HGTC OB Test 2
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| Engagement | The largest diameter of the presenting part reaches or passes through the pelvic inlet
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| Process of engagement in cephalic presentation. Floating | The fetal head is directed down toward the pelvis but can still easily move away from the inlet.
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| Process of engagement in cephalic presentation. Dipping. | The fetal head dips into the inlet but can be moved away by exerting pressure on the fetus.
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| Process of engagement in cephalic presentation. Engaged | The biparietal diameter (BPD) of the fetal head is in the inlet of the pelvis. In most instances the presenting part (occiput) is at the level of the ischial spines (zero station).
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| Powers of Labor:Primary force | Uterine muscular contractions --Causes complete effacement of cervix --Causes dilatation of cervix
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| Powers of Labor: Secondary force | --Abdominal muscles --Used to push during second stage of labor
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| Signs of Labor: Preliminary (Also termed premonitory or prodromal)Signs Preceding Labor | Lightening; Surge of energy; braxton hicks; ripening of cervix; rupture of membrane; bloody show
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| Lightening | Fetus drops: Uterus sinks downward and forward--Occurs about 2 wks before term (Mulitparous: May be after contractions established)
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| Surge of energy | 24 – 48 hrs before labor--Energy to clean and put things in order--Caution not to overexert
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| Braxton-Hicks | Frequent but irregular and intermittent -Become stronger -Abd and groin pain
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| Ripening of cervix | Cervix becomes soft (ripens) -Increase in water -May begin to dilate
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| Rupture of membranes | Membranes may rupture spontaneously --Labor within 12-24 hrs
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| Bloody show | Mucus plug expelled - Brownish or blood-tinged cervical mucus - Labor in 24-48 hrs
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| Other Signs Preceding Labor : Less common occurrence | Diarrhea --N/V --Indigestion - Loss of weight: 1 to 3 lb; loss of water
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| Actual signs of labor | Changes in maternal uterus - Changes in cervix, pituitary gland - Aging of placenta -Increased intrauterine pressure - Effacement - Dilation
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| Actual signs of labor: Uterine contractions change | Regular, progressive - Increase in frequency, duration and intensity - Pain in back and radiated around abdomen
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| Actual signs of labor: Effacement | Thinning of cervix - Muscles of the upper uterine segment shorten -- Drawing upward of the internal os and cervical canal
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| Actual signs of labor:Dilation | Progressive enlargement or widening of cervical opening and canal - Due to fetal axis pressure and hydrostatic pressure of fetal membranes - Diameter increases: < 1 to 10cm - Completely dilated cervix= no longer palpable
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| Stages of Labor: First Stage | Begins with onset of regular contractions (mild) - Ends with full dilation of cervix --Longer than 2nd & 3rd stages
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| First Stage of Labor consists of 3 phases: | Early(latent)- Active - Transition
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| First Stage consists of 3 phases: Phase 1Early (latent) | Progressive effacement of cervix - Little increase in descent - Excited and anxious
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| First Stage consists of 3 phases: Phase 2 Active | Contractions resume - Dilates 3-4 cm to 7 cm - Bearing down efforts by woman - Fetal station is advancing - Anxiety increases – Employ coping strategies
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| First Stage consists of 3 phases: Phase 3 Transition | Contractions more frequent, longer, and stronger-rapid dilation of cervix 8–10cm--Rectal pressure, low backache, belching, nausea or vomiting- Beads of perspiration on lip or brow --Apprehensive, irritable, angry, withdrawn
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| Stages of Labor: Second Stage | Lasts from the time cervix is completely dilated to birth of fetus - Avg 20 min for multip (30min) - Avg 50 min for nulliparous (3hr) - Crowning occurs when birth is imminent -- Head encircled by vaginal introitus - Sense of purpose -- Burning sensation
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| Stages of Labor: Third Stage | From birth of fetus - Until placenta is delivered - Placenta normally separates with 3rd or 4th contraction after fetus is born - Length from 3-5 min to 1 hr -Risk of hemorrhage increases as length of stage increases
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| Stages of Labor: Fourth Stage | Recovery 1-4 hours after delivery of placenta -- Avg 2 hr after birth - Period of immediate recovery, homeostasis -- Observe for complications: Abnormal bleeding
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| Types of deliveries: SVD | Spontaneous Vaginal Delivery:(Cephalic (vertex) most common)
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| Types of deliveries: FAVD | Forceps Assisted Birth (Instrumental or operative vaginal delivery)
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| Types of deliveries: FAVD : Outlet forceps | FAVD: fetal skull reached perineum
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| Types of deliveries: FAVD : Low forceps | FAVD: presenting part at station +2
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| Types of deliveries: FAVD : Midforceps | FAVD: fetal head is engaged
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| Indications for FAVD (Forceps Assisted Birth) | Threat to mother or fetus --History of Heart disease - Pulmonary edema - exhaustion
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| Conditions for forceps use | Cervix completely dilated -ROM (ruptured membranes), engagement - Vertex or face presentation - Bladder empty - CPD ruled out
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| FAVD Risks: Newborn | Ecchymosis and/or edema of face - Lacerations - Caput or cephalhematoma -- Hyperbilirubinemia - Transient paralysis -Cerebral hemorrhage
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| FAVD Risks: Maternal | Lacerations of birth canal -- 3rd of 4th degree extension of episiotomy - Bleeding, bruising, edema
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| FAVD Nursing Care: Decrease need for operative vaginal birth | Correct labor dystocia PRN: Encourage position changes, ambulation -- Empty client bladder frequently / Correct FHR decelerations: Assist with maternal position changes -- Apply oxygen PRN - Increase fluid intake
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| FAVD Nursing Care: | Assist with ID of contactions - Reinforce pushing with traction - Assess newborn for edema, bruising, caput, cephalhematoma - Assess mother for REEDA -- Hematoma, infection
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| REEDA | redness, edema, ecchymosis, drainage, approximation
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| Types of deliveries: VVD (Vacuum Assisted Birth) | Vacuum extractor used to apply suction to fetal head: Traction applied during contractions - Descent should be seen with first two pulls
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| VVD – Vacuum Assisted Birth: Risk | cephalhematoma of newborn
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| VVD – Vacuum Assisted Birth: Nursing care | Keep family informed; Assess FHR -- Reassure that caput will disappear within 3 days -Assess newborn for intracerebral hemorrhage, jaundice
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| Types of deliveries: Cesarean Birth--C-section | Birth of infant through an abdominal and uterine incision: Repeat C/S - Elective C/C --Preservation of pelvic floor
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| Types of deliveries: VBAC | Vaginal Birth After Cesarean
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| Perineal Episiotomy | Surgical incision in perineum to enlarge vaginal outlet
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| Perineal Episiotomy: 1st degree | Extends through the skin
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| Perineal Episiotomy: 2nd degree | Extends though skin and muscle
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| Perineal Episiotomy: 3rd degree | Extends though skin/muscle/anal sphincter
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| Perineal Episiotomy:4th degree | Extends though skin/muscle/anal sphincter/ anal wall
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| Risks for episiotomy | Primigravida - Macrosomia LGA - Forceps or vacuum assisted delivery - Shoulder dystocia
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| Episiotomy: Health Care Provider (HCP) initiated risks | Lithotomy positions -- Breath-holding during pushing -Limited time for 2nd stage
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| Episiotomy:Describe site and direction of incision: Median (midline) | Most common in U.S. -- Effective, easy to repair; Generally, least painful - Extension to or through anal sphincter more likely
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| Episiotomy:Describe site and direction of incision: Mediolateral | Need for posterior extension; 3rd degree lac may occur - Blood loss is greater; Difficult to repair -- More painful
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| Episiotomy Prevention | Prenatal Kegel exercises; Perineal massage; Natural pushing; Sidelying pushing position; Warm compresses; Counterpressure
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| Care of episiotomy | Assist with distraction and discomfort during repair (episiorrhaphy) - Apply ice 20 to 30 minutes - Inspect every 15min x 4 - REEDA
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| Complications Associated with Episiotomy | Blood loss, Infection, pain, perineal discomfort, painful intercourse
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| Need for Mobility - Physiology of contractions: Influence of hormones | Progesterone: causes relaxation of smooth muscle tissue / Estrogen: causes stimulation of uterine muscle = contractions
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| Need for Mobility - Physiology of contractions:Muscle fibers | shorten with contractions; Pushes fetus downward - Pulls lower uterus upward, causing dilation and effacement
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| Uterine contractions: Frequency | Beginning of one contraction to beginning of next
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| Uterine contractions: Duration | Time between the beginning of a contraction to the end of the same contraction
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| Uterine contractions: Intensity | Strength of contraction at peak (acme) -Fundus palpated for indentability - Measured accurately with Intrauterine Pressure Catheter (IUPC)
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| Uterine contractions: Resting tone | Tone of muscle in between contractions
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| Pelvis can be divided into 2 | false pelvis and true pelvis
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| True pelvis – divided into 3 parts | Inlet, outlet, mid-pelvis (pelvic cavity)
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| Pelvic inlet | Upper border of the true pelvis; sacral prominence around superior aspect of symphysis pubis - Widest diameter: transverse 13.5 cm
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| Pelvic Outlet | Lower border of true pelvis; coccyx to ischial tuberosities to inferior aspect of symphysis pubic - Widest diameter: anterior/posterior: 9.5 – 11.5 cm - May be increased by 1.5 cm to 2 cm -Squatting, sitting
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| Passenger: methods to determine fetal presentation | Leopolds maneuvers; Vaginal exams; Auscultation of FHT; Sonography or X-ray
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| Cephalic Presentation | Occurs approx. 96 - 97% births --Head presented into passageway - Classified according to attitude of fetal head: degree of flexion or extension
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| Classification of Cephalic Presentations: Vertex Presentation | (Cephalic Presentation): Most common --Head flexed on chest - Diameter presented to pelvis - Smallest diameter - Suboccipitobregmatic 9.5 cm -Presenting part: occiput
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| Classification of Cephalic Presentations: Military Presentation | (Cephalic Presentation):Head neither flexed nor extended - Diameter presented to pelvis - Occipitofrontal 11.75 cm - Presenting part - Top of head
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| Classification of Cephalic Presentations: Brow Presentation | (Cephalic Presentation):Head is partially extended - Diameter presented to pelvis - largest anterior-posterior diameter - occipitomental --Presenting Part - sinciput
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| Breech Presentation | Occurs in approximately 3% of births ---Buttocks and/or feet presented to pelvis -Sacrum is the landmark
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| Classifications of Breech Presentations | Complete, Frank, Footing
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| Breech Presentations: Complete | Knees and hips flexed; buttocks and feet present -- Landmark: sacrum
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| Breech Presentations: Frank | Hips flexed, knees extended; buttocks present -- Landmark: sacrum
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| Breech Presentations: Footling | Hips and legs extended, feet present - Single footling, Double footling - Landmark: sacrum
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| Pelvis can be divided into 2 | false pelvis and true pelvis
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| True pelvis – divided into 3 parts | Inlet, outlet, mid-pelvis (pelvic cavity)
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| Pelvic inlet | Upper border of the true pelvis; sacral prominence around superior aspect of symphysis pubis - Widest diameter: transverse 13.5 cm
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| Pelvic Outlet | Lower border of true pelvis; coccyx to ischial tuberosities to inferior aspect of symphysis pubic - Widest diameter: anterior/posterior: 9.5 – 11.5 cm - May be increased by 1.5 cm to 2 cm -Squatting, sitting
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| Passenger: methods to determine fetal presentation | Leopolds maneuvers; Vaginal exams; Auscultation of FHT; Sonography or X-ray
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| Cephalic Presentation | Occurs approx. 96 - 97% births --Head presented into passageway - Classified according to attitude of fetal head: degree of flexion or extension
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| Classification of Cephalic Presentations: Vertex Presentation | (Cephalic Presentation): Most common --Head flexed on chest - Diameter presented to pelvis - Smallest diameter - Suboccipitobregmatic 9.5 cm -Presenting part: occiput
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| Classification of Cephalic Presentations: Military Presentation | (Cephalic Presentation):Head neither flexed nor extended - Diameter presented to pelvis - Occipitofrontal 11.75 cm - Presenting part - Top of head
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| Classification of Cephalic Presentations: Brow Presentation | (Cephalic Presentation):Head is partially extended - Diameter presented to pelvis - largest anterior-posterior diameter - occipitomental --Presenting Part - sinciput
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| Breech Presentation | Occurs in approximately 3% of births ---Buttocks and/or feet presented to pelvis -Sacrum is the landmark
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| Classifications of Breech Presentations | Complete, Frank, Footing
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| Breech Presentations: Complete | Knees and hips flexed; buttocks and feet present -- Landmark: sacrum
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| Breech Presentations: Frank | (Breech Presentation) Hips flexed, knees extended; buttocks present -- Landmark: sacrum
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| Breech Presentations: Footling | (Breech Presentation) Hips and legs extended, feet present - Single footling, Double footling - Landmark: sacrum
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| Shoulder Presentation | Presentation: Transverse lie / Horizontal lie - Most frequently, the presenting part is shoulder - Landmark: Acromion process of scapula
Other presenting parts --Arm, back, abdomen, side
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| Cardinal movements: Adaptations that fetus undertakes to maneuver through the pelvis during birth and labor. | Engagement, Descent, Flexion, Internal rotation, Extension, Restitution, External rotation, Expulsion
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| Breathing techniques: Slow chest | Begin slow breathing when contractions are intense enough that you can no longer walk or talk through them without pausing. Switch to another pattern if you become tense and can no longer relax during contractions.
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| Breathing techniques: Accelerated chest | Breathe in and out rapidly through your mouth about one breath per second. Keep your breathing shallow and light. Your inhalations should be quiet, but your exhalation clearly audible.
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| Breathing techniques: Variable (Transition) Breathing | “hee-hee-who” breathing. Breathing combines light shallow breathing with a periodic longer or more pronounced exhalation. Variable breathing is used in the first stage if you feel overwhelmed, unable to relax, in despair, or exhausted.
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| Anesthetics: Regional | Anesthetics: Spinal --Epidural --Intrathecal --Paracervical --Pudendal
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| Anesthetics: Local | Anesthetics:used in repair of perineum
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| Anesthetics: General | Anesthetics: used for C-section
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| Anesthetics: Regional | Anesthetics: Spinal --Epidural --Intrathecal --Paracervical --Pudendal
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| Anesthetics: Local | Anesthetics:used in repair of perineum
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| Side effects: epidural/intrathecal | Hot spots, Has to wear off, Itching,nausea & vomiting, Urinary retention,Side effects decreased with narcan
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| Anesthetics: Regional | Anesthetics: Spinal --Epidural --Intrathecal --Paracervical --Pudendal
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| Anesthetics: Local | Anesthetics:used in repair of perineum
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| Rupture of membranes: Spontaneous(SROM) | Rupture of membranes: Can initiate labor or occur anytime during labor --Usually during transition
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| Anesthetics: General | Anesthetics: used for C-section
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| Epidural/Intrathecal: | Injected into epidural space (L4- L5 or L5- S1) Catheter placed (epidural)--Takes 20-30 minutes to work (epidural) --Lasts 2 hours then needs med re-injected
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| Spinal block/ Intrathecal: | Injected into spinal fluid --Onset quick (intrathecal) --Lasts 18-24 hours
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| Side effects: epidural/intrathecal | Hot spots, Has to wear off, Itching,nausea & vomiting, Urinary retention,Side effects decreased with narcan
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| Rupture of membranes: (kinds) | Spontaneous (SROM}, Prolonged (PROM), Artificial (AROM)
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| Rupture of membranes: Spontaneous(SROM) | Rupture of membranes: Can initiate labor or occur anytime during labor --Usually during transition
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| Rupture of membranes: Prolonged (PROM) | Rupture of membranes: Greater than 24 hours prior to delivery --Risk of infection
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| Rupture of membranes: Nursing Management | Assess FHR prior (if possible) -Assess FHR after - ? Decels – R/O prolapsed cord
- Assess color, odor, clarity, volume, time ----TACO
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| Rupture of membranes: Artificial (AROM) | Rupture of membranes: amniotomy - usually performed using an amnihook or fingercot
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| TACO | T = time the membranes ruptured, A = amount of fluid, C = color of the fluid and O = odor of the fluid.
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| Rupture of membranes: Nursing Management | Assess FHR prior (if possible) -Assess FHR after - ? Decels – R/O prolapsed cord
- Assess color, odor, clarity, volume, time ----TACO
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| TACO | T = time the membranes ruptured, A = amount of fluid, C = color of the fluid and O = odor of the fluid.
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| Define Dystocia | Long, difficult, abnormal labor; Occurs often during 1st stage labor -Primary cause for C/S delivery
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| Suspected Dystocia (S&S) | Alteration in Uterine Contractions (UC’s) characteristics, lack of cervical dilation progression, and/or lack of fetal descent and expulsion progression
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| Dystocia Etiology | Caused by various conditions associated with the 5P’s of labor: Dysfunctional labor (powers); Pelvic structure alteration (passage); Fetal variations (passenger); Mother’s response (psyche) and relationship between passage and passenger
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| Most common cause of dystocia | Dysfunctional Labor
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| Dystocia: Caused by various conditions associated with the 5P’s of labor | 1)Dysfunctional labor (powers); (2)Pelvic structure alteration (passage); (3)Fetal variations (passenger); (4) Mother’s response (psyche); (5) the ralationship between the passage and the passenger
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| Hypertonic Uterine Dysfunction: Primary Dysfunctional Labor : Occurrence | Latent stage, cervical dilation < 4 cm
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| Hypertonic Uterine Dysfunction: Uterus | Contractions: uncoordinated, frequency- increasing - Intensity: decreasing slightly but painful - Resting tone: Increasing
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| Hypertonic Uterine Dysfunction: Maternal complications | Intrauterine infection: Open cervix, long labor - Repeated vaginal exams, exhaustion
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| Hypertonic Uterine Dysfunction: Fetal complications | Fetal distress: Hypoxia: insufficient O2 supply to meet the demands of the fetus.
Decelerations(Prolonged, late) Decreased Uteroplacental blood flow - Increased, prolonged pressure on head - Excessive molding, cephalhematoma
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| Hypertonic Uterine Dysfunction: Treatment | Rest and fluids - Narcotics: Morphine sulfate, meperidine or tocolytics (Inhibits uterine contractions) Reduce pain; encourage rest - Barbituate - To allow patient to sleep - Usually awake with normal labor pattern -Allow labor to begin naturally
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| Hypotonic Uterine Dysfunction: | Normal progress into active labor at least 4 cm - Then UC’s become weak, inefficient --< 25mm Hg or stop completely - Uterine Contractions: Frequency (decreasing); Intensity (decreasing); Resting tone(unchanged)
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| Hypotonic Uterine Dysfunction: Treatment | Ultrasound or x-ray to R/O CPD: cephalic/pelvic disproportion - (CPD and malpositions common cause)Assess FHR and pattern, amniotic fluid (if ruptured) and maternal well being -If above normal, may ambulate, hydrotherapy, ROM - Pitocin augmentation
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| Hypotonic Uterine Dysfunction:Fetal / Maternal complications | Fetal distress -Risk for Infection--tachycardia Maternal complications--Risk for Intrauterine infection -Exhaustion-Dehydration-Risk for postpartum hemorrhage
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| L & D Complication: Pathologic Rings – Soft Tissue Dystocia | Constriction rings --Rare- ring forms and impedes fetal descent
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| Pathologic Rings: Treatment | Analgesics, anesthetics or both to relax rings--C/S
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| L & D Complication: Precipitous labor & delivery | Powers work too well (Labor less than or = 3 hours before birth) Characterized by 5 contractions in 10 minutes -May result from hypertonic UC’s --Intrauterine pressures may reach 50-70 mmHg --Lower uterine segment very soft
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| Precipitous labor & delivery: Nursing Management | Emergency delivery --Stay calm!!! --Encourage to push between contractions -Apply gentle pressure to presenting part -nHead out - check for nuchal cord--Suction nose and mouth - After delivery, clamp cord, cut cord --Assess and place baby to breast
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| Precipitous labor & delivery: Maternal risks | Possible lacerations of birth canal
No gradual stretching of the cervix, vaginal wall or perineum. -Gentle counter pressure placed on fetal head during delivery--Postpartum hemorrhage --Uterine rupture
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| Precipitous labor & delivery: Fetal risks | Possible hypoxia (Resulting from frequent intense contractions, decreased rest periods) ; Trauma to head (Possible resistance of cervix--Intracranial hemorrhage) ; Possible lack of immediate care (lack of attendance of health personnel)
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| L&D Complications: Uterine Rupture : Incomplete rupture | Extends into peritoneum but not into the peritoneal cavity;Abdominal tenderness-Pain with and without contractions;Usually internal bleeding;Palpable retraction ring;Distention of lower uterine segment;Failure of labor to progress
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| L&D Complications:Complete Uterine Rupture: | Extends through entire uterine wall into peritoneal cavity -Profuse bright red bleeding ----“tore away”-Sharp abdominal pain -Abnormal feel and shape of uterus - Rapid onset of hypovolemic shock -Rapid onset of fetal distress -bradycardia
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| Complete Uterine Rupture: Management | Management of shock --Replacement of blood --Hysterectomy?
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| Incomplete rupture: Management | Require laparotomy--Repair of uterus --Blood transfusion
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| Labor Induction: Prostaglandins | Causes softening--Begins dilation and effacement of cervix
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| Labor Induction: Cervidil | Vaginal Insert (dinoprostone, 10 mg)
Gradually released over 12 hrs
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| Labor Induction: Prepidil | Gel -0.5mg/2.5 ml syringe into cervical canal-Repeat in 6 hrs
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| Labor Induction: Laminaria | Mechanical dilator: A small rod-shaped piece of dried seaweed. The species of seaweed serving this purpose is Laminaria digitata.
Inserted into cervix -Absorbs moisture from cervical mucus, expands and dilates the cervix
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| Labor Induction: Amniotomy- AROM | Artificial rupture of membranes ; Condition of cervix favorable (ripe) Labor usually begins in 12 hrs Auscultate FHR: Prior to & immediately after --Document in chart - Risk for infection - Take maternal temp q 1-2 hours
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| Labor Induction: Misoprostol (Cytotec) | Synthetic prostaglandin agent - Administered intravaginally and/or orally to stimulate the onset of UCs - 3 or more UCs in 10 min - Need continuous monitoring of the FHR, uterine activity, and maternal VS
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| Labor Induction: Pitocin | Prior to induction, begin EFM, assess VS and UC’s -Begin primary infusion of IVF --Infuse Pitocin into lowest port of primary IV tubing -Control and titrate on IV pump --Monitor UCs - Monitor FHR closely --Observe fetal response to labor
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| Labor Induction: Pitocin : Stop infusion immediately if: | UCs are closer than 2 minutes, last longer than 90 seconds, or any indication of fetal distress
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| Cord Prolapse: | Umbilical cord lies below presenting part or falls beside or below head (if vertex); ROM may cause frank (visible) prolapsed - May be occult (hidden) prolapse anytime If presenting part is not snug in lower uterine segment
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| Cord Prolapse: Fetal Distress | Cord compression….hypoxia…Variable decelerations
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| Cord Prolapse: Nursing Management | Major goal: Relieve pressure off cord!!
:Knee chest position/genupectoral position-Trendelenburg position - Gentle upward digital pressure on fetal presenting part ; If cord is exposed to room air: Warm sterile saline compresses
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| Persistent Occiput Posterior (POP) Position: | Most common fetal mal-position: Prolonged 2nd stage -Mom c/o severe back labor pains-Fetal head (occiput) pressing against sacrum-Fetal head has to rotate ~ 180° to anterior
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| POP Management: Measures to rotate head | Knee-chest/genupectoral position -Assist in left lateral position - Pelvic rock, lateral stroking -Walk or climbing stairs -Squatting, Hands and knees (all fours)
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| POP Management: Measures to relieve back pain: | Counter pressure: heel of hand or fist to sacrum -Heat/Cold application - Risk for postpartum hemorrhage
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| BREECH Presentation: | FHT above umbilicus in upper quadrants - Often seen in preterm deliveries - Amniotic Fluid may have meconium
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| BREECH Presentation: Primigravida | C-section required
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| BREECH Presentation: Multigravida | Maybe have vaginal birth
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| BREECH Presentation: Maternal risks | Prolonged labor due to decreased pressure on cervix --PROM; increased risk of infection - C/S or forceps delivery-Trauma to birth canal-Intrapartum/postpartum hemorrhage
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| FACE/BROW Presentation: | Sterile Vaginal Exam (SVE) – feel unusual presenting part -Can be delivered but sometimes causes severe facial bruising --May have difficulty sucking
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| TRANSVERSE LIE: | Fetus lying sideways -Fetal axis perpendicular to maternal axis - May not feel fetal parts in fundus or above symphysis pubis - Shoulder is the common presenting part -Pathologic rings of the uterine muscle can occur ; Treatment: C/S
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| Shoulder Dystocia: Management | Head is born but shoulder cannot pass under pubic arch;Maternal position changes;Hands and knees, squatting, lateral recumbent - Suprapubic pressure to anterior shoulder -McRoberts maneuver(knees on abd,legs flexed)- C-section with large babies
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| Shoulder Dystocia: Risk Factors | Prolonged second stage of labor -Excessive Fetal size -Maternal pelvic abnormality
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| Shoulder Dystocia: Fetal complications | Fractures of the humerus and clavicle-Edema, hemorrhage, Erb’s palsy - Caput succedaneum-Asphyxia
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| Shoulder Dystocia: Maternal Complications | Bladder injury -Cervical, vaginal or perineal lacerations - Spontaneous separation of the symphysis - Uterine rupture - Uterine atony and Postpartum hemorrhage
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| Recognition of Shoulder Dystocia: | Slowing progress of labor - Turtle sign- )(fetal head retracts or recoils against the maternal perineum) - External rotation may not occur
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| Shoulder Dystocia: Documentation | Time of maneuvers and time delivered.
Sample documentation:
1210 shoulder dystocia called by Dr. ___.
McRoberts maneuver immediately implemented and suprapubic pressure applied by ______.
1215 infants shoulder and body delivered.
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| Macrosomia | Baby > 4000gms -C-section usually!!
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| Problems with Passageway: CPD : Cephalo-pelvic disproportion (C-section – only treatment): Nurse prepares patient for surgery by | IV access -Foley -Abdominal prep -Informed consent
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| Reasons for C-section / Cesarean delivery | When vaginal delivery unsafe.;Fetal distresS; Fetal macrosomia;Maternal health jeopardized; Previous c-section; Failure to progress ;Active herpes ; multiple fetuses; Primigravida with fetus in breech position
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| Types of C-section | Primary:First c-section ; Repeat:Second or third or etc. ; Pfannensteil incision: Bikini cut -Low-transverse; Classical incision:Vertical incision
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| Preparation for C-section Emergency | IV, foley, prep, consent -Need lots of emotional support
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| C/S Pre-op Teaching | What it expect after surgery -Pain management -Postanesthesia effects - T,C, & DB -Diet -Dressing -Fundal & lochial checks
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| Care During Surgery | Explain procedures if patient awake -Anesthesia -Sterile prep and drapes -Let mom see baby as soon as possible
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| Admission to Postpartum Unit: Receive C-section patient | Assist to bed from stretcher -Vital signs -Focused priority assessment -Complete assessment for baseline
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| Maternal risks with C/S | Aspiration, Hemorrhage -Infections, Injury to bowel or bladder-Thrombophlebitis -Pulmonary embolism
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| Fetal/neonatal risks with C/S | Injury at birth -Respiratory problems
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| Maternal Response to Labor: Cardiovascular and Respiratory Changes | BP rises with contractions and pushing-Increase in O2 demand and consumption Hyperventilation – fall in PaCO2 -Respiratory alkalosis Pushing – rise in PaCO2 and lactate (muscles) -Mild respiratory acidosis occurs
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| Maternal Response to Labor: Renal Changes: | Increase in renin, plasma renin activity, angiotensinogen - Edema of bladder from fetal head pressure
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| Maternal Response to Labor: GI and Immune System: | Gastric motility decreased, emptying prolonged, volume increased -WBC count increases -Blood glucose decreases
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| Fetal Response to Labor | Closely monitor FHR monitor and intervention appropriately - Chapter 18
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| Puerperium Period | Birth until 6 weeks after
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| Puerperium Period: Cervical changes | soft & easily dilated; Bruised and flabby; External os permanently changed; Dimple to lateral slit
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| Uterine Involution: Involution | rapid reduction in size of uterus - return to pre-pregnant state
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| Uterine Involution: Exfoliation of placenta site | allows for healing and is important part of involution
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| Uterine Involution: Exfoliation of placenta site; Enhanced by: | uncomplicated labor and birth -complete expulsion of placenta or membranes
–breastfeeding
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| Uterine Involution: Fundal position changes; After delivery of placenta | Uterus is Between symphysis pubis and umbilicus
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| Uterine Involution: Fundal position changes; Within 6 to 12 hours after childbirth | Uterus is at level of umbilicus
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| Uterine Involution: Norms | Decreases by one fingerbreadth per day -Descends into pelvis by 10th day - Pre-pregnancy size by 5-6 wks
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| Documentation: Fundus | Firm and midline; Appropriate progression of involution ; Fundal height recorded in fingerbreadths ; 2 FB below (down arrow) U ; Uterus boggy; firm with light massage
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| Documentation: Lochia rubra | red/fresh – day 1-3
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| Documentation: Lochia serosa | pinkish-brown – day 3-10
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| Documentation: Lochia alba | white/yellow – additional wk or 2
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| Sterilization: Bilateral Tubal Ligation (BTL) – Female Sterilization | Fallopian tubes crushed, ligated, banded
; Usually done during postpartum period
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| Sterilization: Bilateral Tubal Ligation (BTL) – Female Sterilization: Complications: | Coagulation burns on bowel -Bowel perforations - Hemorrhage, Infection
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| Sterilization: Vasectomy - Male Sterilization | Surgical severing of the vas deferens in the scrotum– 3 – 36 ejaculations needed to clear the vas deferens ; Alternative birth control required untill then ; 2-3 sperm samples and Rechecked at 6 and 12 months
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| Sterilization: Vasectomy - Male Sterilization: Side effects | pain, infection, hematoma, granulomas
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| Reproductive Assessment: Breasts; Lactation | Initiated by decreased hormones -Initial milk is colostrum ; Prolactin stimulates the production of milk ; Suckling at the breast will continue lactation ; Milk comes in on the 3rd to 5th day
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| Reproductive Assessment: Perineum ; Lacerations/Tears/ 1st Degree | skin
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| Reproductive Assessment: Perineum ; Lacerations/Tears/ 2nd degree | skin & muscle
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| Reproductive Assessment: Perineum ; Lacerations/Tears/ 3rd degree | rectal sphincter involved
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| Reproductive Assessment: Perineum ; Lacerations/Tears/ 4th degree | beyond the rectal sphincter into the rectal wall
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| Reproductive Assessment: Perineum ; Episiotomy | Median or Mediolateral
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| Evaluation of Episiotomy Healing:R E E D A | R- Redness; E- Edema ; E- Ecchymosis ; D- Discharge/ Drainage ; A- Approximation
Initial healing within 2-3 weeks
Completely within 4-6 months
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| Nutrition: after birth: | Increased need for protein -Increased need for iron
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| Nutrition: Lactation diet | Additional 200 kcal above pregnancy requirements ; increase calcium, protein and fluids
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| Postpartum Weight Loss: Return to pre-pregnancy wt in | 6-8 wks -If average wt gain 25 – 30 lbs
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| Postpartum Weight Loss: Initial loss | 10 – 12 lbs - Infant, placenta, amniotic fluid
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| Postpartum Weight Loss: Puerperal diuresis/diaphoresis | 5 lbs - Increased urination, sweating
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| Comfort/Sleep Interventions | Warm bath-Sitz bath-Peri care-Back rub -NSAIDS - Analgesics/Narcotics - PCA
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| Elimination: Bladder Assessment | First void since delivery-Palpate for fullness or distention - Amount of first voiding -Assess for perineal swelling
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| Elimination: Bladder Assessment: Fundus higher than normal upon palpation;Not in midline; Suspect distended bladder | Assist to BR to void ; Reassess uterus ; Unable to void ; In and out cath
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|
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