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