Intrapartum
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| Powers | 1. Uterine Contractions (Primary) 2. Abdominal Muscles (Secondary)
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| Contraction Frequency | Beginning of one contraction to the beginning of the next contraction.
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| Cephalic Fetal Presentation | Vertex, Military, Brow, Face
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| Factors Influencing Response of Mom | Cultural values and beliefs, Previous childirth experience, Anxiety and fear, Support from significant other, Childbirth education classes.
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| Positions of Mother During Labor | Upright, Knee-Chest, Semi-recumbent, Squat-stand, Lateral
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| Causes of Labor | 1. Normally occurs during the 38th-42nd week
2. Progesterone-smooth muscle relaxation
3. Estrogen-stimulates uterine muscle contractions
4. Connective tissues loosens-softening and thinning of cervix
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| Process of Labor: Myometrial Activity | 1. Physiologic Retraction Ring
2. Effacement: shortening and thinning of the cervix 0-100%
3. Dilation: enlargement or widening of the cervical opening (closed-10cm)
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| Mechanisms/Cardinal Movements of Labor | Engagement, Decent, Flexion, Internal Rotation, Extension, Restitution, External Rotation, Expulsion.
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| What are the 3 phases of the first stage of labor? | 1. Latent Phase: 1-3cm
2. Active Phase: 4-7cm
3. Transition Phase 8-10cm
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| Second Stage of Labor | Full dilation to the delivery of baby.
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| Third Stage of Labor | Birth of baby to delivery of placenta
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| Fourth Stage of Labor | First 1-2 hours after birth
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| Factors that Influence the Duration of Labor | 1. Parity (#of times you have been pregnant)
2. Shape and size of pelvis
3. Position and size of fetus
4. Strength and effectiveness of contractions
5. Maternal emotions
6. Position and level of activity of mom
7. Medications: i.e. epidural
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| Assessment-Signs preceding labor | Lightening, Braxton Hicks, Cervixs Softens (ripens), Bloody Show, SROM-spontaneous ruptur of membranes, Burst of energy-nesting, GI symptoms.
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| What is the "Bloody Show"? | Loss of mucus plug. May occur before labor starts or during early labor.
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| True Labor | Regular progressive contractions, Increase in frequency, duration and intensity of contractions, Resulting in effacement and dilation of the cervix, Do not disappear with activity.
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| False Labor | Occur at irregular intervals, Do not increase in duration, intensity or frequency, Do not result in effacement or dilation, Disappear with activity.
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| Hospital Admission Assessment of Mother | # of weeks gestation, Gravida, Para, Onset of Labor, frequency of contractions, Status of membranes (ROM)- date/time; color/odor, Cervical dilation and effacement, VS, Fetal Heart Rate, Comfort Level, Prenatal Hx-pregnancy & Medical complications.
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| Hospital Admission Assessment of Mother Continued... | Birth plans, infant feeding plan, Labs-blood type & Rh factor, GBS, Medications-legal/illegal; currently taking, Time last ate.
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| Hospital Admission Assessment of Fetus | Fetal Heart Rate (FHR): 110-160 bpm, Leopold's Maneuvers, Auscultation-doppler, fetoscope, Electronic Fetal Monitoring (external, internal, fetal heart rate recognition).
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| Internal Fetal Monitoring Options | FSE- Fetal Scalp Electrode, Intrauterine Pressure Catheter (IUPC)
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| Fetal HR Patterns | Baseline Rate: 110-160 bpm, Bradycardia: <110 bpm x 10min, Tachycardia: >160 bpm x 10min, Baseline Variability: Absent-undetectable (minimal ≤5 bpm, moderate 6-25 bpm, marked >25 bpm).
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| FHR Variability | -Decreased (Absent or minimal) (Hypoxia, CNS depression, narcotics, fetal sleep, congenital anomolies), Increased (Moderate or Marked)(Mild hypoxia, contractions, mom activity, fetal stimulation (vag exams).
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| Causes of Bradycardia | Clenched cord
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| Causes of Tachycardia | If mother has fever, anxiety, dehydration, certain medications.
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| Acceleration | -abrupt increase in FHR ≥15bpm over baseline FHR for ≥15 sec and <2min, Normal with fetal movement and contractions, Not normal if FHR doesn't return to baseline and sustains tachycardia.
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| Deceleration | Early-head compression, Late-uteroplecental insufficiency, Variable-cord compression, Prolonged-abrupt decrease in FHR below baseline ≥15bpm lasting ≥2 min but ≤10 min.
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| Early Decelertaions: Causes & What to do | caused by head compression, occur at peak of contraction, benign, seen with pushing, monitor for changes in FHR.
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| Variable Decelerations: Causes & What to do | caused by cord compression, occur randomly, not normal, change maternal position to L or R side, monitor FHR, turn off Oxytocin/pitocin PRN, perform vag exam for prolapsed cord and progress of dilation.
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| Late Deceleration: Causes & What to do | caused by uteroplacental insuffiency, occur at peak or after contraction, not normal, turn mom to L side, IV hydration, O2 at 8-10L/min prn, turn off oxytocin/pitocin prn, assess for hypotension, notify MD/CNM.
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| NICHD | NICHD-National Institute of Child Health and Human Development-standardized language for FHR interpretation
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| 3 Tier FHR Interpretation System (Category I) | Category I: Normal-baseline 110-160, variability moderate, no late or variable decels, early decels and accels absent or present.
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| 3 Tier FHR Interpretation System (Category II) | Category II: Indeterminate-bradycardia with variability, tachycardia, minimal variability, marked variability, No accels after fetal stimulation, reccurent variables, prolonged decels, recurrent late decels.
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| 3 Tier FHR Interpretation System (Category III) | Category III: Abnormal-recurrent late decels, recurrent variable decels, bradycardia, sinusoidal pattern.
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| Interventions for NICHD Criteria For Each Category | Category I - Normal FHR-continue auscultation and palpation or EFM,
Category II Indeterminate FHR-increase auscultation frequency, initiate some or all intrauterine resuscitation, Category III Abnomal FHR-maintain continuous EFM, intrauterine resusitatio
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| Intrauterine Resuscitation Measures | -Change Maternal Position, administer O2 8-10 L/min via mask, IV hydration (at least 500ml LR), Notify MD or CNM for bedside consultation, consider amnioinfusion if ordered, assess uterine activity, perform vag exam, consider tocolysis, prepare 4
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| Latent Phase | *Onset of Labor to full dilation*
1. Latent phase-begin of labor-3cm, contractions mild, regular, q 10-20 min x 15-20 sec ---> q5-7 min x 30-40 sec, Length 8-20 hours, Mom usually excited and sociable.
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| Active Phase | 4cm to 7cm, Effacement complete, descend beginds, contractions mod, regular, increase freq and duration; q3-5 min x 40-70 sec, Length 1-2 hours, Mom more uncomfortable and inward focused.
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| Transition Phase | 8-10cm, intense contractions, q 2-3min x 60-90 sec, length 1-3 hours, mom may be irritable, n&v, leg tremors, may have urge to push, "can't do this".
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| Assessment During 1st Stage of Labor | Continue assessment of contractions, FHR, V/S. pain & support to mom. How often to assess: Latent Phase -q 30-60 min, Active Phase -q30 min, Transition Phase- q 15 min.
*Change frequency as risk factors present*
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| Assessment of Progress of Labor | Status of membranes & Vaginal Exams.
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| ROM-Rupture of Membranes | SROM may occur before labor or during stage 1 or 2, Tests: Nitrazine paper turns blue when in contact with amniotic fluid, Fern test-ferning pattern of fluid in presence of amniotic fluid, PROM rupture > 18 hours, risk for infection.
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| Nursing Care During The Latent Phase | Establish trusting relationship, provide support/encouragement, teaching/anticipatory guidance, Check FHR and contractions q 30-60min, mom's v/s q 30-60min, moms temp q2hr if ROM, ambulate ad lib, void q2-3hr, clear liquids, ice chips.
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| Regional Anesthesia | 1. Epidural 2. Spinal (Advantages: good pain relief, mother awake and alert, partial motor paralysis, dose may be modified)
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| Nursing Care During The Active Phase | Be available, provide support/encouragement, change breathing patterns, non-Pharmacologic measures-therapeutic touch, distractions, imagery, focal point, hypnosis, aroma tx, accupressure, position changes, birthing balls, tub/shower, backrub, medication.
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| Pain During Labor & Delivery | Pain 1st stage due to cervical dilation, Pain in 2nd stage due to stretching of vagina/perineum, Contractions-intermittent, begins in back, radiates over entire abdomen, diminishes during rest period.
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| Pain During Labor & Delivery | Lower uterine and pelvic pressure- nerves & organs compressed; tissue stretched, Pressure can extend pain into rest periods.
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| Management of Discomfort | Childbirth education, water,position change, effleurage, hypnosis, acupuncture, TENS, nitrous oxide, medications: nubain, stadol, demerol, Anesthesia: epidural, spinal, general.
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| Pharmacologic Measures | (ALL systemic drugs cross placental barrier)
RISKS: to early in labor=depression of labor, to late in labor=newborn respiratory depression at birth. Narcotics-Demerol; Sublimaze are short acting, may cause respir. depres. in newborn if to close to birth.
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| Pharmacologic Measures Continued.... | Agonist-Antagonist Compounds-Nubain, Stadol-less respiratory depression in NB.
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| Regional Anesthesia-Advantages | Epidural or Spinal Advantages: good pain relief, mother awake and alert, partial motor paralysis (epidural), dose may be modified.
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| Regional Anesthesia-Disadvantages | Disadvantages: must have IV, severe maternal hypotension, may slow labor progress (impede fetal decent & pushing, statistically increases c/s rate, increase need for pitocin and vacuum and urinary retention.
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| Nursing Care with Epideral | Start IV, give bolus as ordered-500-1000mL Lactaid Ringers, Assist with positioning, Monitor maternal hyportension (Ephedrine must be available, Have O2 available, Monitor FHR, Monitor contractions, Assess for bladder distention).
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| General Anesthesia | Use only in emergency, Serious respiratory depression in newborn
80% of obstetric anesthesia related mortality associated with obesity.
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| Nursing Care During The Transition Phase | Listen to PT, Provide praise, Encourage support person participation, Avoid hyperventilation, Cannot push until fully dilated, Change of breathing patterns-pant/blow.
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| Nursing Care-2nd Stage of Labor | Encourage Rest, Labor down-wait for urge to push, Provide emotional support, Use gravity position, Open glottis with pushing, Pushing before 10cm = cervical edema or laceration, Usually > parity = < time to push
Controlled delivery = < perineal laceratio
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| Pushing | Open glottis, Pant/blow to slow or stop pushing, Head crowns then recedes.
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| Episiotomy/Lacerations | Episiotomy ( 1. midline 2. Mediolateral)
Lacerations (1st through skin, not muscle, 2nd through muscle, 3rd through anal sphincter muscle, 4th involves anterior rectal wall.
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| Immmediate Care of Newborn | Suction as necessary, Wipe dry and put skin to skin, APGARS @ 1 and 5 minutes: HR, Resp. rate, muscle tone, reflex irritability, color, Score 0-10, 7-10 - no intervention, 4-6-stimulate, O2, 0-3 full resuscitation.
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| Nursing Care During 3rd Stage of Labor | Birth of Baby to Birth of Placenta: Look for signs of placental separation: uterus becomes globular shaped, umbilical cord becomes longer, sudden gush of blood. Considered retained if more than 30 min, repair episiotomy/laceration prn, palpate fundus, Med
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| Types of Pelves | Gynecoid-round, android-heart-shaped, anthropoid-oval, platypelloid-flattened round.
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| Fetal Attitude | The relationship of the fetal body parts to each other. Normal=flexion of the head, arms to chest, and legs to abdomen.
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| Labor Nurse | On monitor tracing the nurse will document: vag exam, ROM, V/S (maternal), maternal position or changes, application of internal monitoring systems, O2 administration, fetal scalp stimulation, vomiting, pushing, meds.
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| Nursing Diagnoses | -acute pain r/t contractions +/or perineal pressure
-impaired gas exchange (fetal) r/t altered placental perfusion or cord compression
-anxiety r/t situational crisis, threat to self or fetus
-deficient knowledge: l&d r/t lack of exposure, experience
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| Nursing Diagnoses Continued.... | -impaired urinary elimination r/t compression of bladder, regional anesthesia
-risk for individual ineffective coping r/t pain, lack of support
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| Regional Anesthesia Disadvantages | Disadvantages: must have IV, severe maternal hypotension, may slow labor progress-iimpede fetal descent, may impede pushing, statistically increases c/s rate, increase need for Pitocin and vacuum, urinary retention
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| Delivery | Head is supported as shoulder is delivered. Cords-nuchal cord can be around neck, true knot.
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| 5 "P"s of Labor | 1. Passageway 2. Passenger 3. Powers 4. Psychological Response 5. Position of Mother
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| Fetal Lie | Relationship of the long axis of the fetus to the long axis of the Mom.
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| Biparietal Diameter | The diameter of the fetal head as measured from one parietal eminence to the other.
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| Sutures in Fetal Head | Sagital, Coronal, Lambdoidal
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| Fontanelles | Anterior & Posterior
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| Fetal Presentation | Presenting part which first enters pelvis.
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| Breech Fetal Presentation | Complete, frank, footling
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| Nursing Care During 4th Stage of Labor | *First 1-2 hours after Birth*; Stabilize mother and baby-assess fundus, lochia, perineum, v/s q 15min x4; q 30 min x2; q 1hr x2; encourage voiding; provide warm blanket for mom "Shaking chill"; Newborn v/s & maintain temp;facilitate attachment/bonding.
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| EBL | Estimated blood loss; Normal amount vaginally=500mL; C-Section=1000mL
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| Methods to Induce Labor | Amniotomy, Cervical ripening agents, Oxytocin
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| Bishops Scale Assessment for Readiness to Induce | Dilation, Effacement, Station, Cervical Consistency, Cervical position.
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| Partically Compensatory Nursing System | Electronic Fetal Monitoring, Pain Management, Induction of Labor, Medical Treatment Assistance, Commonly Occurring Health Deviations.
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| Amniotomy | AROM- Artificial Rupture of Membranes; purpose is to induce labor or augment if slowing; commitment to birth within 18 hours; fetus should be engaged; immediately check FHR; noted color & ordor; After AROM check mom's temp q2h.
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| Why encourage Voiding after delivery | A full bladder will prevent the firmness of the fundus/uterus; void within 4-8 hours after birth; woman who have c-section will have Foley.
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| Purpose of Cervical Ripening Agents | To soften and thin the cervix to facilitate induction with Oxytocin.
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| When are Cervical Ripening Agents Used? Different types? | Used prior to induction. Ex: Protaglandin E2 gel or insert (Cervidil Misoprostil).
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| What is Oxytocin/Pitocin? | A hormone produced by the posterior pituitary gland that causes uterine contractions.
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| How much Oxytocin/Pitocin should be given? | 10 units in 1000mL IV solution via piggy back on pump.
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| What to Assess during Pitocin Induction... | Frequently assess FHR pattern, Mom's v/s, contraction pattern and resting tone, I&O; In case of emergency- discontinue pitocin, turn mom on left side and give O2.
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| What is an Amnioinfusion? | Internal supplementation of amniotic fluid.
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| What is Tocolysis? | Medication to stop preterm labor.
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| Forceps | Instrument to assist extraction of baby.
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| What is External Cephalic Version? | An attempt to turn breech baby to vertex. Breech babies have an increased risk of birth trauma and prolapsed cord. This is done at 36-38 weeks, head not engaged, not in labor.
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| Side Effects of Cervical Ripening Agents | N/V, diarrhea, hypotension, hyperstimulation of uterus, fetal passage of meconium.
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| Antenatal Glucocorticoids | Betamethasone & Dexamethasone-given to mother to promote fetal lung maturity. Given between 24-34 weeks when in preterm labor.
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| Risks of Using Forceps | Facial lacerations/edema, facial bruising, transient facial paralysis, lacerations to birth canal, extension of episiotomy to anus, bruising & bleeding.
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| Risks during Vacuum Extraction | Cephalohematoma, Head bruising and edema, lacerations.
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| When are Forceps Used? | 2nd stage exhaustion, fetal distress, strong epidural.
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| Dystocia | Long, difficult or abnormal labor.
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| Causes of Dystocia | Powers-uterine dysfunctional labor; Passageway-alteration in pelvic structure; Passenger-fetal-malposition, malpresentation (breech, face), abnormalities, multi-fetal; Position-psychological of mom.
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| When is Dystocia Suspected? | When lack of progress in effacement, dilation or descent.
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| What is dysfunctional labor? | Abnormal contractions-fail to dilate, efface, descend
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| Classifications of Dysfunctional Labor | Hypertonic, Hypotonic, Prolonged, Precipitous.
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| What is Hypertonic Labor? | Painful frequent contractions in latent phase. Contractions are irregular, short, poor quality and ineffective. Contractions originate in mid section of uterus.
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| Maternal and Fetal Risks of Hypertonic Labor | Maternal Exhaustion, increased discomfort. Fetal stress, increase pressure on head.
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| Treatment for Hypertonic Labor | Sedation, pharmacologic treatment and hydration.
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| What is Hypotonic Labor? | During Active Phase-contractions become weak and ineffective; <2-3 contractions in 10 min.
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| Maternal and Fetal Risks of Hypotonic Labor | R/O CPD or fetal malposition; Maternal exhaustion, stress, postpartum hemorrhage. infection if have PROM.
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| Treatment for Hypotonic Labor | Ambulation, AROM, Oxytocin.
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| Cephalopelvic Disproportion (CPD) | Large size fetus or small or contracted pelvis. Usual fetal size of over 4000gms. Macrosomia due to maternal diabetes, obesity, multiparity, or large parent.
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| What is Fetal Malposition? | Persistent Occiput Posterior Position (OP)-fetal occiput directed toweard back of maternal pelvis.
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| Risks of Fetal Malposition | Severe maternal back pain, hypotonic labor.
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| Treatment of Fetal Malposition | Maternal position change to rotate fetus, pelvic rocking, knee-chest position.
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| Cesarean Section Birth Facts | 33% national rates (2012); Risen 56$ since 1996; VBAC trial of Laboe (TOL) 60-90% success.
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| Indications that a C-Section is needed | Fetal distress, CPD, malpositions, cord prolapse, multiple gestation. Mom-preeclampsia/HELLP, HSV, HIV, DM, elective cesarean, placenta previa, dysfunctional labor.
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| Cesarean Section Incision | Low lying/transverse are preferred. Results in less blood loss, decrese in infections, decrease in subsequent uterine ruptures, candidate for VBAC. Type of uterine incision determines future pregnancy delivery options.
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| Risks of VBAC | Uterine rupture
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| Shoulder Dystocia | Head is born but the anterior shoulder cannot pass under the pubic arch.
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| Complications Related to Shoulder Dystocia | Fetal death, fetal asphyxia, clavical fx, brachial plexus injury.
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| Interventions for Prolapsed Cord | Call for assistance, relieve pressure, O2, cover cord, continue to monitor FH, c/s stat.
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| Signs of Shoulder Dystocia | Turtle sign, external rotation doesn't occur.
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| McRobert's Maneuver | Suprapubic pressure
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| Prolapsed Cord | Umbilical cord precedes fetal presenting part-complete or occult; Cord compression/occlusion can lead to fetal death; Often occurs with ROM-especially hydramnios, unengaged, long cord, breech.
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| Gaskin's Maneuver | All Fours, corkscrew.
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| Amniotic Fluid Embolism | When fluid enters into the maternal vascular system either through a tear in cervix, tear in amnion or chorion high in uterus, or enters at site of placental tear. The force of the contractions drives the fluid into maternal circulation and to the lungs.
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| Signs & Symptoms of Amniotic Fluid Embolism | Respiratory distress, acute hemorrhage, chest pain, dyspnea, cyanosis, frothy sputum, hypotension, tachycardia.
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| When Amniotic Fluid Embolism Occurs | Occurs most commonly during or after the birth. Higher risk with precipitous or difficult labors.
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