| Question | Answer |
| What are the preliminary signs of labor? | Lightening
Increase in level of activity- “Nesting”
Braxton Hick’s contractions
Ripening of the cervix
Slight weight loss |
| What are the signs of true labor? | Regular uterine contractions every 3-5 minutes apart
Dilating
Bloody show (pink tinged)
Rupture of membranes (ROM)
Lower back ache sweeps to abdomen |
| What are the signs of false labor? | Contractions stop with ambulating or sleep
No cervical dilation
Patient comfortable |
| What are the 4 components of labor? | Passage-pelvis
Passenger-baby
Power-contractions
Psyche-mom’s behavior |
| “male pelvis” pubic arch is at an angle, fetus will have difficulty coming out. | Android pelvis |
| “ape-like” narrow, transverse and the fetal head will not fit | Anthropoid pelvis |
| “normal” well rounded all around, pubic arch is wide. | gynecoid pelvis |
| “flattened” oval, if posterior presentation, might not allow head to rotate | Platypelloid |
| Change in the shape of the head, Bones overlap, Not a permanent condition
Common after birth | Molding |
| describes the degree of flexion a fetus assumes during labor or the relation of the fetal parts to each other. | fetal attitude |
| vertex means | complete flexion, baby is chin is tucked to chest |
| military means | position moderate flexion, baby is coming down and chin is not touching chest |
| Brow means | position partial extension, brow is coming through first |
| face means | complete extension, face is showing, neck is completely extended, could break baby's neck, need C/S! |
| settling of the presenting part into the pelvis at the level of the ischial spine | engagement |
| the relationship b/n the long axis of the fetal body and the long axis of the woman’s body. | fetal lie |
| the relationship of the presenting part of the fetus to the level of the ischial spines. | Station |
| 0 station means | baby's head is at the ischial spine |
| - station means | baby is above the ischial spine |
| + station means | below the ischial spine |
| If the baby is "floating" what station is it at and what could be the complication? | baby is at - station and the umbilical cord could prolapse which is an emergency |
| fetal head is the body part that first contacts the cervix. | Cephalic presentation |
| buttocks or feet are first body part in contact with the cervix. | Breech presentation |
| fetus lying horizontally in the pelvis | Shoulder presentation |
| Cephalic-vertex-occiput all refer to | the head presenting first |
| The fetal position includes what 3 factors? | Maternal pelvis (L,R,T)
Fetal landmarks (O,M,S,A)
if the baby is Ant or Posterior (A,P) |
| Abdominal palpation to assess presentation and position of the fetus in utero. | Leopold's Maneuver |
| 0-10 cm. 3 phases: latent, active, transition | stage one |
| complete dilation and pushing to delivery | stage two |
| delivery time to placental delivery time | stage three |
| first four hours after the placenta is delivered | stage four |
| shortening and thinning of cervix | effacement |
| the enlargement of the cervix from 0-10 cm | dilation |
| This accompanies dilation | bloody show |
| What is the care for a woman in the first stage of labor? | Respect contraction time
Promote changes in position
Promote voiding,Offer support, Amniotomy
Early labor the patient can eat, drink and rest, Active labor only ice chips or clear liquids |
| Why would you not want to perform an amniotomy if the baby is in negative station? | if you rupture them membrane the umbilical cord may prolapse |
| What are the nursing measures for a woman in the latent phase? | Vitals every 4 hours, Contractions & Fetal Heart Rate every 30 minutes, Pain scale with vitals, Patient may walk, be active, Aromatherapy, distraction techniques |
| What meds can be given in the latent phase? | Sedatives for brief sleep/rest periods
Ambien: Use only when birth is 12-24 hours away |
| Sedating the mom and if she were to deliver quickly after | then be prepared to resuscitate a sleepy baby |
| What are the nursing measures for the active phase? | Administer epidural, Nubain or Stadol
Vitals every 30 minutes along with EFM status, Position changes every 2 hours
Comfort measures: pillows b/n knees, back rubs, ice chips, Void every 2 hours, Rupture membranes if engaged fetus, Increased show |
| What is the nursing care after an amniotomy? | Must check fetal heart rate immediately after rupture, Temperature every 2 hours, Chart, date, time and color
Nitrazine paper, Alkaline >6.5, Fern test, COAT (color, odor, amount, time) |
| After an amniotomy what color should the liquid be? | clear, yellow=blood incompatibility, green= meconium stained |
| What are the functions of the amniotic fluid? | Maintain temperature/prevents heat loss
Source of oral fluids, Barrier to infection, Permits normal fetal lung development and symmetrical growth |
| What are the nursing measures in the transition phase? | Calm mom down if able
Prepare for delivery
Keep informed of progress
Encourage to rest in b/n ctx’s
Cool wash cloth to forehead
Keep bladder empty
No pushing until pt is complete |
| What happens in the second stage of labor? | Complete dilatation to birth of the baby
Changes in the contraction patterns
Uncontrollable urge to push
Baby putting pressure on the rectum
Presenting part descends with pushing
Perineum begins to bulge
Crowning |
| What is the care of the woman in the second stage of labor? | Position mom for birth
Promote second stage pushing
Support
Perineal cleaning
Episiotomy
Birth |
| What happens in the third stage of labor? | Delivery of the placenta
5-30 minutes
Contractions are mild which aids in separating the placenta from the uterus.
Stitching may occur.
Shiny schultze on the left and dirty duncan on the right.
Patient bears down and the placenta delivers. |
| What are the signs of placental separation | Appear about 5 minutes after delivery
Rise of the fundus in the abdomen
Sudden gush or trickle of blood
Further protrusion of the umbilical cord
Normal length of time for separation is 5-30 minutes |
| How do you care for the woman in the third stage | Start oxytocin after delivery of the placenta
Perineal repair if needed |
| How do you care for the woman in the fourth stage? | Assessment of mom’s fundus, lochia, etc
Encourage bonding with the baby
Increase fluids, offer regular diet |
| What are the advantages of an epidural? | Causes relaxation, labor progresses
Pain free delivery
Preserves maternal energy
Minimal affect on the fetus
May decrease the length of labor
Able to labor down |
| What are the disadvantages of an epidural? | Hypotension to mom and eventually the fetus also
Can slow the second stage pushing
Decrease the urge to push
Decreases the urge to void
“Hot spot” |
| What is the nursing care for a mother getting an epidural? | Obtain consent from patient,Educate mom on the procedure, 1000ml LR IV bolus, Continuous EFM- observe the FHR throughout the procedure and afterwards,Vital signs q 1min-15min (ephedrine available, Foley placed after patient comfortable |
| What are the potential complications of a spinal or epidural? | spinal headache, so apply a blood patch |
| What are the indications of a C section | Malpresentation (CPD, breech)
Complete placenta previa/abruption
Fetal distress
Chronic maternal conditions
Failure to progress
Repeat cesarean section
HIV or HSV positive
Classical uterine incision on uterus |
| What is the pre-op nursing care for a mom going in for c-section? | Assessment of mom and baby
Pre-op Teaching
Foley Catheter
Abdominal Shave Prep
IV #18 and a 1000ml bolus
Obtain consent
NPO at least 4-8 hours prior |
| What are the two types of skin incision? | Transverse or Pfannensteil “bikini cut” and
Vertical |
| What are the two types of uterine incision? | Classical and transverse |
| Always have to have a cesarean and risk uterine rupture if go into labor if they get a | classical uterine incision |
