contractions
Pelvis can be divided into 2 false pelvis and true pelvis
True pelvis – divided into 3 parts Inlet, outlet, mid-pelvis (pelvic cavity)
Pelvic inlet Upper border of the true pelvis; sacral prominence around superior aspect of symphysis pubis - Widest diameter: transverse 13.5 cm
Pelvic Outlet Lower border of true pelvis; coccyx to ischial tuberosities to inferior aspect of symphysis pubic - Widest diameter: anterior/posterior: 9.5 – 11.5 cm - May be increased by 1.5 cm to 2 cm -Squatting, sitting
Passenger: methods to determine fetal presentation Leopolds maneuvers; Vaginal exams; Auscultation of FHT; Sonography or X-ray
Cephalic Presentation Occurs approx. 96 - 97% births --Head presented into passageway - Classified according to attitude of fetal head: degree of flexion or extension
Classification of Cephalic Presentations: Vertex Presentation (Cephalic Presentation): Most common --Head flexed on chest - Diameter presented to pelvis - Smallest diameter - Suboccipitobregmatic 9.5 cm -Presenting part: occiput
Classification of Cephalic Presentations: Military Presentation (Cephalic Presentation):Head neither flexed nor extended - Diameter presented to pelvis - Occipitofrontal 11.75 cm - Presenting part - Top of head
Classification of Cephalic Presentations: Brow Presentation (Cephalic Presentation):Head is partially extended - Diameter presented to pelvis - largest anterior-posterior diameter - occipitomental --Presenting Part - sinciput
Breech Presentation Occurs in approximately 3% of births ---Buttocks and/or feet presented to pelvis -Sacrum is the landmark
Classifications of Breech Presentations Complete, Frank, Footing
Breech Presentations: Complete Knees and hips flexed; buttocks and feet present -- Landmark: sacrum
Breech Presentations: Frank Hips flexed, knees extended; buttocks present -- Landmark: sacrum
Breech Presentations: Footling Hips and legs extended, feet present - Single footling, Double footling - Landmark: sacrum
Pelvis can be divided into 2 false pelvis and true pelvis
True pelvis – divided into 3 parts Inlet, outlet, mid-pelvis (pelvic cavity)
Pelvic inlet Upper border of the true pelvis; sacral prominence around superior aspect of symphysis pubis - Widest diameter: transverse 13.5 cm
Pelvic Outlet Lower border of true pelvis; coccyx to ischial tuberosities to inferior aspect of symphysis pubic - Widest diameter: anterior/posterior: 9.5 – 11.5 cm - May be increased by 1.5 cm to 2 cm -Squatting, sitting
Passenger: methods to determine fetal presentation Leopolds maneuvers; Vaginal exams; Auscultation of FHT; Sonography or X-ray
Cephalic Presentation Occurs approx. 96 - 97% births --Head presented into passageway - Classified according to attitude of fetal head: degree of flexion or extension
Classification of Cephalic Presentations: Vertex Presentation (Cephalic Presentation): Most common --Head flexed on chest - Diameter presented to pelvis - Smallest diameter - Suboccipitobregmatic 9.5 cm -Presenting part: occiput
Classification of Cephalic Presentations: Military Presentation (Cephalic Presentation):Head neither flexed nor extended - Diameter presented to pelvis - Occipitofrontal 11.75 cm - Presenting part - Top of head
Classification of Cephalic Presentations: Brow Presentation (Cephalic Presentation):Head is partially extended - Diameter presented to pelvis - largest anterior-posterior diameter - occipitomental --Presenting Part - sinciput
Breech Presentation Occurs in approximately 3% of births ---Buttocks and/or feet presented to pelvis -Sacrum is the landmark
Classifications of Breech Presentations Complete, Frank, Footing
Breech Presentations: Complete Knees and hips flexed; buttocks and feet present -- Landmark: sacrum
Breech Presentations: Frank (Breech Presentation) Hips flexed, knees extended; buttocks present -- Landmark: sacrum
Breech Presentations: Footling (Breech Presentation) Hips and legs extended, feet present - Single footling, Double footling - Landmark: sacrum
Shoulder Presentation Presentation: Transverse lie / Horizontal lie - Most frequently, the presenting part is shoulder - Landmark: Acromion process of scapula  Other presenting parts --Arm, back, abdomen, side
Cardinal movements: Adaptations that fetus undertakes to maneuver through the pelvis during birth and labor. Engagement, Descent, Flexion, Internal rotation, Extension, Restitution, External rotation, Expulsion
Breathing techniques: Slow chest Begin slow breathing when contractions are intense enough that you can no longer walk or talk through them without pausing. Switch to another pattern if you become tense and can no longer relax during contractions.
Breathing techniques: Accelerated chest Breathe in and out rapidly through your mouth about one breath per second. Keep your breathing shallow and light. Your inhalations should be quiet, but your exhalation clearly audible.
Breathing techniques: Variable (Transition) Breathing “hee-hee-who” breathing. Breathing combines light shallow breathing with a periodic longer or more pronounced exhalation. Variable breathing is used in the first stage if you feel overwhelmed, unable to relax, in despair, or exhausted.
Anesthetics: Regional Anesthetics: Spinal --Epidural --Intrathecal --Paracervical --Pudendal
Anesthetics: Local Anesthetics:used in repair of perineum
Anesthetics: General Anesthetics: used for C-section
Anesthetics: Regional Anesthetics: Spinal --Epidural --Intrathecal --Paracervical --Pudendal
Anesthetics: Local Anesthetics:used in repair of perineum
Side effects: epidural/intrathecal Hot spots, Has to wear off, Itching,nausea & vomiting, Urinary retention,Side effects decreased with narcan
Anesthetics: Regional Anesthetics: Spinal --Epidural --Intrathecal --Paracervical --Pudendal
Anesthetics: Local Anesthetics:used in repair of perineum
Rupture of membranes: Spontaneous(SROM) Rupture of membranes: Can initiate labor or occur anytime during labor --Usually during transition
Anesthetics: General Anesthetics: used for C-section
Epidural/Intrathecal: Injected into epidural space (L4- L5 or L5- S1) Catheter placed (epidural)--Takes 20-30 minutes to work (epidural) --Lasts 2 hours then needs med re-injected
Spinal block/ Intrathecal: Injected into spinal fluid --Onset quick (intrathecal) --Lasts 18-24 hours
Side effects: epidural/intrathecal Hot spots, Has to wear off, Itching,nausea & vomiting, Urinary retention,Side effects decreased with narcan
Rupture of membranes: (kinds) Spontaneous (SROM}, Prolonged (PROM), Artificial (AROM)
Rupture of membranes: Spontaneous(SROM) Rupture of membranes: Can initiate labor or occur anytime during labor --Usually during transition
Rupture of membranes: Prolonged (PROM) Rupture of membranes: Greater than 24 hours prior to delivery --Risk of infection
Rupture of membranes: Nursing Management Assess FHR prior (if possible) -Assess FHR after - ? Decels – R/O prolapsed cord - Assess color, odor, clarity, volume, time ----TACO
Rupture of membranes: Artificial (AROM) Rupture of membranes: amniotomy - usually performed using an amnihook or fingercot
TACO T = time the membranes ruptured, A = amount of fluid, C = color of the fluid and O = odor of the fluid.
Rupture of membranes: Nursing Management Assess FHR prior (if possible) -Assess FHR after - ? Decels – R/O prolapsed cord - Assess color, odor, clarity, volume, time ----TACO
TACO T = time the membranes ruptured, A = amount of fluid, C = color of the fluid and O = odor of the fluid.
Define Dystocia Long, difficult, abnormal labor; Occurs often during 1st stage labor -Primary cause for C/S delivery
Suspected Dystocia (S&S) Alteration in Uterine Contractions (UC’s) characteristics, lack of cervical dilation progression, and/or lack of fetal descent and expulsion progression
Dystocia Etiology Caused by various conditions associated with the 5P’s of labor: Dysfunctional labor (powers); Pelvic structure alteration (passage); Fetal variations (passenger); Mother’s response (psyche) and relationship between passage and passenger
Most common cause of dystocia Dysfunctional Labor
Dystocia: Caused by various conditions associated with the 5P’s of labor 1)Dysfunctional labor (powers); (2)Pelvic structure alteration (passage); (3)Fetal variations (passenger); (4) Mother’s response (psyche); (5) the ralationship between the passage and the passenger
Hypertonic Uterine Dysfunction: Primary Dysfunctional Labor : Occurrence Latent stage, cervical dilation < 4 cm
Hypertonic Uterine Dysfunction: Uterus Contractions: uncoordinated, frequency- increasing - Intensity: decreasing slightly but painful - Resting tone: Increasing
Hypertonic Uterine Dysfunction: Maternal complications Intrauterine infection: Open cervix, long labor - Repeated vaginal exams, exhaustion
Hypertonic Uterine Dysfunction: Fetal complications Fetal distress: Hypoxia: insufficient O2 supply to meet the demands of the fetus. Decelerations(Prolonged, late) Decreased Uteroplacental blood flow - Increased, prolonged pressure on head - Excessive molding, cephalhematoma
Hypertonic Uterine Dysfunction: Treatment Rest and fluids - Narcotics: Morphine sulfate, meperidine or tocolytics (Inhibits uterine contractions) Reduce pain; encourage rest - Barbituate - To allow patient to sleep - Usually awake with normal labor pattern -Allow labor to begin naturally
Hypotonic Uterine Dysfunction: Normal progress into active labor at least 4 cm - Then UC’s become weak, inefficient --< 25mm Hg or stop completely - Uterine Contractions: Frequency (decreasing); Intensity (decreasing); Resting tone(unchanged)
Hypotonic Uterine Dysfunction: Treatment Ultrasound or x-ray to R/O CPD: cephalic/pelvic disproportion - (CPD and malpositions common cause)Assess FHR and pattern, amniotic fluid (if ruptured) and maternal well being -If above normal, may ambulate, hydrotherapy, ROM - Pitocin augmentation
Hypotonic Uterine Dysfunction:Fetal / Maternal complications Fetal distress -Risk for Infection--tachycardia Maternal complications--Risk for Intrauterine infection -Exhaustion-Dehydration-Risk for postpartum hemorrhage
L & D Complication: Pathologic Rings – Soft Tissue Dystocia Constriction rings --Rare- ring forms and impedes fetal descent
Pathologic Rings: Treatment Analgesics, anesthetics or both to relax rings--C/S
L & D Complication: Precipitous labor & delivery Powers work too well (Labor less than or = 3 hours before birth) Characterized by 5 contractions in 10 minutes -May result from hypertonic UC’s --Intrauterine pressures may reach 50-70 mmHg --Lower uterine segment very soft
Precipitous labor & delivery: Nursing Management Emergency delivery --Stay calm!!! --Encourage to push between contractions -Apply gentle pressure to presenting part -nHead out - check for nuchal cord--Suction nose and mouth - After delivery, clamp cord, cut cord --Assess and place baby to breast
Precipitous labor & delivery: Maternal risks  Possible lacerations of birth canal No gradual stretching of the cervix, vaginal wall or perineum. -Gentle counter pressure placed on fetal head during delivery--Postpartum hemorrhage --Uterine rupture
Precipitous labor & delivery: Fetal risks Possible hypoxia (Resulting from frequent intense contractions, decreased rest periods) ; Trauma to head (Possible resistance of cervix--Intracranial hemorrhage) ; Possible lack of immediate care (lack of attendance of health personnel)
L&D Complications: Uterine Rupture : Incomplete rupture Extends into peritoneum but not into the peritoneal cavity;Abdominal tenderness-Pain with and without contractions;Usually internal bleeding;Palpable retraction ring;Distention of lower uterine segment;Failure of labor to progress
L&D Complications:Complete Uterine Rupture: Extends through entire uterine wall into peritoneal cavity -Profuse bright red bleeding ----“tore away”-Sharp abdominal pain -Abnormal feel and shape of uterus - Rapid onset of hypovolemic shock -Rapid onset of fetal distress -bradycardia
Complete Uterine Rupture: Management Management of shock --Replacement of blood --Hysterectomy?
Incomplete rupture: Management Require laparotomy--Repair of uterus --Blood transfusion
Labor Induction: Prostaglandins Causes softening--Begins dilation and effacement of cervix
Labor Induction: Cervidil Vaginal Insert (dinoprostone, 10 mg) Gradually released over 12 hrs
Labor Induction: Prepidil Gel -0.5mg/2.5 ml syringe into cervical canal-Repeat in 6 hrs
Labor Induction: Laminaria Mechanical dilator: A small rod-shaped piece of dried seaweed. The species of seaweed serving this purpose is Laminaria digitata. Inserted into cervix -Absorbs moisture from cervical mucus, expands and dilates the cervix
Labor Induction: Amniotomy- AROM Artificial rupture of membranes ; Condition of cervix favorable (ripe) Labor usually begins in 12 hrs Auscultate FHR: Prior to & immediately after --Document in chart - Risk for infection - Take maternal temp q 1-2 hours
Labor Induction: Misoprostol (Cytotec) Synthetic prostaglandin agent - Administered intravaginally and/or orally to stimulate the onset of UCs - 3 or more UCs in 10 min - Need continuous monitoring of the FHR, uterine activity, and maternal VS
Labor Induction: Pitocin Prior to induction, begin EFM, assess VS and UC’s -Begin primary infusion of IVF --Infuse Pitocin into lowest port of primary IV tubing -Control and titrate on IV pump --Monitor UCs - Monitor FHR closely --Observe fetal response to labor
Labor Induction: Pitocin : Stop infusion immediately if: UCs are closer than 2 minutes, last longer than 90 seconds, or any indication of fetal distress
Cord Prolapse: Umbilical cord lies below presenting part or falls beside or below head (if vertex); ROM may cause frank (visible) prolapsed - May be occult (hidden) prolapse anytime If presenting part is not snug in lower uterine segment
Cord Prolapse: Fetal Distress Cord compression….hypoxia…Variable decelerations
Cord Prolapse: Nursing Management Major goal: Relieve pressure off cord!! :Knee chest position/genupectoral position-Trendelenburg position - Gentle upward digital pressure on fetal presenting part ; If cord is exposed to room air: Warm sterile saline compresses
Persistent Occiput Posterior (POP) Position: Most common fetal mal-position: Prolonged 2nd stage -Mom c/o severe back labor pains-Fetal head (occiput) pressing against sacrum-Fetal head has to rotate ~ 180° to anterior
POP Management: Measures to rotate head Knee-chest/genupectoral position -Assist in left lateral position - Pelvic rock, lateral stroking -Walk or climbing stairs -Squatting, Hands and knees (all fours)
POP Management: Measures to relieve back pain: Counter pressure: heel of hand or fist to sacrum -Heat/Cold application - Risk for postpartum hemorrhage
BREECH Presentation: FHT above umbilicus in upper quadrants - Often seen in preterm deliveries - Amniotic Fluid may have meconium
BREECH Presentation: Primigravida C-section required
BREECH Presentation: Multigravida Maybe have vaginal birth
BREECH Presentation: Maternal risks Prolonged labor due to decreased pressure on cervix --PROM; increased risk of infection - C/S or forceps delivery-Trauma to birth canal-Intrapartum/postpartum hemorrhage
FACE/BROW Presentation: Sterile Vaginal Exam (SVE) – feel unusual presenting part -Can be delivered but sometimes causes severe facial bruising --May have difficulty sucking
TRANSVERSE LIE: Fetus lying sideways -Fetal axis perpendicular to maternal axis - May not feel fetal parts in fundus or above symphysis pubis - Shoulder is the common presenting part -Pathologic rings of the uterine muscle can occur ; Treatment: C/S
Shoulder Dystocia: Management Head is born but shoulder cannot pass under pubic arch;Maternal position changes;Hands and knees, squatting, lateral recumbent - Suprapubic pressure to anterior shoulder -McRoberts maneuver(knees on abd,legs flexed)- C-section with large babies
Shoulder Dystocia: Risk Factors Prolonged second stage of labor -Excessive Fetal size -Maternal pelvic abnormality
Shoulder Dystocia: Fetal complications Fractures of the humerus and clavicle-Edema, hemorrhage, Erb’s palsy - Caput succedaneum-Asphyxia
Shoulder Dystocia: Maternal Complications Bladder injury -Cervical, vaginal or perineal lacerations - Spontaneous separation of the symphysis - Uterine rupture - Uterine atony and Postpartum hemorrhage
Recognition of Shoulder Dystocia: Slowing progress of labor - Turtle sign- )(fetal head retracts or recoils against the maternal perineum) - External rotation may not occur
Shoulder Dystocia: Documentation Time of maneuvers and time delivered. Sample documentation: 1210 shoulder dystocia called by Dr. ___. McRoberts maneuver immediately implemented and suprapubic pressure applied by ______. 1215 infants shoulder and body delivered.
Macrosomia Baby > 4000gms -C-section usually!!
Problems with Passageway: CPD : Cephalo-pelvic disproportion (C-section – only treatment): Nurse prepares patient for surgery by IV access -Foley -Abdominal prep -Informed consent
Reasons for C-section / Cesarean delivery When vaginal delivery unsafe.;Fetal distresS; Fetal macrosomia;Maternal health jeopardized; Previous c-section; Failure to progress ;Active herpes ; multiple fetuses; Primigravida with fetus in breech position
Types of C-section Primary:First c-section ; Repeat:Second or third or etc. ; Pfannensteil incision: Bikini cut -Low-transverse; Classical incision:Vertical incision
Preparation for C-section Emergency IV, foley, prep, consent -Need lots of emotional support
C/S Pre-op Teaching What it expect after surgery -Pain management -Postanesthesia effects - T,C, & DB -Diet -Dressing -Fundal & lochial checks
Care During Surgery Explain procedures if patient awake -Anesthesia -Sterile prep and drapes -Let mom see baby as soon as possible
Admission to Postpartum Unit: Receive C-section patient Assist to bed from stretcher -Vital signs -Focused priority assessment -Complete assessment for baseline
Maternal risks with C/S Aspiration, Hemorrhage -Infections, Injury to bowel or bladder-Thrombophlebitis -Pulmonary embolism
Fetal/neonatal risks with C/S Injury at birth -Respiratory problems
Maternal Response to Labor: Cardiovascular and Respiratory Changes BP rises with contractions and pushing-Increase in O2 demand and consumption Hyperventilation – fall in PaCO2 -Respiratory alkalosis  Pushing – rise in PaCO2 and lactate (muscles) -Mild respiratory acidosis occurs
Maternal Response to Labor: Renal Changes: Increase in renin, plasma renin activity, angiotensinogen - Edema of bladder from fetal head pressure
Maternal Response to Labor: GI and Immune System: Gastric motility decreased, emptying prolonged, volume increased -WBC count increases -Blood glucose decreases
Fetal Response to Labor Closely monitor FHR monitor and intervention appropriately - Chapter 18
Puerperium Period Birth until 6 weeks after
Puerperium Period: Cervical changes soft & easily dilated; Bruised and flabby; External os permanently changed; Dimple to lateral slit
Uterine Involution: Involution rapid reduction in size of uterus - return to pre-pregnant state
Uterine Involution: Exfoliation of placenta site allows for healing and is important part of involution
Uterine Involution:  Exfoliation of placenta site; Enhanced by: uncomplicated labor and birth -complete expulsion of placenta or membranes –breastfeeding
Uterine Involution: Fundal position changes; After delivery of placenta Uterus is Between symphysis pubis and umbilicus
Uterine Involution: Fundal position changes; Within 6 to 12 hours after childbirth Uterus is at level of umbilicus
Uterine Involution: Norms Decreases by one fingerbreadth per day -Descends into pelvis by 10th day - Pre-pregnancy size by 5-6 wks
Documentation: Fundus Firm and midline; Appropriate progression of involution ; Fundal height recorded in fingerbreadths ; 2 FB below (down arrow) U ; Uterus boggy; firm with light massage
Documentation: Lochia rubra red/fresh – day 1-3
Documentation: Lochia serosa pinkish-brown – day 3-10
Documentation: Lochia alba white/yellow – additional wk or 2
Sterilization: Bilateral Tubal Ligation (BTL) – Female Sterilization Fallopian tubes crushed, ligated, banded ; Usually done during postpartum period
Sterilization: Bilateral Tubal Ligation (BTL) – Female Sterilization: Complications: Coagulation burns on bowel -Bowel perforations - Hemorrhage, Infection
Sterilization: Vasectomy - Male Sterilization Surgical severing of the vas deferens in the scrotum– 3 – 36 ejaculations needed to clear the vas deferens ; Alternative birth control required untill then ; 2-3 sperm samples and Rechecked at 6 and 12 months
Sterilization: Vasectomy - Male Sterilization: Side effects pain, infection, hematoma, granulomas
Reproductive Assessment: Breasts; Lactation Initiated by decreased hormones -Initial milk is colostrum ; Prolactin stimulates the production of milk ; Suckling at the breast will continue lactation ; Milk comes in on the 3rd to 5th day
Reproductive Assessment: Perineum ; Lacerations/Tears/ 1st Degree skin
Reproductive Assessment: Perineum ; Lacerations/Tears/ 2nd degree skin & muscle
Reproductive Assessment: Perineum ; Lacerations/Tears/ 3rd degree rectal sphincter involved
Reproductive Assessment: Perineum ; Lacerations/Tears/ 4th degree beyond the rectal sphincter into the rectal wall
Reproductive Assessment: Perineum ; Episiotomy Median or Mediolateral
Evaluation of Episiotomy Healing:R E E D A R- Redness; E- Edema ; E- Ecchymosis ; D- Discharge/ Drainage ; A- Approximation  Initial healing within 2-3 weeks  Completely within 4-6 months
Nutrition: after birth: Increased need for protein -Increased need for iron
Nutrition: Lactation diet Additional 200 kcal above pregnancy requirements ; increase calcium, protein and fluids
Postpartum Weight Loss: Return to pre-pregnancy wt in 6-8 wks -If average wt gain 25 – 30 lbs
Postpartum Weight Loss: Initial loss 10 – 12 lbs - Infant, placenta, amniotic fluid
Postpartum Weight Loss: Puerperal diuresis/diaphoresis 5 lbs - Increased urination, sweating
Comfort/Sleep Interventions Warm bath-Sitz bath-Peri care-Back rub -NSAIDS - Analgesics/Narcotics - PCA
Elimination: Bladder Assessment First void since delivery-Palpate for fullness or distention - Amount of first voiding -Assess for perineal swelling
Elimination: Bladder Assessment: Fundus higher than normal upon palpation;Not in midline; Suspect distended bladder Assist to BR to void ; Reassess uterus ; Unable to void ; In and out cath
Created by: kholman