Maternity Ch 7-8 CCC PN105
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| Types of classes | gestational diabetes; early pregnancy; exercise; infant care; breastfeeding; sibling; grandparent; adolescent; refresher; cesarean; VBAC
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| Ideally, preparing for childbirth begins ____ | before conception
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| Basic class content | pregnancy changes; fetal development; prenatal care; hazardous substances; nutrition; discomforts; exercise; work; labor/delivery coping
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| How childbirth pain is different | Part of normal birth process; several months to prepare; self-limiting and rapidly declines
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| pain threshold | pain perception; failry constant; least amount of sensation that a person perceives as painful
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| pain tolerance | amount of apin one is willing to endure; can change under different conditions
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| primary nursing responsibility regarding childbirth pain | modify as many factors as possible so that the woman can better tolerate labor
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| sources of labor pain | dilation and stretching of cervix; reduced uterine blood supply during contractions (ischemia); pressure of fetus on pelvis; stretching of vagina and perineum
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| Gate control theory | how pain impulses reach the brain for interpretation; pain is transmitted through small nerve fibers, stimulation of large nerve fibers temporarily interferes with pain conduction through small fibers and "closes the gate"
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| gate control theory techniques | stroking or massage; palm and fingertip pressure; heat and cold applications (gripping cool bedrail); foot rubbing; pressure;
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| endorphins | natural body substances similar to morphine; increase during pregnancy and peak during labor
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| why can laboring women often tolerate more pain than usual | increased endorphins and concern for infant's well-being
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| maternal condition during labor | cervical readiness (dilation and effacement); size and shape of pelvis; labor intensity; fatigue
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| how does labor intensity effect labor | short, intense labor is often more painful than gradual birth process
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| how does fatigue effect labor | reduces pain tolerance and ability to use coping skills
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| what are common interruptors of sleep during pregnancy | active fetus, frequent urination, shortness of breath why lying down
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| effect of fetus in abnormal presentation | applies uneven pressure to cervis resulting in less effective effacement and dilation, prolonging labor and delivery
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| fetal occiput in posterior pelvic quadrant pushing again mother's sacrum results in ___ | persistent and poorly relieved back pain, often longer labor
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| interventions that may add to labor pain | IV lines, continuous fetal monitoring, anmniotomy, vaginal exams
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| advantages of nonpharmacological pain management | do not harm mother or fetus, do not slow labor if provide adequate pain control, no risk of allergy or adverse effects
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| types of nonpharmacological pain management | Dick-Read method; Bradley method; Lamaze method; relaxation techniques; skin stimulation; positioning; diverstion and distraction; breathing
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| importance of nonpharmacological pain management | most medication do not eliminate pain and additional methods to manage remaining discomfort are needed
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| Dick-Read method | education and relazation techniques interrupt the fear of childbirth cycle reducing labor pain
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| Bradley method | "husband-coached method"; emphasizes slow abdominal breathing and relaxation techniques
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| Lamaze method | "psychoprophylactic method"; mental techniques that condition woman to respond to contractions with relaxation rather than tension; uses mental and breathing techniques to occupy mind
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| Lamaze techniques | breathing should be no slower than half of baseline respiratory rate and no faster than twice the baseline rate
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| method that is the basis of most childbirth preparation classes in US | Lamaze method
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| relaxation techiniques | require concentration thereby occupying the mind while reducing muscle tension; used in both pharmacological and nonpharmacological pain maagement
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| types of skin stimulation | effleurage, sacral pressure, thermal stimulation
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| effleurage | stimulates the large nerve fibers that inhibit painful stimuli traveling through small nerve fibers; storking abdomen in circular pattern; tracing figure 8 on bed
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| sacral pressure | firm pressure against the lower back; helps with back labor
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| thermal stimulation | heat applied with warm blanket or glove filled with warm water; warm shower; cool cloth on face
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| positioning | frequent changing of position relieves muscle fatigue and strain and promotes labor
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| types of diversion and distraction techniques | focal point, imagery, music, television
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| types of breathing techniques | slow-paced, modified paced, patterned pace
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| technique to use for first-stage breathing | do not use until needed; selected pattern begins and ends with cleansing breath
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| cleansing breath | deep inspiration and expiration, similar to deep sigh
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| slow paced breathing | beginning of first state breathing; slow breathing like during sleep; half the usual respiratory rate
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| modified paced breathing | more rapid and shallow breaths, more more than twice usual rate
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| nursing considerations during modified pace breathing | hyperventilation; watch for dizziness, tingling, numbness around mouth, spasms in fingers and feet; blurred vision
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| patterned paced breathing | "pant-blow" or "hee-hoo" breathing; rapid breaths punctuated with intermittent slight blow - constant and/or stairstep patterns used
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| constant patterned pace breathing | pant-pant-pant-blow; pant-pant-pant-blow; etc
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| stairstep patterned pace breating | pant-blow; pant-pant-blow; pant-pant-pant-blow; etc
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| second stage breathing | used when time to push; cleansing breath, deep breath, and push while exhaling to count of 10; blows out, deep breath, and pushes again while exhaling
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| do not interfere if woman is | successfully using a safe, nonpharmacologic pain control technique
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| measures to correct hyperventilation | slow breathing while exhaling; breathe into cupped hands; moist washcloth over mouth and mose while breathing; hold breath for few seconds before exhaling
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| in using analgesia and anesthesia, the pregnant woman is at higher risk for hypoxia due to | pressure of enlarging uterus on diaphragm
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| in using analgesia and anesthesia, the pregnant woman is at higher risk for vomiting and aspiration due to | sluggish GI tract
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| in using analgesia and anesthesia, the pregnant woman is at higher risk for aortocaval compression due to | hypotension and development of shock
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| limitations of pharmacologic pain management | effect and impact on fetus must be considered
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| advantages of pharmacologic pain management | allows mother to be more comfortable and relaxed; increased relaxation aids in ability to participate in care
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| types of pharmacologic pain management | narcotic (opiod) analgesic; narcotic antagonist; adjunctive drugs
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| most common type of labor analgesia in US | systemic opiods (narcotic analgesics)
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| in using narcotic analgesics _____ | avoided if birth expected with 1 hr; only small doses given to prevent fetal respiratory depression
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| narcotic antagonist | reverses respiratory depression, usually in infant, caused by opiod drugs (not effective for other causes)
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| type of narcotic antagonist | Narcan (naloxone)
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| adjunctive drugs | enhance pain-relieving action of analgesic and reduce nausea
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| types of adjunctive drugs | Vistoril, Phenergan
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| regional analgesics and anesthetics | placement of an anesthetic in the epidural or subarachnoid space of spinal cord
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| epidural block | provides analgesia and allows woman to ambulate with assistance; must have good blood counts; give 500mL Ringers solution immediately prior; constantly infused or intermittently repeated
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| regional anesthetics block _____ | sensation to varying degrees, depending on type of block used, quantity of medication, and drugs injected
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| subarachnoid (spinal) block | "one shot" block; provides analgesia but prevents ambulation; does not place catheter for reinjection; not used for vaginal births
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| types of regional anesthetics | local infiltration; pudendal block, epidural block; subarachnoid (spinal) block
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| types of analgesics given right before delivery, do not help with contraction pain | local infiltration and pudendal block
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| adverse effects of epidural | maternal hypotension and urinary retention (palpate bladder q2h)
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| adverse effects of subarachnoid (spinal) | maternal hypotension and urinary retention (palate bladder q2h); postspinal headache due to spinal fluid loss
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| treatment of spinal headache | bed rest, analgesics, oral and IV fluids; blood patch if necessary
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| uses for general anesthesia | emergency cesarean; cesarean birth in woman who refuses or has contraindication to epidural or subarachnoid block; always presume mother has fullo stomach
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| general anesthesia adverse maternal effects | reguritation with aspiration; chemical injury to lungs; aspiration pneumonia
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| general anesthesia adverse neonate effects | respiratory depression is main risk
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| nurse role in pharmacoloic techniques | begins at admission; question about allergies to food and drugs; pain relief preferences; observe for hypotension if block is given
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| if pain relief drugs are given _______ | keep side rails up for safety
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| amnioinfusion | injection of warmed sterile saline or lactated Ringers solution into uterus via intrauterine pressure catheter during labor after membranes have ruptured
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| indications for amnioinfustion | oligohydramnios (lower than normal amniotic fluid); umbilical cord compression; to reduce recurrent variable decelerations of fetal heart rate; to dilute meconium stained amniotic fluid
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| purpose of amnioinfusion | to replace the cusion for the umbilical cord and relive variable decelerations of the fetal heart rate during contractions with decreased amniotic fluid
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| nursing considerations during amnioinfusion | continuous monitoring of uterine activity and fetal heart rate (not below 110 or above 160); change underpands on bed as needed; document color, amount and odor from expelled fluid
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| amniotomy | artificial rutpure of amniotic sac (AROM) by using a sterile sharp instrument to stimulate contractions
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| effects of amniotomy | stimulates prostaglandin secretion which stimulates labor but can result in umbilical cord compression
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| amniotomy technique | disposable plastic hook is passed through cervix and amniotic sac is snagged to create hole to release fluid
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| complications of amniotomy (or from spontaneous rupture SROM) | prolapsed cord; infection; abruptio placentae
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| cord prolapse | umbilical cord slips downward with the gush of amniotic fluid
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| infection from amniotomy | membranes no longer block vaginal organisms from entering uterus; delivery must be within certain time frame
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| amniotomy and abruptio placentae | more likely to occur if uterus is overdistended with amniotic fluid prior to rupture of membranes
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| nursing considerations of amniotomy | observe for complications; record fetal heart rate for minimum 1 min; color, odor, amount of fluid; remp taken q2-4h; change underpads often to prevent growth of microorganisms
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| cloudy, yellow, or malodorous fluid | suggests infection
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| green fluid | fetus passed first meconium; associated with fetal compromise and distress
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| induction of labor | intentional initiation of labor before it begins naturally
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| augmentation of labor | stimulation of contractions after they have begun naturally
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| considerations prior to induction | fetal maturity and status of cervix
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| Bishop score | used to assess status of cervix in determining its response to induction; 6+ is favorable
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| nursing considerations during labor induction | continuous monitoring of uterine activity and fetal heart rate
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| indications to induce labor | hypertension, ruptured membranes, uterine infection, worsening medical problems, fetal problems, placental insufficiency, fetal death
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| contraindications to labor induction | placenta previa, cord prolapse, abnormal fetal presentation, high station of fetus, active herpes infection, abnormal size/structure of pelvis, previous classic cesarean incision
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| pharmacological methods to stimulate contractions | cervical ripening, oxytocin administration
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| cervical ripening (Cervidil) | prostaglandin gel softens the cervix prior to induction; after insertion woman remains on bed rest 1-2h and uterine contractions monitored to watch for uterine hyperstimulation
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| uterine hyperstimulation | contractions longer than 90s, more than 5 contractions in 10m
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| oxytocin administration | most common method of induction and augmentation; in diluted IV solution; begins at low rate and is adjusted up or down according to fetal response to labor; dose is individual to every woman
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| nonpharmacological methods to stimulate contractions | walking, nipple stimulation
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| walking to stimulate labor | stimulation of contractions, eases pressure of fetus on back, adds gravity to downward force of contractions
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| nipple stimulation to stimulate labor | causes posterior pituitary to naturally secrete oxytocin; pull/roll, brush with dry washcloth, water in whirlpool tyb/shower, suction with breast pump
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| augmentation complications | most common complication is overstimulation of contractions leading to fetal compromise and uterine rurpure; impairment of placental exchange; water intoxication
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| evidence of excessive uterine contractions | frequency greater than every 2m, duration longer than 90s, resting intervals shorter than 60s
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| nursing considerations during induced/augmented labor | signs and symptoms of increased uterine activity; monitor fetal heart rate every 15m during active labor and every 5m during transitional phase; monitor BP, pulse, respirations every 30-60m, temp q2-4h, intake and output
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| version | method of changing fetal presentation from breech to cephalic
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| version methods | external and internal, external is more common
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| risks and contraindications of version | fetus becoming entangled in cord and cord compression
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| external version technique | done after 37 eks but before labor; physican pushes fetal buttocks up out of pelvis while pushing fetal head down toward pelvis in clockwise/counterclockwise turn
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| internal version technique | emergency procedure usually performed to change position of twins for second twin birth
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| episiotomy | surgical enlargement of vagina during birth
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| laceration | uncontrolled tear of tissues that result in jagged wound
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| types of episiotomies | first, second, third, and fourth degree
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| first degree episiotomy | superficial vaginal mucosa or perineal skin
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| second degree episiotomy | vaginal mucosa, perineal skin, deeper tissues of perineum
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| third degree episiotomy | same as second but also involves anal sphincter
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| fourth degree episiotomy | extends through anal sphincter into rectal mucosa
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| third or fourth degree episotomy considerations | no enemas or suppositories; high fiber diet, stool softeners, and adequate fluids to prevent constipation
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| indications for episiotomy | better control over where and how much vaginal opening is enlarged; clean edge rather than ragged tear
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| episiotomy techniques | midline (median) and mediolateral
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| midline episiotomy | extends directly from lower vaginal border toward anus; heals easier and easier to repair
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| mediolateral episiotomy | extends from lower vaginal border toward mothers right or left
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| nursing care for episiotomy | cold packs for first 12h to reduce pain, bruisin, and edema; sitz bath to increase blood circulation for comfort and healing; dermaplast spray to cool area
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| forceps and vacuum extraction | provides traction and rotation to fetal head when mothers pushing efforts are insufficient to accomplids a safe deliver
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| forceps | instrument with curved blades that fit around fetal head without unduly compressing it
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| vacuum extractor | suction applied to fetal head so the physican can assist the mothers expulsive efforts
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| indications for use of forceps or vacuum | to end second stage labor if in best interest of mother or fetus; cervis must be fully dilated, membranes ruptured, bladder empty, and fetal head engaged at +2 station
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| risks of forceps or vacuum | trauma to maternal or fetal tissues is main risk; laceration or hematoma in vagina; vacuum causes harmless circular edema on fetal scalp
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| concern with forcep or vacuum marks on infant | reassure parents that marks are temporary and usually resolve without treatment
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| nursing care for forceps or vacuum | care is similar to episiotomy and perineal lacerations; infant head examined for lacerations, abrasions, bruising; infant facial asymmetry from forcep pressure
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| cesarean birth | surgical delivery of fetus through incisions in mothers abdomen and uterus
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| indications of cesarean birth | abnormal labor; inability of fetus to pass through pelvis; maternal conditions such as hypertension or diabetes; active herpes; previous uterine surgery; fetal compromise; placenta previa; abruptio placentae
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| maternal risks of cesarean birth | anesthesia; respiratory complications; hemorrhage; blood clots; urinary tract injury; delayed intestinal peristalsis; infection
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| newborn risks of cesarean birth | inadvertent preterm birth; respiratory problems; injury
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| cesarean births can be _________ | planned, unplanned, or emergency
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| types of cesarean incisions | vertical or transverse skin incisions; low transverse, low vertical, or classic uterine incisions - uterine incision is most important
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| vertical skin incision | allows more room, done faster for emergencies
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| transverse skin incision (Pfannenstiel) | nearly invisible when healed; cannot always be used in obese women or for large fetus
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| low transverse uterine incision | preferred; not likey to rupture during another birth, causes less blood loss, easier to repair; VBAC possible
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| low vertical uterine incision | minimal blood loss and allows delivery of large fetus; more likely to rupture during another birth
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| classic uterine incision | rarely used; more blood loss and most likely to rupture during another pregnancy
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| cesarean sequence | spinal anesthetic given; mother scrubbed and draped; physician makes skin incision and then uterine incision and ruptures membranes; lift out fetal head or buttocks; infant mouth and nose are quickly suctioned; cord is clamped
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| nursing considerations for cesarean birth | mother needs greater emotional support due to grief, guild, or anger and change of expected outcome; feeling may resurface during another pregnancy
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| recovery room assessments for cesarean birth | vital signs to identify hemorrhage or shock; IV site and rate of solution flow; fundus (GENTLY!) for firmness, height, and midline position; dressing for drainage; lochia (bleeding) quantity, color, and clot presence; urine output from catheter
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| assessing uterus after cesarean important because __________ | causes much discomfort, but can determine relaxed uterus that causes excessive blood loss
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| abnormal labor (dysfunctional labor) | does not progress
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| dystocia | difficult labor
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| four Ps of labor | abnormalities in Powers, Passengers, Passage, Psyche
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| risk factors in dysfunctional labor | advanced maternal age, obesity, overdistention of uterus, abnormal presentation, CPD, overstimulation of uterus, maternal fatigue/dehydration/fear, lack of analgesia
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| hypertonic labor dysfunction (Powers) | caused by frequent cramplike poorly coordinated contractions; increased muscle tone; during latent phase; painful but not productive; leads to reduced bloodflow to placenta
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| hypotonic labor dysfunction (Powers) | labor begins normally but diminishes during active phase; decreased muscle tone; more like to occur if overdistended; stretched muscle finbers have reduced ability to contract effectively
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| ineffective maternal pushing | may not understand proper technique
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