Care of the Childbearing Family Exam 2
Fetal monitoring: STUDY VEAL CHOP!
V ariables = C ord compression E arly = H ead compression A ccelerations = O kay L ate = P lacental insufficiency
Antepartum/high risk: Additional information about gestational hypertension/preeclampsia/eclampsia
(From less of a problem to a higher problem) Gestational hypertension (affects ALL PEOPLE) -> Pre-eclampsia (usually African Americans) -> Eclampsia (affects ALL) HELLP Syndrome: H-emolysis, EL-evated L-iver E-nzymes, LP (low platelet count)
Intrapartum: Describe the four stages of labor; the timing for when each starts and ends - First stage
(Labor/dilation) - The first stage of labor lasts from the onset of regular uterine contractions to full dilation of the cervix
Intrapartum: Describe the four stages of labor; the timing for when each starts and ends - Third Stage
(Placental) - The third stage of labor lasts from the infant's birth to the expulsion of the placenta
Intrapartum: Describe the four stages of labor; the timing for when each starts and ends - Second stage
(Pushing) - The second stage of labor lasts from the time of full cervical dilation to the birth of the infant
Intrapartum: Describe the four stages of labor; the timing for when each starts and ends - Fourth stage
(Recovery or Immediate Postpartum) - The fourth stage of labor begins with the delivery of the placenta and includes at least the first 2 hours after birth
Postpartum: Describe abnormal vs. normal assessment parameters for an episiotomy
Abnormal: oozing, drainage, smell
Intrapartum: Contraindications for epidural (lab tests results and non-lab issues)
Active or anticipated serious maternal hemorrhage. Acute hypovolemia leads to increased sympathetic tone to maintain the blood pressure. Any anesthetic technique that blocks the sympathetic fibers can produce significant hypotension that can endanger the mother and fetus. o Maternal hypotension o Coagulopathy = if a woman is receiving anticoagulant therapy or has a bleeding disorder, injury to a blood vessel may cause the formation of a hematoma that may compress the cauda equina or the spinal cord and lead to serious CNS complications o Infection at the needle insertion site. Infection can be spread through the peridural or subarachnoid spaces if the needle traverse an infected area o Increased intracranial pressure caused by a mass lesion o Allergy to the anesthetic drug o Maternal refusal or inability to cooperate o Some types of maternal cardiac conditions
Newborn care: Breast feeding: Methods and advantages
Advantages: nutrients, skin to skin contact, immunity
Intrapartum: The sequential cardinal movements of labor - Flexion
As soon as the descending head meets resistance from the cervix, pelvic wall, or pelvic floor, it normally flexes so that the chin is brought into closer contact with the fetal chest
Intrapartum: Impact on blood pressure by uterine contractions
Blood pressure (both systolic and diastolic) increases during contractions and returns to baseline levels between contractions. Systolic values increase more than diastolic values.
Newborn care: Indications by newborn of effective breastmilk intake amounts
By pooping (8-10 poops a day for breastfed babies)
Intrapartum: The sequential cardinal movements of labor
Engagement, descent, flexion, internal rotation, extension, restitution and external rotation, and expulsion
Newborn care: What are the five factors that make up the Apgar score?
Heart rate, respiratory effort, muscle tone, reflex irritability, color
Postpartum: Physiologic changes that cause diaphoresis and diuresis
Hormone fluctuations cause diaphoresis
Intrapartum: What factors influence labor progress: 5 "Ps" of Labor - Position
Position affects the woman's anatomic and physiologic adaptations to labor
Fetal monitoring: Describe the findings for Non-Stress Test (NST)
Reactive NST = Good thing Nonreactive NST = Requires further evaluation
Newborn care: Describe parental behaviors that facilitate and/or inhibit attachment to infant
Skin-to-skin contact (SSC) with the mother beginning immediately after birth and breastfeeding within the first 1 to 2 hours after birth are important in promoting maternal-infant attachment. Early mother-infant contact produces physiologic benefits for the neonate and the mother. SSC promotes physiologic stability of the newborn. Maternal levels of oxytocin and prolactin rise with SSC and early breastfeeding. Rooming-in after birth until discharge from the birthing facility promotes parent-infant interaction.
Intrapartum: The sequential cardinal movements of labor -Internal rotation
The maternal pelvic inlet is widest in the transverse diameter; therefore, the fetal head passes the inlet into the true pelvis in the occipitotransverse position. The outlet is widest in the anteroposterior diameter; for the fetus to exist, the head must rotate. Internal rotation begins at the level of the ischial spines but is not completed until the presenting part reaches the lower pelvis.
Newborn care: Describe predominant pattern of normal newborn breathing
The newborn should be breathing spontaneously. The trunk and lips should be pink; bluish discoloration of the hands and feet (acrocyanosis) is a normal finding.
Intrapartum: What factors influence labor progress: 5 "Ps" of Labor - Passageway
The passageway, or birth canal, is composed of the mother's rigid bony pelvis and the soft tissues of the cervix, the pelvic floor, the vagina, and the introitus (the external opening to the vagina).
Newborn care: Rationales for administering to newborn - Vitamin K
To help with clotting (baby doesn't have clotting factors)
Newborn care: Rationales for administering to newborn - Hepatitis B vaccine
To prevent Hepatitis B (especially if mother has it)
Newborn care: Rationales for administering to newborn - Erythromycin ophthalmic ointment
To prevent infections
Intrapartum: The sequential cardinal movements of labor - Expulsion
When the baby has emerged completely, birth is complete, and the second stage of labor ends.
Intrapartum: The sequential cardinal movements of labor - Engagement
When the biparietal diameter of the head passes the pelvic inlet
Intrapartum: The sequential cardinal movements of labor - Extension
When the fetal head reaches the perineum for birth, it is deflected anteriorly by the perineum. The occiput passes under the lower border of the symphysis pubis first, and then the head emerges by extension: first the occiput, then the face, and finally the chin.
Antepartum/high risk: Define screening tests and diagnostic tools; know when (how many weeks gestation) they should be used during pregnancy and why (reasons for using them) - Percutaneous umbilical blood sampling (PUBS)
When: second and third trimesters Indications: PUBS is used for fetal blood sampling and transfusion
Intrapartum: Priority nursing action after spontaneous rupture of membranes (SROM)
o A big danger is a prolapsed cord (when the cord is hanging out -> compression of the cord = danger to the baby; risk of infection increases) -> STAT/PRIORITY 1 o A sterile vaginal exam is conducted by the physician so that an assessment can be done on the physical structures o During the triage process, the nurse must determine the status of the woman's amniotic membranes. If the woman has noticed a gush or leakage of fluid, the membranes may have ruptured (spontaneous rupture of membranes [SROM]). If there has been a discharge that may be amniotic fluid, in many instances a sterile speculum examination and Nitrazine (pH) and fern tests can determine whether the membranes have ruptured (Box 19.1).
Newborn care: Easy way to prevent neonatal infection by nurses
o As part of Standard Precautions, the nurse should wear gloves when handling the newborn until blood and amniotic fluid are removed by the initial bath. o Proper hand hygiene
Intrapartum: Nursing Interventions for the Woman Receiving Neuraxial Anesthesia - While the block is wearing off after birth
o Assess regularly for the return of sensory and motor function. o Continue to monitor maternal vital signs as ordered. o Monitor for bladder distention: o Assist with spontaneous voiding on bedpan or toilet. o Insert a urinary catheter if necessary. o Promote safety: o Keep the side rails up on the bed. o Place the telephone and call light within easy reach. o Instruct the woman not to get out of bed without help. o Make sure there is no prolonged pressure on anesthetized body parts. o Keep the epidural catheter insertion site clean and dry. o Continue to monitor for anesthetic side effects
Intrapartum: Nursing Interventions for the Woman Receiving Neuraxial Anesthesia - Prior to the block
o Assist obstetric care provider and/or anesthesia care provider with explaining the procedure and obtaining the woman's informed consent. o Assess maternal vital signs, level of hydration, labor progress, and fetal heart rate (FHR) and pattern. o Start an intravenous (IV) line and infuse a bolus of fluid (lactated Ringers solution or normal saline) if ordered (e.g., 500-1000 mL 15-30 min before induction of the anesthesia). o Obtain laboratory results (hematocrit or hemoglobin level, other tests as ordered). o Assess the woman's level of pain using a pain scale (from 0 [no pain] to 10 [pain as bad as it could possibly be]). o Assist the woman to void.
Intrapartum: Nursing Interventions for the Woman Receiving Neuraxial Anesthesia - During initiation of the block
o Assist the woman to assume and maintain the proper position. o Verbally guide the woman through the procedure, explaining sounds and sensations as she experiences them. o Assist the anesthesia care provider with documentation of vital signs, time and amount of medications given, etc. o Monitor maternal vital signs (especially blood pressure) and FHR as ordered. o Have oxygen and suction readily available. o Monitor for signs of local anesthetic toxicity (see Box 17.5) as the test dose of medication is administered.
Postpartum: Discharge to home teaching plan for teen moms related to infant care
o Availability of resources, support system, etc. o Education on immunizations and birth control
Antepartum/high risk: Plan of care for eclamptic seizures
o Brain dysfunction o Seizures put the mother at risk -> can develop into a coma -> ultimately harms the baby (lack of oxygen and nutrients) o Eclampsia Tonic-Clonic Convulsion -> Interventions § Keep airway patent: turn head to one side, place pillow under one shoulder or back if possible § Call for assistance. Do not leave bedside. § Raise side rails, and pad them with a folded blanket or pillow, if possible. § Observe and record convulsion activity
Postpartum: Signs, symptoms, and comfort measure treatments for postpartum maternal breast engorgement
o Cabbage leaves have an enzyme that draws out engorgement o Engorgement is a common response of the breasts to the sudden change in hormones and the onset of significantly increased milk volume in lactogenesis stage II. It usually occurs 3 to 5 days after birth as the milk transitions from colostrum to mature milk. o Signs/symptoms § Edema § Milk cannot flow easily § Breasts can become firm, tender, and hot, and can appear shiny and taut § The areolae are firm, and the nipples can flatten (making it difficult for the infant to latch on to the breast) § Milk supply can diminish if milk is not removed from the breasts o Comfort measures/treatments § Early and frequent feedings may help prevent engorgement § Emptying one breast at feeding and alternating which breast is offered first at each feeding § Pumping milk § Cold packs § Warmth (warm compresses, warm showers) § Cabbage leaves § Anti-inflammatory medications § Breast massage § Hand expression or pumping
Newborn care: Information about circumcision and PlastiBell technique
o Circumcision is the removal of the foreskin (prepuce) of the penis, exposing the glans. o The health benefits of NMC (newborn male circumcision) cited by the AAP include prevention of urinary tract infection in male infants younger than 1 year of age, reduced risk for penile cancer, and reduced risk for heterosexual acquisition of sexually transmitted infections, particularly HIV. In spite of the new evidence, the AAP (and CPS) does not recommend the practice of routine newborn circumcision. o Circumcision is a matter of personal parental choice. o PlastiBell technique § The plastic bell is first fitted over the glans, a suture is tied around the rim of the bell, and excess foreskin is cut away. The plastic rim remains in place for about 1 week; it falls off after healing has taken place, usually within 5 to 7 days. Petrolatum or dressings are usually not applied to the penis following circumcision with the PlastiBell.
Intrapartum: Nursing Interventions for the Woman Receiving Neuraxial Anesthesia - While the block is in effect
o Continue to monitor maternal vital signs and FHR as ordered (continuous monitoring of maternal heart rate [electrocardiogram] and blood pressure may be ordered to monitor for accidental IV injection of medication). o Continue to assess the woman's level of pain with every check of vital signs using a pain scale (from 0 [no pain] to 10 [pain as bad as it could possibly be]). o Monitor for bladder distention: o Assist with spontaneous voiding on bedpan or toilet. o Insert a urinary catheter if necessary. o Encourage or assist the woman to change positions from side to side every hour. o Promote safety: o Keep the side rails up on the bed. o Place the telephone and call light within easy reach. o Instruct the woman not to get out of bed without help. o Make sure there is no prolonged pressure on anesthetized body parts. o Keep the insertion site for the epidural catheter clean and dry. Continue to monitor for anesthetic side effects
Postpartum: Signs and symptoms of hemorrhage or hypovolemia
o Excessive blood loss is the clinical finding that warrants prompt action o Hypotonic or boggy uterus o There can be multiple sources of the bleeding (treatment depends on source)
Intrapartum: What factors influence labor progress: 5 "Ps" of Labor - Powers
o Involuntary and voluntary powers combine to expel the fetus and placenta from the uterus § Involuntary uterine contractions, called the primary powers, signal the beginning of labor § Once the cervix has dilated, voluntary bearing-down efforts by the woman, called the secondary powers, augment the force of the involuntary contractions
Fetal monitoring: Describe the findings for Contraction Stress Test (CST)
o Nipple stimulation or oxytocin is used for positive stimulation of contractions o Late decelerations mean placental insufficiency POSITIVE = BAD NEGATIVE = GOOD
Antepartum/high risk: Plan of care for severe gestational hypertension
o Parameters of hypertension: greater than 140/90 mmHg blood pressure § Parameters of chronic hypertension: hypertension for greater than 6 months o How many weeks gestation? The point after 20 weeks (a fetus is considered viable at 20 weeks) o Box 27.1: § Gestational hypertension: development of hypertension after week 20 of pregnancy in a previously normotensive woman without proteinuria or other system findings
Postpartum: Describe normal vs. abnormal lochial changes in the postpartum period and when they should occur
o Post birth discharge consists of blood, uterine tissue debris, leukocytes, and bacteria. o Lochia should be mild to moderate. Heavy lochia indicates postpartum hemorrhage. Persistent red lochia in the post-partum period may indicate continued bleeding from retained placental fragments o Lochia rubra (red) § First 3 days after pregnancy o Lochia serosa (pink) § 4-10 days after pregnancy o Lochia alba (white) § 11-21 days after pregnancy
Newborn care: Identify periods of newborn reactivity
o Respirations: § First period (reactivity): 50-60/min § Second period: 50-70/min § Stabilization: 30-40/min
Newborn care: Describe senses of newborns in regard to smelling, seeing, hearing, etc.
o Sight § Can focus only at close range § Uncoordinated eye movements o Hearing § Fully developed in newborns o Smell § Have a strong sense of smell (prefer the smell of their own mother, especially her breastmilk) o Taste § Strong preference for human milk and breastfeeding o Touch § Babies are comforted by touch and are able to feel things
Postpartum: Nursing priority action for signs of postpartum hemorrhage
o Sign 1: cumulative blood loss greater than or equal to 1000 mL or... o Sign 2: bleeding associated with signs/symptoms of hypovolemia within 24 hours of the birth process regardless of type of birth o Excessive blood loss is the clinical finding that warrants prompt action
Fetal monitoring: Prioritize list of nursing plan of care for abnormal fetal heart rate patterns
o The average FHR at term is 140 beats/minute; the normal range is 110 to 160 beats/minute. Earlier in gestation, the FHR is higher, with an average of approximately 160 beats/minute at 20 weeks of gestation. The rate decreases progressively as the maturing fetus reaches term. o Basic interventions: § Administer oxygen by nonrebreather face mask at a rate of 10 L/min for approximately 15-30 minutes § Assist woman to a side-lying (lateral) position § Increase maternal blood volume by increasing rate of primary IV infusion
Postpartum: Identify parameters of normal postpartum uterine involution (fundal heights)
o The return of the uterus to a nonpregnant state after birth is called involution. o The uterus should have returned to its nonpregnant location by 6 weeks after birth o Subinvolution is the failure of the uterus to return to a nonpregnant state due to ineffective uterine contractions. The most common causes of subinvolution are retained placental fragments and infection.
Intrapartum: What factors influence labor progress: 5 "Ps" of Labor - Passenger
o The way the passenger, or fetus, moves through the birth canal is determined by several interacting factors: § The size of the fetal head § Fetal presentation § Fetal lie § Fetal attitude § Fetal position
Newborn care: Describe items and value amounts of Apgar Scores at 1 minute and 5 minutes; know how to calculate Apgar Scores
o Timings depend on the baby's score (1 minute and 5 minutes are for normal babies) o Apgar scores of 0 to 3 indicate severe distress, scores of 4 to 6 indicate moderate difficulty, and scores of 7 to 10 indicate that the newborn is having minimal or no difficulty adjusting to extrauterine life. o Based off 5 factors § Heart rate (good sign: greater than or equal to 100 beats per minute) § Respiratory effort (good sign: good cry) § Muscle tone (good sign: well flexed) § Reflex irritability (good sign: crying) § Color (good sign: completely pink)
Intrapartum: Describe the signs/symptoms of true and false labor
o True Labor Contractions: § Occur regularly, becoming stronger, lasting longer, and occurring close together § Become more intense with walking § Are usually felt in the lower back, radiating to the lower portion of the abdomen § Continue despite use of comfort measures o False Labor Contractions: § Occur irregularly or become regular only temporarily § Often stop with walking or position change § Can be felt in the back or the abdomen above the umbilicus § Can often be stopped through the use of comfort measures
Antepartum/high risk: Plan of care for mild and severe preeclampsia
o What raises the likelihood of this happening? (look at box 27.1) § Gestational hypertension -> Preeclampsia -> Eclampsia § Criteria for preeclampsia and preeclampsia with severe features: hypertension, proteinuria, thrombocytopenia, impaired liver function, renal insufficiency, pulmonary edema, cerebral or visual disturbances § The unnatural growth and development of the placenta affects the mother and the baby (leads to pre-eclampsia) o There are proteins in urine that are present o Usually occurs in the first pregnancy (primigravida (before 20 weeks)/nulliparous (after 20 weeks)) o Risk factors: first pregnancy, chronic hypertension, obesity, diabetes (high blood sugar damages the inside of the arteries), kidney diseases, lupus, multiple pregnancy (twins, etc.), previous pregnancy complications, family history, age o Symptoms: proteins in urine, swelling in face/hands, headache, blurred vision, right upper quadrant pain, nausea/vomiting, decreased urine output, shortness of breath -> NEED TO KNOW FOR THE TEST! o The unnatural growth and development of the placenta affects the mother and the baby (leads to pre-eclampsia) o Things that help: delivering the baby, bed rest, hospitalization, medications for hypertension, anticonvulsive medications, corticosteroids (for baby's lungs - surfactant is needed which only comes at 27 weeks) o Magnesium sulfate helps to relax muscles and reduce the risk of seizures (page 593) § Calcium gluconate is the antidote for too much magnesium sulfate
Postpartum: Normal and abnormal fundal heights during early postpartum and later postpartum period
o Within 12 hours, the fundus may rise to the level of the umbilicus or slightly above or below it o 24 hours after birth, the fundus should be 1 cm below the umbilicus and continues to decrease by 1 cm to 2 cm every 24 hours o The uterus should not be palpable 2 weeks after birth
Intrapartum: Additional information about pain and epidurals
o Women cannot walk when they have had an epidural (because the drug affects the extremities) o The behavior during labor is pain.
Intrapartum: Describe the meaning and values of a sterile vaginal exam (SVE) findings during labor - Station: Level of the presenting part (+ or -)
§ 0, +1, -1 § Station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines and is a measure of the degree of descent of the presenting part of the fetus through the birth canal. The placement of the presenting part is measured in centimeters above or below the ischial spines. For example, when the lowermost portion of the presenting part is 1 cm above the spines, it is noted as being minus (-) 1. At the level of the spines, the station is referred to as 0 (zero). When the presenting part is 1 cm below the spines, the station is said to be plus (+) 1. Birth is imminent when the presenting part is at 4+ to 5+ cm.
Antepartum/high risk: Define screening tests and diagnostic tools; know when (how many weeks gestation) they should be used during pregnancy and why (reasons for using them) - Amniocentesis
§ Amniocentesis is performed to obtain amniotic fluid § When: Possible after week 14 of pregnancy § Indications: prenatal diagnosis of genetic disorders or congenital anomalies, assessment of pulmonary maturity, and diagnosis of fetal hemolytic disease
Antepartum/high risk: Define screening tests and diagnostic tools; know when (how many weeks gestation) they should be used during pregnancy and why (reasons for using them) - Amniocentesis
§ Amniocentesis is performed to obtain amniotic fluid § When: Possible after week 14 of pregnancy § Indications: prenatal diagnosis of genetic disorders or congenital anomalies, assessment of pulmonary maturity, and diagnosis of fetal hemolytic disease
Antepartum/high risk: Define screening tests and diagnostic tools; know when (how many weeks gestation) they should be used during pregnancy and why (reasons for using them) - Biophysical profile (BPP)
§ Biophysical profile is a noninvasive dynamic assessment of a fetus that is based on acute and chronic markers of fetal disease. Uses ultrasound and FHR reactivity determined by means of the NST (non-stress test). § When: late second and the third trimester § Indications: for a detailed assessment of the physical and physiologic characteristics of the developing fetus and cataloging of normal and abnormal biophysical responses to stimuli. § Daily fetal movement count: (also called kick count) Used to monitor the fetus in pregnancies complicated by conditions that may affect fetal oxygenation. The presence of movements is generally a reassuring sign of fetal health.
Antepartum/high risk: Define screening tests and diagnostic tools; know when (how many weeks gestation) they should be used during pregnancy and why (reasons for using them) - Chorionic villi sampling
§ Chorionic villi sampling is a popular technique for genetic studies in the first trimester (popular because of earlier diagnosis and rapid results) § When: can be performed in the first or second trimester § Indications: (SAME AS AMNIOCENTESIS) prenatal diagnosis of genetic disorders or congenital anomalies, assessment of pulmonary maturity, and diagnosis of fetal hemolytic disease
Intrapartum: Describe the meaning and values of a sterile vaginal exam (SVE) findings during labor - Cervical dilation: Centimeters (cm)
§ Dilation of the cervix is the enlargement or widening of the cervical opening and the cervical canal that normally occurs once labor has begun. The diameter of the cervix increases from less than 1 cm to full dilation (approximately 10 cm) to allow birth of a term fetus. When the cervix is fully dilated (and completely retracted), it can no longer be palpated by an examiner. Full cervical dilation marks the end of the first stage of labor. § 10 cm
Intrapartum: Epidural (block) anesthesia
§ Epidural (block) anesthesia · Relief from the pain of uterine contractions and birth (vaginal and cesarean) can be achieved by injecting a suitable local anesthetic agent, an opioid analgesic, or both (preferred for a greater degree of motor function) into the epidural (peridural) space. · The injection is made between the 4th and 5th lumbar vertebrae for a lumbar epidural block. o Vaginal birth: block from T10 to S5 is required o Cesarean birth: block from at least T8 to S1 is essential · Most effective pharmacologic pain relief method available · Pressure sensations are still felt by most women · Obese women have a difficult time getting an effective epidural (block) anesthesia because of the excess adipose tissue · Advantages: o The most effective form of pain relief is provided o Good relaxation is achieved o Airway reflexes remain intact o Only partial motor paralysis develops · Disadvantages: o Limited control of labor by mother o Orthostatic hypotension, dizziness, sedation, weakness of legs o CNS effects o Respiratory arrest o Fevers o Hypotension o Urinary retention and stress incontinence o Pruritis (with some opioids like fentanyl)
Intrapartum: Phases and Stages of Labor
§ First stage of labor (Dilation): The first stage of labor lasts from the onset of regular uterine contractions to full dilation of the cervix · Phase 1: Early 0-6 cm · Phase 2: Active 6-8 cm · Phase 3: Transition 8-10 cm § Second stage of labor (Pushing): The second stage of labor lasts from the time of full cervical dilation to the birth of the infant § Third stage of labor (Placenta): The third stage of labor lasts from the infant's birth to the expulsion of the placenta § Fourth stage of labor (Recovery): The fourth stage of labor begins with the delivery of the placenta and includes at least the first 2 hours after birth
Antepartum/high risk: Define screening tests and diagnostic tools; know when (how many weeks gestation) they should be used during pregnancy and why (reasons for using them) - Maternal serum alpha-fetoprotein (MSAFP) screening
§ Indications: used as a screening tool for NTDs (neural tube defects) in pregnancy § When: between 15 and 20 weeks of gestation (16-18 weeks is ideal)
Intrapartum: Tests for rupture of membrane - Nitrazine test
§ Nitrazine Test for pH · Procedure: o Perform hand hygiene and put on sterile gloves o Use a cotton-tipped applicator impregnated with Nitrazine dye for determining pH (differentiates amniotic fluid, which is slightly alkaline, from urine and purulent material [pus], which are acidic). o Dip the cotton-tipped applicator deep into the vagina to sample fluid (this procedure may be performed during speculum examination) · Results: o Membranes probably intact -> identifies vaginal and most body fluids that are acidic § Yellow pH 5.0 § Olive-yellow pH 5.5 § Olive-green pH 6.0 o Membranes probably ruptured: identifies amniotic fluid that is alkaline § Blue green = pH 6.5 § Blue gray = pH 7.0 § Deep blue = pH 7.5
Antepartum/high risk: Define screening tests and diagnostic tools; know when (how many weeks gestation) they should be used during pregnancy and why (reasons for using them) - Coombs test
§ Screening tool for Rh incompatibility § Can also detect other antibodies that may place the fetus at risk for incompatibility with maternal antigens
Intrapartum: Definition of labor
§ The term labor refers to the process of moving the fetus, placenta, and membranes out of the uterus and through the birth canal. · Various changes take place in the woman's reproductive system in the days and weeks before labor begins. o Labor itself can be discussed in terms of the mechanisms involved in the process and the stages through which the woman moves.
Intrapartum: Describe the meaning and values of a sterile vaginal exam (SVE) findings during labor - Cervical effacement: Percent (%)
§ This is the shortening and thinning of the cervix during the 1st stage of labor § 100% effacement is ideal
Newborn care: Assessments: Need to know normal and expected vital signs!
§ Visible pulsations § 80-100 beats min (when sleeping) to 160 beats/min (when crying) § Auscultation · S1 and S2 sounds; murmur is normal § Peripheral pulses are equal and strong § Temperature: 36.5-37.5 degrees Celsius (97.7-99.5 F) § Respirations: 30-60 per minute without any signs of respiratory distress or apnea § Blood pressure: depends on gestational age, weight, change in activity level · For term newborn of average weight = 60-80/40-50 mm Hg § Weight: 2700-4000g (6-9 pounds) § Length: 48-52 cm
Antepartum/high risk: Define screening tests and diagnostic tools; know when (how many weeks gestation) they should be used during pregnancy and why (reasons for using them) - Ultrasound
§ When: Transvaginal ultrasonography is more useful in the first trimester. Abdominal ultrasonography is more useful after the first trimester when the pregnant uterus becomes an abdominal organ. § Why: provides critical information to health care providers regarding fetal activity and gestational age, normal versus abnormal fetal growth curves, fetal and placental anatomy, fetal well-being, and visual assistance with which invasive tests can be performed more safely § No side effects § Effect: is used to determine fetal development; can be used to define things; most critical effect is to see if the pregnancy is troublesome or good
Intrapartum: The sequential cardinal movements of labor - Restitution and external rotation
· After the head is born, it rotates briefly to the position it occupied when it was engaged in the inlet. This movement is referred to as restitution. · The 45-degree turn realigns the infant's head with the back and shoulders. The head can then be seen to rotate further. This external rotation occurs as the shoulders engage and descend in maneuvers similar to those of the head.
Intrapartum: Maternal Physiologic Changes During Labor
· Cardiac output increases 10%-15% in first stage, 30%-50% in second stage · Heart rate increases slightly in first and second stages · Blood pressure (both systolic and diastolic) increases during contractions and returns to baseline levels between contractions. Systolic values increase more than diastolic values. · White blood cell (WBC) count increases · Respiratory rate increases · Temperature may be slightly elevated · Proteinuria may occur · Gastric motility and absorption of solid food are decreased; nausea and vomiting may occur during transition to second stage labor · Blood glucose level decreases
Intrapartum: Nonpharmacologic Strategies to Promote Relaxation and Reduce Pain
· Cutaneous stimulation strategies o Counterpressure o Effleurage (light massage) o Therapeutic touch and massage o Walking o Rocking o Changing positions o Application of heat or cold o Transcutaneous electrical nerve stimulation (TENS) o Acupressure o Water therapy (showers, baths, whirlpool baths) o Intradermal water block · Sensory stimulation strategies o Aromatherapy - uses oils distilled from plants, flowers, herbs, and trees to promote health and to treat and balance the mind, body, and spirit. o Breathing techniques o Music o Imagery o Use of focal points · Cognitive strategies o Childbirth education o Hypnosis § Box 17.3: Paced Breathing Techniques · Cleansing breath · Slow-paced breathing (approximately 6-8 breaths/min) · Modified-paced breathing (approximately 32-40 breaths/min) · Patterned-paced or pant-blow breathing (same rate as modified)
Intrapartum: Pharmacologic Control of Discomfort by Stage of Labor and Method of Birth
· First stage o Opioid agonist analgesics o Opioid agonist-antagonist analgesics o Epidural (block) analgesia o Combined spinal-epidural (CSE) analgesia · Second stage o Nerve block analgesia and anesthesia § Local infiltration analgesia § Pudendal block § Spinal (block) anesthesia § Epidural (block) analgesia § CSE analgesia o Nitrous oxide · Vaginal birth o Local infiltration anesthesia o Pudendal block o Epidural (block) analgesia and anesthesia o Spinal (block) anesthesia o CSE analgesia and anesthesia o Nitrous oxide · Cesarean birth o Spinal (block) anesthesia o Epidural (block) anesthesia o General anesthesia
Intrapartum: Side Effects of Neuraxial Anesthesia
· Hypotension · Local anesthetic toxicity o Light-headedness o Dizziness o Tinnitus (ringing in ears) o Metallic taste o Numbness of the tongue and mouth o Bizarre behavior o Slurred speech o Convulsions o Loss of consciousness · Fever · Urinary retention · Pruritus (itching) · Limited movement · Longer second-stage labor · Increased use of oxytocin · Increased likelihood of forceps- or vacuum-assisted birth · High or total spinal anesthesia
Intrapartum: Impact of uterine contractions on labor - Voluntary vs involuntary contractions
· Involuntary contractions: o Also called primary powers o Signal the beginning of labor o Are responsible for the effacement and dilation of the cervix and descent of the fetus · Voluntary contractions: o Also called secondary powers o When the presenting part reaches the pelvic floor, the contractions change in character and become expulsive o Secondary powers (bearing-down efforts) are used to aid in the expulsion of the fetus as she contracts her diaphragm and abdominal muscles and pushes o The secondary powers have no effect on cervical dilation, but they are of considerable importance in the expulsion of the infant from the uterus and vagina after the cervix is fully dilated
Intrapartum: Tests for rupture of membrane - Test for ferning or fern pattern
· Procedure: o Perform hand hygiene and put on sterile gloves, obtain a sample of fluid (usually during a sterile speculum examination) o Spread a drop of fluid from the vagina on clean glass slide with a sterile cotton-tipped applicator o Allow the fluid to dry o Examine the slide under the microscope; observe for the appearance of ferning (a frond-like crystalline pattern). Do not confuse this with the cervical mucus test where high levels of estrogen also cause ferning. o Observe for absence of ferning (alerts staff to possibility that amount of specimen was inadequate or that specimen was urine, vaginal discharge, or blood). o Provide continuing care as needed. o Remove gloves and perform hand hygiene
Intrapartum: Suggested Measures for Supporting a Woman in Labor
· Provide companionship and reassurance · Offer positive reinforcement and praise for her efforts · Encourage participation in distracting activities and nonpharmacologic measures for comfort · Give nourishment (if allowed by obstetric health care provider) · Assist with personal hygiene · Offer information and advice · Involve the woman in decision making regarding her care · Interpret the woman's wishes to other health care providers and to her support group · Create a relaxing environment · Use a calm and confident approach · Support and encourage the woman's support people by role-modeling labor support measures and providing times for breaks
Intrapartum: The sequential cardinal movements of labor - Descent
· The progress of the presenting part through the pelvis · Depends on at least four forces: o Pressure exerted by the amniotic fluid o Direct pressure exerted by the contracting fundus on the fetus o Force of the contraction of the maternal diaphragm and abdominal muscles in the second stage of labor o Extension and straightening of the fetal body
