344 EX 2, labor 1

active phase

4-7cm, UC moderate to strong, 50-60 sec, every 2-5 min. Average 6 hours. Ideally woman should be admitted during this phase.

During the assessment of a laboring woman, it is noted the fetal station is +2. You interpret this to mean?

The baby's presenting part is 2 cm below the ischial spine.

frequency of contractions

The complete relaxation of the uterus at the end of a contraction to the start of the next contraction beginning of the next contraction is the accepted way of determining it

effacement

The gradual thinning of the cervix, measured in percentages from 0-100%

Signs of placental separation

(1) a globular-shaped uterus, (2) a rise of the fundus in the abdomen, (3) a sudden gush or trickle of blood, and (4) further protrusion of the umbilical cord out of the vagina.

Nursing Care in 3rd Stage

- encourage skin-to-skin contact - ensure newborn warm & dry - monitor newborn's adaptation to extrauterine life (APGARs, respirations) - prepare/administer pitocin - monitor maternal bleeding, fundus - assist with perineal repair

The baby's presenting part is 2 cm above the ischial spine.

-2

descent at ischial spines level is

0

Stage 1: Latent phase

0 to 3 cm Contractions irregular, mild to moderate, occurring every 5 to 10 min, lasting 30 to 45 seconds Mom - some dilation and effacement, talkative and eager average 8 hours

. Interventions throughout stage 1

1. Monitor maternal vital signs. 2. Monitor FHR via ultrasound Doppler, fetoscope, or electronic fetal monitor. 3. Assess FHR before, during, and after a contraction, noting that the normal FHR is 110 to 160 beats per minute. 4. Monitor uterine contractions by palpation or tocodynamometer, determining frequency, duration, and intensity. 5. Assess status of cervical dilation and effacement. 6. Assess fetal station presentation and position by Leopold's maneuvers. 7. Assist with pelvic examination and prepare for a fern test.

placenta delivery

3rd stage of labor within 1-30 minutes after birth management that need to be done are cord contractions, massaging the uterus, give medicine such as pitocin to help contract the uterus before or after the delivery of placenta

descent at sacral promontory is

5+ (indicate birth)

transition phase

8-10 cm, UC strong, 50-70 sec, every 2-5 min. Ave 15 - 60 min. Common signs: nausea, vomiting, shaking tearing off clothes, snapping at partner, not wanting to be touched "I can't do it!"

Which is the appropriate nursing action for a client in active labor whose cervix is dilated 4 cm and 100% effaced with the fetal head at 0 station?

Assist the client's coach in helping her with the use of breathing techniques. R-

initial nursing action when a multipara requests something for pain

Examining the client's cervix for dilation and effacement R- Evaluating the client's cervical dilation and effacement determines her progress in labor and reveals whether it is safe to administer analgesia or anesthesia.

the cervix of a woman in labor is dilated 9 cm, she states that she has the urge to push. Which action would the nurse implement at this time?

Having her pant-blow during contractions R- the information given indicates that the best response is inhibiting pushing by having the client use pant-blow breathing.

Which action would the nurse take when a client who is performing patterned, paced breathing during the transition phase of labor experiences tingling and numbness of the fingertips?

Tell the client to breathe into a paper bag. rational= A paper bag enables the client to rebreathe carbon dioxide, which helps correct the respiratory alkalosis resulting from hyperventilation

duration of the contraction

The time between beginning of a contraction and the end of that contraction

stage 4 Assessment

a. Blood pressure returns to prelabor level. b. Pulse is slightly lower than during labor. c. Fundus remains contracted, in the midline, 1 or 2 fingerbreadths below the umbilicus.

assessment of latent phase

a. Cervical dilation is 1 to 3 cm. b. Uterine contractions occur every 15 to 30 minutes, are 15 to 30 seconds in duration, and are of mild intensity.

assessment of active p.

a. Cervical dilation is 4 to 7 cm. b. Uterine contractions occur every 3 to 5 minutes, are 30 to 60 seconds in duration, and are of moderate intensity.

assessment of TP.

a. Cervical dilation is 8 to 10 cm. b. Uterine contractions occur every 2 to 3 minutes, are 45 to 90 seconds in duration, and are of strong intensity.

intervention of Active P.

a. Encourage maintenance of effective breathing patterns. b. Provide a quiet environment. c. Keep mother and partner informed of progress. d. Promote comfort with back rubs, sacral pressure, pillow support, and position changes. e. Instruct partner in effleurage (light stroking of abdomen). f. Offer fluids and ice chips and ointment for dry lips. g. Encourage voiding every 1 to 2 hours.

Interventions of latent p.

a. Encourage mother and partner to participate in care. b. Assist with comfort measures, changes of position, and ambulation. c. Keep mother and partner informed of progress. d. Offer fluids and ice chips. e. Encourage voiding every 1 to 2 hours.

transition phase nursing care

a. Encourage rest between contractions. b. Wake mother at beginning of contraction so she can begin breathing pattern. c. Keep mother and partner informed of progress. D. Provide privacy. e. Offer fluids and ice chips and ointment for dry lips. f. Encourage voiding every 1 to 2 hours

Disseminated Intravascular Coagulation (DIC)

abnormal blood clotting in small vessels throughout the body that cuts off the supply of oxygen to distal tissues, resulting in damage to body organs

Cultural Variations in Women's Responses to Labor

depends on both their personality and their cultural expectations. Some cultures expect women to be stoic, bearing labor pain quietly. Others allow or even encourage loud vocalization, rocking, pacing, thrashing knowing typical responses to labor in different cultures helps the nurse interpret the behavior of a particular woman, and adapt her interventions

define "descent"

fetal head journey through the pelvis until crowning process that the fetal head undergoes as it begins its journey through the pelvis.

Dilation

gradual opening of the cervix measured in cm from 0-10 cms

anatomical land mark of measuring "descent" of the baby head

ischial spines and the sacral promontory

general anesthesia

presents a maternal danger of respiratory depression, vomiting, and aspiration.

descent is measure by

station

"SHINY" Schultze placenta size

the side from the baby where the baby's surface is delivered first

An oxytocin infusion is discontinued if

uterine contraction frequency is less than 2 minutes or duration is longer than 90 seconds, or if fetal distress is noted.

Duncan mechanism

where the maternal side is delivered first. This side will be dull/dirty, red, and rough and is the side from the mother. remember that the mother is dirty from labor and is in rough shape.

Perineal Repair

without epidural, A local anesthetic such as lidocaine or xylocaine is given before the repair

Second stage without epidural

¡Spontaneous urge to push after short latent period. ¡Spontaneous bearing down reflex when vertex presses on pelvic floor (Ferguson's reflex). ¡Can try various positions.

¨Second stage with epidural

¡Suppressed bearing down reflex. ¡Limited positions. ¡Longer 2nd stage. ¡Increased instrumental deliveries.

Fourth Stage

¨1 - 4 hours after birth ¨Opportunity for family bonding. ¨Avoid separating mother & baby!

Third Stage

¨Birth through delivery of placenta. ¨Usually 2-30 minutes after delivery.

Fourth Stage: Skin to Skin Contact benefit

¨Calms and relaxes both mother and baby ¨Regulates newborn heart rate and breathing ¨Regulates newborn temperature ¨Enables colonization of baby's skin with mother's friendly bacteria, providing protection against infection ¨Stimulates the release of hormones to support breastfeeding and mothering ¨Improves breastfeeding duration ¨Helps preterm babies grow and develop better

Nursing Care:Pushing with Epidural

¨Encourage passive descent. ¨Active coaching if mom can't feel UC. ¨Turn epidural down if pushing ineffectively. ¨Allow additional hour for 2nd stage.

Nursing Care in 4th Stage

¨Monitor mom : ¡VS, bleeding, uterine tone. ¡Uterine massage if uterus boggy. ¡Empty bladder. ¨Monitor baby for warmth, breathing. ¨VS q15-30 min. x 4. (Perform maternal assessments every 15 minutes for 1 hour, every 30 minutes for 1 hour, and hourly) ¨Skin to skin. ¨Promote breastfeeding. ¨Assess: ¡Fundus (remains contracted, in the midline, 1 or 2 fingerbreadths below the umbilicus.) ¡Lochia (Monitor lochia discharge. may be moderate in amount and red in color) ¡Perineum (Apply ice packs to the perineum) ¡Recovery from analgesia ¨Nutrition - offer food for woman and infant ¨Freshen up environment ¨Support significant other & extended family

Nursing Care in 2nd Stage

¨Preparing for birth ¨Coaching/encouraging pushing efforts ¨Repositioning for effective pushing ¨Monitoring baby's response to descent ¨Perineal compresses, cleansing ¨Comforting: ice, sips, cool cloth ¨Coping with feelings of pressure & burning

second stage

¨Pushing (and passive descent) ¨Complete cervical dilation to birth of the baby ¨Few minutes - 4 hours. ¨Requires very active work from the woman. ¨A woman-directed approach is supported by research.

nursing care in active phase

¨VS q15-30 minutes. ¨FHR q15-30 minutes. ¨Continuous EFM if epidural, pitocin, or other risk factors. ¨Pain management: labor support, analgesia, epidural.