Labor (Exam 2)
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| Analgesia given too early.. | may prolong labor and depress fetus
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| Analgesia given too late.. | may causes neonatal respiratory depression w/ no benefit to mother
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| Safest form of anesthesia? | Local Infiltration
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| General Anesthesia | Used for emergency c section or vaginal birth
- give just before birth to limit fetal exposure
**risk of aspiration**
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| For moms given general.. | - place wedge under hip, tilt to side
- give 30 ml of Bicitra before a c-section
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| Bicitra (SODIUM CITRATE-CITRIC ACID) | - Alkalizing agent that decreases acidity of gastric contents to minimize pneumonia if aspiration should occur
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| Regional Anesthesia | - temporary and reversible loss of sensation by injection of an agent into an area with direct contact to nervous tissue
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| Epidural Block | - given b/t contractions in L2-L5
- Marcaine or Xylocaine
- Maternal hypotension possible
- GOLD STANDARD FOR PAIN MANAGEMENT
- Position on side with feet to chest for administration
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| Spinal Anesthesia | - may be used in low or midforceps & vacuum delivery
- often used for c-sect
-injected into l3-l5
Side effects: spinal headache, need a "blood patch"
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| Pudenal Block | - minor regional block that is effective & safe
- given through vagina by placing local into the area of the pudenal nerve
- use for spontaneous vaginal delivery
Advantages: no neonatal respiratory depression
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| Paracervical block | - LA injected into lateral aspects of the cervix during active or transition phases
-Monitor FHR for bradycardia
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| opoids | - Morphine has a depressive effect on fetus.
- Meperidine (Demerol) has lesser impact on infant
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| Fentyl | - more potent but has a shorter duration of action than Morphine
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| Stadol & Nubain | - Stadol given if mom itches because of epidural
- DO NOT GIVE WITH LATE DECELERATIONS
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| Precipitate labor | - Rapid labor less than 3 hours resulting in precipitous unattended birth/nurse attended
- risk oh hemorrhage, & hypoxia to newborn
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| Pitocin drip too high.. | - may cause hypertonic uterine dyfunction
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| Tocolytic drugs.. | - prolong pregnancy for 2-7 days
- Mg sulfate & nifedipine (Procardia)
mg sulf antidote= calcium gluconate
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| Steroids are given.. | to assist with lung maturity
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| Postterm Labor | after 42 weeks
- non stress test 2x weekly
- daily fetal movement counts
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| Umbilical Cord Prolapse | - partial/ total occlusion of cord w/ rapid fetal demise
- knee chest position
(?? give o2 & place pt on left side??)
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| Uterine rupture | - onset marked by sudden fetal bradycardia
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| Amniotic fluid embolism | - respiratory distress in mother
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| Labor induction & augmentation | - Induction: stimulating contractions via medical or surgical means
Augmentation: enhancing ineffective contractions after labor has begun (Pitocin)
- cervical ripening to assist Pitocin
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| Amniofusion | - indications
severe variable decelerations due to cord compression
oligohydramnios
thick meconium fluid
preterm labor w/ premature rupture of membranes
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| Forceps/ Vacuum | uses: prolonged second stage of labor, non-reassuring FHR pattern, ect
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| Cesarean Birth | - classic or low transverse incision
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| Vaginal birth after c-sec (VBAC) | - Controversy related to risk of uterine rupture & hemorrhage
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| External monitoring | - ultrasound transducer placed over fetal back and detects movements of the fetal heart
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| Internal Monitoring | - inserted through cervix
- must be 2 cm dilated
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| Baseline Heart rate | - average heart rate between contractions
- Normal 120-160
- Tachycardia >160
- Bradycardia <120 or <110 in book
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| Nursing interventions for early deceleration | - perform vaginal exam
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| Baseline Variability | measure of interplay b/t sympathetic & parasympathetic nervous system
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| Short Term Variability | - change in rate between one fetal heart beat & the next
- creates jaggedness or zig-zag
- AKA beat to beat variability
ONLY measured by internal electrode
- Classified as present or absent
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| Long term Variability | - waviness or rhythmic fluctuations (cycles)
- classified as absent, decreased, average, increased, marked
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| Most important aspect is LVT | - Even in presence of abnormal FHR, if variability is normal, fetus is NOT suffering from cerebra asphyxia
-Occurs 2-6 times per minute
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| Causes of decreased variability | - hypoxia & acidosis
- demerol, valium, vistaril that depress fetal CNS
- Fetal sleep
- fetus less than 32 weeks
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| causes of increase variability | - early/mild hypoxia
- fetal stimulation
- accoustic stimulation
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| Ominous sign | - decreasing variability that does not appear
- associated w/ fetal sleep cycle or drugs
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| Accelerations | - transient increases in the FHR normally caused by fetal movements
-sign of WELL-BEING
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| Non stress test | - accelerations w/ fetal movement form basis for nonstress test
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| Decelerations | - periodic decreases in FHR from the normal baseline
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| early decelerations | - decrease in FHR beginning at onset of a contraction and return to baseline by the end of contraction
- caused by fetal head compression, usually benign
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| Late decelerations | - onset of deceleration occurs after onset of the contraction & is considered a non assuring pattern
- occurs as result of uteroplacental insufficiency
- results from decrease blood flow & o2 transfer
**DISCONTINUE OXYTOCIN***
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| Variable deceleration | - occurs if umbilical cord becomes compromised
- fetal hypertension
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| Sinusoidal pattern | includes presence of LTV, absence of STV, and accelerations with fetal movements
-associated w/ RH isoimmunization fetal anemia, chronic fetal bleed
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| Amnio-infusion | - installation of warm saline through intrauterine pressure catheter & may be used to recreate cushioning effect of the umbilical cord during contraction
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| Scalp Stimulation | - done by applying pressure w/ finger to the fetal scalp through dilated cervix
- tactile response
- assessment of acid-base balance
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| Acoustic stimulation | - sharp sound next to women's abdomen
- used w/ nonstress test
- used during labor to demonstrate fetus is reactive
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| Fetal blood sampling | - determine hypoxia
- no pain
- sample of capillary blood taken from fetus scalp
**FETUS SHOULD NOT BE DELIVERED W/ VACUUM AFTER THIS TEST**
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| Ataratics: decrease n& v, anxiety, decrease narcotic requirements | - Vistaril (hydroxyzine)
- Phenrgan (promethazien
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| Oxytocin | - plays important role in onset & maintenance of labor
estrogen also increased myometrial sensitivity to oxytocin
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| Passageway | - relaxin & estrogen soften cartilage & increase strength & elasticity of pelvic organs
- allows pelvic joints to seperate slighty
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| False pelvis | - shallow upper section of pelvic
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| true pelvis | - lower curved bony canal that includes the inlet, cavity, & outlet
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| Station | - relationship b/t ischial spines in the passage & the presenting part of the fetus
- Ischial spines are at "station 0"
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| Wide suprapubic arches (gynecoid & platypelloid) | - allow for normal delivery
* gynecoid most common
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| Narrow Arches (android & anthropoid) | - increase risks for forceps & c-section
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| Fontanels | points of intersection of membranous sutures
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| Anterior fontanel | - diamond shape
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| Posterior fontanel | - triangle shape
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| Fetal presentation can be determined by.. | locating the fontanel
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| Molding | overlapping of the fetal skull that helps the skull adapt to size & shape of the maternal pelvis
- may take up to 3 days for effective molding to resolve
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| Fetal presentation | - refers to anatomic part that is either closest or in the canal
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| Fetal lie | - describes the relationship of the fetal long (head to toe) axis
- in breech or cephalic presentation, lie is longitudinal
- should presentation = transverse= unlikely vaginal birth
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| Oblique lie | - indicates the fetus is at a 45 degree angle to the maternal long axis & is unstable
- often converts to longitudinal or transverse lie
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| Fetal attitude | - relationship of fetal body parts to one another
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| Typical fetal attitude.. | - flexion of the head wherein the chest rest on the sternum & arms and legs are flexed against the chest & back is bowed out
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| Largest diameter? | biparietal diameter @ 9.25 cm
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| fetal postion | - relationship of fetal presenting part to the left or right side of the maternal pelvis
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| 1st maneuver | - determine which fetal pole is present in fundal area
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| 2nd maeuver | - In a vertex/ breed presentation, one side will feel smooth & firm which indicates the back
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| 3rd maneuver | - fetal attitude can be determined in a cephalic presentation
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| 4th maneuver | - Dr will face clients feet to assess further fetal attitude
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| Primary powers | - uterine contractions are involuntary & generally independent of extrauterine control
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| Physiological retraction ring | - divides itself into two portions
upper part thickens & lower segment thins out
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| Whats responsible for effacement and dilation of the cervix? | - uterine contractions
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| Effacement | shortening & thinning of the cervix
- described in terms of %
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| Dilation | - widening of the cervical opening that occurs from myometrial contractions in labor
- cervix is closed and then opens 10cm as labor advances
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| Cervix is no longer palpable when..? | - it is fully dilated & retracted
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| In primigravida.. | - effacement of the cervix begins before dilation
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| In multipara.. | - effacement & dilation progress together
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| Position | Lateral recumbent is most comfortable & best for fetal well being
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| First task of maternal role attainment.. | - mother seeks safe passage for herself & child during pregnancy
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| Early signs of labor | - lightening
- 1-3 pound weight reduction
- energy boost
- false labor
- bloody show
- nesting
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| Lightening | - descent of fetus & uterus into the pelvic cavity 2-3 weeks before onset of labor
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| Braxton hicks contractions | - produce no cervical change
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| bloody show | - thick tenacious mucus forms inside cervical canal to act as protective barrier
- as cervix begins to soften & dilate, mucus plug is expelled 24-48 hours before labor begins
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| Nesting occurs | 24-48 hours prior to labor
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| 1st stage of labor | longest in duration
- begins w/ reg. contractions & ends when cervix is completely dilated
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| latent stage | - begins with onset of contractions
- 15-20 mins apart lasting 20-30 secs
- begins w/ little or no dilation and ends w/ cervix dilated 3 - 4 cm
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| Active phase | - 3 - 4 cm dilated & ends when she is 8 cm dilated
- contractions q 2-3 mins lasting 60 seconds apart
- pain relief requested
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| trasnition stage | - contractions q 1.5 - 2 mins lasting 60-90 seconds
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| 2nd stage of labor | - begins when cervix is completely dilated
7 effaced and ends when fetus is expelled
- AKA pushing stage
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| Crowning | - point at which the fetal head is visible at the vulvar opening
- birth is imminent
- Lithotomy most common position for this stage
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| Descent | - progression of fetal head into the pelvis
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| flexion | - occurs when fetal head meets resistance from the pelvic floor and walls as well as the cervix causing head to flex w/ chin against fetal chest
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| internal rotation | - rotation of head from occiput transverse to occiput anterior
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| extension | - passing of fetal head under symphysis pubis
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| Restitution | - after birth of the head, head turns to realign w/ shoulder
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| external rotation | - rotation of shoulders so they are in an anteroposterior position
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| expulsion | - birth of entire body
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| 3rd stage of labor | - begins as soon as fetus is delivered & ends when placenta is delivered
- after expulsion of fetus, uterus contracts q 3-4 mins
- within 10-15 minutes of baby, placenta is expelled
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| schultz | fetal side
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| Duncan | uterine side
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| 4th stage of labor | first hour after delivery
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| Labor induction | - stimulation of uterine contractions before spontaneous onset of labor for the purpose of accomplishing delivery
- most common reason is post term gestation
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| Bishop Score | - score of 6 or more = likelihood of successful induction
- 13 point scoring scale
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| Cytotec (Misoprostol) | - synthetic prostaglandin administration orally / vaginally to produce contractions
- side effects: hypertonic contractions, elevated resting tone
**25-50 mg dose**
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| Pitocin (Oxytocin) **ALWAYS 2NDARY MEDICATION) | - helps induce labor, continue labor, or control bleeding after delivery.
- produced naturally by the posterior pituitary gland and stimulates contraction of uterus
- diluted w/ 10 units in 1 liter of isotonic solution
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| Pitocin continued.. | - DOES NOT cross placenta
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| Pitocin SIDE EFFECTS | - FHR decelerations
- uterine hyperstimulation
- uterine rupture
- hypotension
- diuresis (H20 intoxication)
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| Stripping of membranes | - assists w/ spontaneous labor
- placing finger through cervical & sweeping in a circular motion
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| Aminiotomy | - artificial rupture of membrane
- performed early in labor for urgent induction
- (preeclampsia)
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| Spontaneous rupture of membranes | - CHECK FHR first!!!
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| Outlet forceps | when head is crowning
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| low forceps | when head is at +2 station or lower but NOT crowning
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| Traction of forceps.. | only applied during contractions
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| Supine hypotension syndrome | - decreases cardiac output & stroke volume
- heavy uterus can cause vena cava compression
- MOTHER SHOULD LIE ON HER SIDE OR BACK W/ UTERUS TILTED TO ONE SIDE
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| PMI.. | - slightly more to the left
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| IV site | 18-20 gauge
- need 1000 cc LR or D5wLR
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| Nitrazine paper | yellow paper turns blue when in contact w/ amniotic fluid
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| Fern Test | - amniotic fluid dries into a fernlike pattern on the microscope
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| DTR OF 3+ INNDICATES.. | - Clonus associated w/ preeclampsia
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| Test for clonus | - knee is supported in a partially flexed position while nurse applies sharp dorsiflexion to the foot
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| Hemoglobin below 11 or hematocrit below 32% relfects.. | anemia or hemmorhage
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| If a woman has an epidural does she need a cath?? | YES
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| Episiotomy | - surgical cut at opening of vagina during child birth
* midline- cut from vagina directly toward anus
* mediolateral- cut from vagina at an angle off to one side of the anus
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| Brethine | - for preterm labor & uterine hyperstimulation
- prevents and slows contractions of the uterus
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| Amnisure test | - test for premature rupture of membrane
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| Apgar Score | - 0,1,2 for Activity, pulse, grimace. appearance, & respiration
- 10 is best possible score
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| fetal station +5 | - fetal head fills vaginal canal, right before birth
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| amount of blood lost in vaginal birth | - 500 ml
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| amount of blood lost in csection | 1000
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