Module 2: Intrapartum Care
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| What is required for all other mechanisms of labor to occur and an infant to be born? | Descent
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| What is it called if contractions gradually develop a regular pattern? | True labor
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| What is it called if contractions are irregular? | False labor
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| What is it called if contractions become stronger and more effective with walking? | True labor
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| What is it called if walking relieves contractions? | False labor
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| What is it called if there is discomfort in lower back and abdomen? | True labor
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| What is it called if discomfort is felt in the fundus and groin? | False labor
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| What is it called when bloody show is often present? | True labor
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| What is it called when bloody show is usually not present? | False labor
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| What is it called when there is progressive dilation and effacement of cervix? | True labor
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| What is it called when there is no change in dilation and effacement of cervix? | False labor
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| Describe the latent phase in the first stage of labor? | 4-6 hours; 1-4cm cervix dilation
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| Describe the active phase in the first stage of labor? | 2-6 hours; 4-7cm cervix dilation
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| Describe the transition phase in the first stage of labor? | 30 min - 2 hours; 7-10cm cervix dilation
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| Describe what happens during the second stage of labor? | 30 min - 2 hours; expulsion of fetus
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| Describe what happens during the third stage of labor? | Expulsion of placenta
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| Describe what happens during the fourth stage of labor? | Recovery
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| What are the nursing interventions for the second stage of labor? | Assist woman to position that helps her push, assist with glottis pushing technique and coping strategies, support coach, and maintain communication with HCP
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| What are the nursing interventions for the third stage of labor? | Observe and document blood loss, document delivery of placenta, monitor mother's v/s every 15 minutes, assess vaginal discharge, fundal massage, obtain cord blood if needed, perform Apgar evaluation
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| What are the nursing interventions for the fourth stage of labor? | Provide proper ID of mom, baby, and partner. Assess maternal voiding, monitor newborn vital signs, assess for newborn anomalies, assess fundus & massage, assess lochia (no more than 1 pad/hour)
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| What are patient teaching for expectant mothers concerning when to go to the hospital? | Regular contractions 5 mins apart, ruptured membranes, bleeding other than bloody show, decreased fetal movement, and any other concerns
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| What is the nursing assessment during admission to the birthing unit? | Fetal condition, maternal condition, and impending birth
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| What is a normal baseline fetal heart rate? | 110-160bpm
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| What is fetal bradycardia? | <110bpm
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| What is fetal tachycardia? | >160bpm
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| What is the cause of absent variability? | Uteroplacental insufficiency, maternal hypertension, cord compression, and fetal hypoxia
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| What are the nursing interventions for absent variability? | Position mother on side, increase IV rate, increase O2, and notify HCP
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| What do accelerations mean? | Suggest fetus is well oxygenated and is a reassuring pattern. Occurs with fetal movement
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| What do early decelerations result from? | Compression of fetal head and is a reassuring sign
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| What does variable deceleration suggest? | Umbilical cord is compressed, could be around neck or inadequate amniotic fluid
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| What are the nursing interventions for variable deceleration? | Position mother on side, increase O2, increase IV rate, and notify HCP
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| What does it suggest if there are late decelerations? | Placenta is not delivering O2 to the fetus
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| What are the nursing interventions for late decelerations? | Position mother on side, increase O2, increase IV rate, STOP Pitocin, and notify HCP
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| What is the cause of prolonged deceleration? | Cord compression or prolapse, maternal hypotension, or regional anesthesia
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| What are the four P's on the birth process? | Power, Passage, Passenger, and Psyche
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| What is the power? | Uterine contractions & mothers pushing efforts
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| What is the passage? | Bony pelvis and soft tissue
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| What is the passenger? | Fetus, placenta, amniotic membranes, and amniotic fluid
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| What is the psyche? | Childbirth is more than a physical process; it involves the woman's entire being
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| What should NOT begin until the cervix is fully dilated? | Pushing
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| What is the optimal position for the passenger? | Longitudinal lie
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| What is external monitoring? | Doppler transducer is placed on outside of abdomen; intensity cannot be monitored
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| What is internal monitoring? | Requires that the membranes are ruptured and cervix is dilated 1-2cm; intensity can be monitored
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| When must you report frequency, duration, and intensity of contractions? | Contractions occur more frequently than every 2mins., last longer than 90 sec., and have interval's shorter than 60 sec.
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| Describe Leopold's maneuver? | Used to determine fetal position and presentation by abdominal palpations (laying on of hands)
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| Who preforms the vaginal exam? | RN/MD
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| Describe the vaginal exam? | Sterile gloves; used to determine cervical effacement & dilation, and assess progression of labor
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| When should a vaginal exam NOT be done? | In the presence of blood (risk of bleeding)
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| Describe the significance of the various colors of amniotic fluid | Normal = clear with specks of white vernex; Green = fetus may have passed meconium; Cloudy/yellow with foul odor = indicates infection
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| What assessment must be done after the membranes have been ruptured? | Fetal heart rate for 1 full minute; must be recorded and reported
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| What is progressive relaxation? | Contracting and relaxing different muscles
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| What is skin stimulation? | Firm pressure on lower back for back labor
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| What is positioning? | Any position except supine; upright positions favor fetal descent, change positions every 30-60 minutes
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| What is diversion/distraction? | Focal point, imagery, and music
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| What is breathing? | Used when woman can no longer walk/talk during contraction, don't use before then because woman will hyperventilate, start & end with deep cleansing breath
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| What are the signs and symptoms of hyperventilation? | Dizziness, tingling in hands, feet, mouth, cramps & muscle spasms, and blurred vision
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| What is the treatment for hyperventilation? | Breathe slowly, especially when exhaling. Breathe into cupped hands, place moist wash cloth over mouth & nose while breathing, hold breath for a few seconds before exhaling
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| What are the principles that influence choice of drug given during labor? | How it affects the mother and fetus; methods that use drugs for reducing pain during birth
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| Describe narcotic analgesics | Opioids; avoid if birth is anticipated with 1 hour, because the medications cross the placenta and may cause respiratory depression for mother and baby
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| Describe narcan | Antagonist; used to reverse respiratory depression, usually in the infant but may also be given to the mother
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| Describe epidural block | Not used if the woman has abnormal clotting, infection in the area of injection, hypovolemia. Adverse effects: maternal hypotension and urinary retention
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| Describe spinal block | Dura is punctured with a thin needle. Anesthesia occurs more quickly and profound than epidural. Adverse effects: maternal hypotension and urinary retention
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| What are the adverse effects of general anesthesia? | Mother: regurgitation with aspiration of gastric contents that can result in chemical injury to lungs. Neonate: respiratory depression that may require aggressive resuscitation
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| What are the factors that effect the psyche in relation to prolonged labor? | Lack of analgesic control of excessive pain, absence of support person or coach to assist with non-pharmacologic pain relief measures, immobility, restriction to bed, and lack of ability to carry out cultural traditions
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| What is dysfunctional labor? | Labor that does not progress
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| What is dystocia? | Difficult labor R/T the fetus being to large; fetal chest cannot expand and fetus needs to be able to breath
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| What is the treatment/nursing care for dystocia? | After delivery mom and baby need to be assessed for injury
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| What is precipitate delivery? | Birth that is completed in less than 3 hours; O2 may be compromised, birth injury may occur, intracranial hemorrhage, and nerve damage
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| What is a premature rupture of membranes (PROM)? | Spontaneous rupture at term 1 hour before contractions begin, patient at risk infection
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| How is the rupture of membranes verified? | Nitrazine paper test, ferning pattern under microscope (more up to date test is amniosure)
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| What is preterm labor? | Occurs after 20 weeks gestation before 37 weeks, main risk are problems of immaturity with newborn
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| What are the nursing interventions for preterm labor? | Position woman on her side for better blood flow assessing vital signs frequently, notify HCP if tachycardia occurs
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| What is prolapsed umbilical cord? | Cord slips downward in the pelvis after the membranes rupture; can be compressed between fetal head and woman's pelvis, interrupting blood supply to and from the placenta
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| What is the nursing interventions for prolapsed cord? | Displace fetus upward to stop compression against the pelvis, place patient in knee to chest or trendelenburg position; assist with emergency procedures, and help calm the mother
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| What is a prolonged pregnancy? | Last longer than 42 weeks gestation; placenta ages making delivery of O2 and nutrients to fetus less efficient, fetus may lose weight, fetal skin may peel
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| What are the nursing interventions for prolonged pregnancy? | Observe the fetus during labor to identify signs associated with poor placental flow, such as decelerations. After birth, observe newborn for respiratory distress
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| What is a uterine rupture? | Tear in the uterine wall; occurs if the muscle cannot withstand the pressure inside the organ.
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| What are the nursing interventions for uterine rupture? | Be aware of who is at risk and monitoring labor is essential. Take measure to alleviate anxiety in woman and partner, watch for hypovolemic shock
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| What is placental previa? | Abnormal implantation of placenta in lower uterus, bright red bleeding that is not painful
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| What are the nursing interventions for placenta previa? | Monitor FHR and character of contractions. Document and record vaginal blood loss, assess v/s every 15min to watch for shock
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| What is abruptio placenta? | Premature separation of placenta, may be partial or total. Bleeding is dark red and painful
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| What are the nursing interventions for abruptio placenta? | Prep for cesarean and closely monitor vital signs, s/s of shock, a rapid increase in size of uterus could indicate internal bleeding
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| What are the indication for cesarean birth? | Abnormal labor, inability of fetus to pass through mothers pelvis, maternal conditions such as GH, DM, active maternal herpes virus, previous surgery on uterus, fetal compromise, placenta previa/abruptio, and fetal death
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| What are the risk of cesarean birth? | Mom: hemorrhage, blood clots, injury to urinary tract, delayed intestinal peristalsis, and infection. Baby: inadvertent preterm birth, respiratory problems, injury
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| What are the nursing interventions after cesarean delivery? | Vital signs identify hemorrhage or shock, monitor IV site & rate of solution flow, monitor fundus for firmness, height, midline position, assess uterus after cesarean, assess dressing for drainage, lochia for quantity, color, and presence of clots, U/O
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| What are the maternal indications for induction of labor? | GH, ruptured membranes without spontaneous onset of labor, infection with the uterus, medical conditions in the woman that worsens during pregnancy, such as DM, kidney/pulmonary disease
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| What are the fetal indication for induction of labor? | Fetal problems such as slowed growth, prolonged pregnancy, or incompatibility between fetal and maternal blood types, placental insufficiency, fetal death
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| What is anmiotomy? | Artificial rupture of membranes, done to stimulate or enhance contractions. Commits woman to delivery, stimulates prostaglandin secretion
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| What is prostaglandin? | Gel or vaginal insert that is applied before labor induction to soften cervix. CONTRAINDICATED: in women with history of uterine myomectomy surgery or previous cesarean because of risk of uterine rupture
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| What is augmentation? | Process of augmenting labor that is progressing slowly because of ineffective uterine contractions
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| What are the use, side effects, and nursing measures for Oxytocin? | Initiate/stimulate contractions, uterus is more sensitive to drug when labor has already begun. Won't work if cervix is not ripened, STOP if there are signs of fetal compromise. Complications are H2O intoxication, uterine rupture, hyperactive contractions
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| What are indications of an episiotomy? | Better control over where & how much the vaginal opening is enlarged. Opening with clean edge is better than a ragged opening of tear
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| What are the nursing interventions for episiotomy? | Cold packs applied to perineum for first 12 hours, after that, warm compresses & sitz bath, oral analgesics are usually sufficient
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| What do forceps do? | Provides traction and rotation of fetal head when mother's pushing efforts are insufficient to accomplish safe delivery
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| What are nursing interventions for forceps? | Place sterile equipment on table, ice is applied to perineum to prevent bruising and edema after delivery. Exam infants head for lacerations, abrasions, or bruising
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| How does vacuum extractor assist in delivery? | Use of suction is applied to fetal head so physician can assist the mother's expulsion efforts
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| What are nursing interventions for vacuum extraction? | Place sterile equipment on table, ice is applied to perineum to prevent bruising and edema after delivery. Reassure mother that edema will subside
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| What is the nursing care for the mother immediately after birth? | Observe for hemorrhage every 15 mins for first hour, vital signs, skin color, assess fundus, lochia, fullness of bladder, U/O, and pain. Promote comfort (keep warm, apply ice packs to perineum) and encourage breast feeding
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| What is the nursing care for the newborn immediately after birth? | Maintain thermoregulation, cardiorespiratory function, observe for urination & passing of meconium (document) identify mom & partner (place ID bracelets on mom, baby, partner) assess for anomalies, and administer meds (erythromycin eye drops & vit. K)
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| When is the Apgar test performed? | 1 minute & 5 minutes after birth (can be done on mother)
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| What does the Apgar test assess? | Infant's condition and response to resuscitation that was provided at birth
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| What are the factors that are evaluated in the Apgar test? | Ranked in order of importance: Heart rate, respiratory effort, muscle tone, reflex response to suction or stimulation on soles of feet, skin color
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| What are the three major assessments done on admission? | Fetal condition, maternal condition, impending birth
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| What procedures are done upon admission? | Permits/consent, lab test (Hct, Hgb), IV infusion, perineal prep, determine fetal position & presentation, patient kept NPO but may have orders for ice chips or clear liquids (popsicle) *Larger IV catheter is used
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| What is frequency of contractions? | Measured from beginning of one contraction to the beginning of the next contraction
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| What is duration of contractions? | Length of time one contraction last. (Beginning of one contraction to end of same contraction)
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| What is intensity of contractions? | Approx. strength of contraction. Usually described as mild, moderate, or strong
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| What is interval of contractions? | Amount of time the uterus relaxes between contractions
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| What position have less intense contractions, although may be more frequent? | Supine
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| What position have more intense contractions, so labor may progress more quickly? | Side-lying
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| What are nursing responsibilities during birth? | Prepare delivery instruments, perineal scrub, administer meds, provide initial care to infant, assess Apgar score, examine placenta, identify mother & infant, promote parent infant bonding
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| What are the advantages of non-pharmacological pain management? | Do not harm the mother or fetus, do not slow labor while providing adequate pain control, carry no risk for allergy or adverse drug effects
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| What is hydrotherapy? | Whirlpool or shower; increases maternal endorphin level
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| What is the MOST important thing to remember if a woman is successfully using a safe, non-pharmacologic pain control technique? | Do not interfere
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| What are nursing interventions for abnormal fetal presentation or position? | Encourage woman to assume positions that favor fetal rotation and descent and reduce back pain
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| What positions favor descent and reduce back pain? | Sitting, kneeling, or standing while leaning forward, rocking pelvis back & forth while on hands & knees, side-lying, squatting, lunging by placing one foot in chair with foot and knee pointed to that side
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| What can abnormal duration of labor cause? | Maternal or newborn infection, maternal exhaustion, postpartum hemorrhage, and greater anxiety/fear
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| What is the goal of tocolytic therapy? | Stop uterine contractions
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| What drugs are used to suppress labor? | Magnesium sulfate, Brethine, Indocin, Yutopar, and Procardia
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| What does magnesium sulfate do? | Relaxes smooth muscle
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| What is the antidote for magnesium sulfate? | Calcium gluconate
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| What does Procardia cause? | Maternal flushing and hypotension
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| What are the contraindications for tocolytic therapy? | Preeclampsia, placenta previa, abruptio placenta, chorioamnionitis, and fetal demise
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| What are the initial measures to stop preterm labor? | Identify & treat infection, activity restriction, avoid sexual intercourse, and hydration
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| What is done if preterm labor is inevitable? | Steroid (Betamethasone) is given to increase fetal lung maturity; thyroid releasing hormone also enhances lung maturity in fetuses younger than 28 weeks
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| What is induction? | Initiation of labor before it begins naturally
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| What are contraindications to labor induction? | Placenta previa, prolapsed cord, abnormal fetal presentation, high station of fetus, active herpes infection in birth canal, abnormal size/structure of mother's pelvis, and previous classic cesarean
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