Exam 2 Labor & Delivery & Postpartum
List 3 facts about "afterpains"
* intermittent contractions- normal especially when breast feeding because it releases oxytocin. A good thing because is helping uterus to clamp down. 1. The discomfort is more acute for multiparas because of repeated stretching of muscle fibers which leads to loss of muscle tone that causes alternate contraction and relaxation of the uterus. 2. Analgesics are used to manage discomfort of after pains. The benefits of pain relief facilitate the milk ejection reflex or letdown reflex. 3. Some mothers find that lying in a prone position with a small pillow or folded blanket under the abdomen helps keep the uterus contracted and provides relief.
What are 4 potential complications from an epidural block?
***Hypotension is biggest risk 1. Mom will need a urinary catheter- risk of CAUTI 2. Headache, nausea 3. Increased risk for C Section because of mom not being able to push. 4. Backache
Define VBAC and TOLAC:
*can have both. After 2 C sections not a good candidate for VBAC. VBAC: Vaginal birth after cesarean TOLAC: Trial of labor after cesarean
List 2 measures to suggest for a mother who is attempting to suppress lactation.
1. A firm bra 2. Cold packs 3. No warm shower 4. Cabbage leaves
List 4 findings on your assessment of a postpartum patient that would be ABNORMAL:
1. BP of 140/90 or higher 2. Bradycardia 40-50 BPM 3. Excessive lochia 4. Bladder distention
Reasons for labor induction
1. Fetal compromise (such as intrauterine growth restriction, maternal- fetal blood incompatibility) 2. Spontaneous rupture of the membrane's at or near term without onset of labor (PROM) 3. Post term pregnancy: baby will likely poop (dealing with meconium) The placenta is old. 4. Chorioamnionitis (inflammation of the amniotic sac) 5. Hypertension associated with pregnancy or chronic hypertension 6. Abruptio placentae- would just have to be partial rupture 7. Maternal medical conditions that are worsening with the continuation of pregnancy 8. Fetal death 9. Preeclampsia and eclampsia- only way to help with this is the delivery of the baby
Julie has been in labor for 6 hours. She has reached 5cm dilation. She starts to cry and states that she can't go another 6 hours to get to 10 cm. What do you~ tell her?
1. I would explain to her that she is almost out of the active phase of labor which is when the cervix is dilated 4-7 cm. Once she reaches 8-10 cm it should only last about an hour. I would do everything I could do to encourage her. **0-5 is 2/3 of labor time. 6-10 is a 1/3 of the labor time 21. not sure about the hour but 0-5 is usually 2/3 of the time of labor
List 3 nursing interventions for perineal discomfort from hemorrhoids, episiotomy, or lacerations:
1. Ice 2. Perineal care 3. Topical anesthetics 4. Ordered analgesics
List 4 reasons why the HCP wouldn't induce labor.
1. Placenta previa (implantation in the lower uterus) which can result in hemorrhage during labor. 2. Vasa previa, on which fetal umbilical cord vessels branch over the amniotic sac rather than inserting into the placenta. Fetal hemorrhage is a possibility. 3. Abnormal presentation for which vaginal birth is often hazardous. 4. Umbilical cord prolapse, because immediate birth by cesarean is indicated.
What are the 3 major risks with an amniotomy?
1. Prolapse of the umbilical cord- the umbilical cord will slip down in the gush of fluid. The cord can be compressed between the fetal presenting part and the woman's pelvis obstructing blood flow to and from the placenta and reducing fetal gas exchange. 2. Infection- vaginal organisms have free access to the uterine cavity and may cause chorioamnionitis or infection of the amniotic sac. The risk is low at first but increases as the interval between membrane rupture and birth increases. 3. Abruptio placentae- premature separation of the normally implanted placenta. May occur if the uterus is distended when the membranes rupture.
List 4 findings on your assessment of a postpartum patient that would be NORMAL:
1. Soft and non-tender breasts 2. No calf pain 3. 12-20 breaths per minute 4. Firm fundus in the midline of umbilicus
List 5 steps a nurse should take if she/he notices that the baby is decelerating significantly during labor:
1. Stop oxytocin or other uterine stimulants. 2. Reposition the woman, avoiding supine position. 3. Increase the rate of infusion if a nonadditive IV fluid. Which increases blood volume so more perfusion to baby. 4. Administer oxygen by facemask at 8-10 L/min to increase maternal blood oxygen saturation. 5. Consider starting continuous EFM with internal devices. 6. Notify the physician. Check for prolapsed cord- if so then lift moms hip up.
List 6 important nursing responses to a non-reassuring fetal heart rate pattern:
1. Stop oxytocin or other uterine stimulants. 2. Reposition the women, avoiding supine position. 3. Increase the rate of infusion if a nonadditive IV fluid. 4. Administer oxygen by facemask at 8-10 L/min to increase maternal blood oxygen saturation. 5. Consider starting continuous EFM with internal devices. 6. Notify the physician.
List 4 methods of inducing or augmenting labor and how they are done:
1. Stripping membranes 2. Cytoteck- given rectally or orally 2. Oxytocin- strengthens contractions 3. Prostaglandin- cervical ripening- will help if not dilated at all 4. Artificial rupture of membranes Bishop score- low score if cervix is thick and baby is high Ptosis vs cytoteck- can control the amout of ptosin Activity can help
List 3 key points to include in a teaching plan for a woman who is learning how to breast feed:
1. Teach the mother the correct positions (e.g. Cross cradle hold) 2. Latch techniques 3. Frequency of feedings 4. Care of nipples 5. How much baby poops and pees 6. Signs of mastitis- hard and red streaks
Breech presentations occur in about 3% of births. List 3 disadvantages to this type of presentation:
1. The buttock are not smooth and firm like the head and are less effective at dilating the cervix. 2. The fetal head is the last part to be born. By the time the fetal head is deep in the pelvis, the umbilical cord is subject to compression between the baby's head and the mother's pelvis. 3. Because the umbilical cord can be compressed after the fetal chest is born the head must be delivered quickly to allow the infant to breathe. This necessary speed does not permit gradual molding of the fetal head as it passes through the pelvis.
What are the 4 potential sources of labor pain?
1. Tissue ischemia (not enough O2) 2. Cervical dilation 3. Pressure and pulling on cervix 4. Distention of vagina and perineum
List 4 theories of what triggers labor:
1. Uterine stretching 2. Pressure on cervix 3. Oxytocin stimulation (what mom releases) 4. Placental age (40 + weeks) 5. Increased fetal cortisol levels 6. Prostaglandin production by fetal membranes
List 3 reasons why the number of c-sections is increasing in the U.S.
1. Women are having fewer children, and those having their first baby are likely to have a cesarean than those who have delivered vaginally in the past. 2. Both medically indicated and elective inductions continue to rise increasing the risk for cesarean, particularly for the nullipara having an induction. 3. Obesity is prevalent which increases the risk for pregnancy complications that result in cesarean.
Judy gained 22 pounds with her pregnancy. How much (on average) can she expect to lose with delivery of her child?
12 pounds
Where should the fundus be when palpating day 3 after delivery?
3 cm below umbilicus. Within 12 hours the fundus rises to about the level of the umbilicus. Then the fundus descends 1 cm or 1 finger breath per day so that the 14th day the fundus cannot be palpated abdominally.
Ovulation after childbirth can occur as early as
3 weeks
When a woman presents to the L& D unit, what assessment data is most important to collect/review within the first ½ hour of her admission?
A focused assessment, fetal assessment, maternal vital signs, consent forms, alert the physician, EDD. GBS status, if positive then get IV fluid going, C section if herpes is active.
Define: spinal headache and how it is treated.
A spinal headache can occur after a spinal block. A spinal headache is postural, worse when the woman is upright and may disappear when she is lying flat. ***treated with taking blood from mom and infusing it back into the epidural site (blood patch)
1. A toctranducer "toco" monitor will work best with each of the following (select all that apply) a. An 8-pound fetus- works better with heavier babies b. A 4-pound fetus c. A woman with a BMI of 29- doesn't work well with higher amounts of abdominal fat. d. When it is located over the fundus- where it is the strongest.
A/D
The most important nursing measure following an amniotomy is the same as with a SROM. What is it?
Assess the fetal HR for at least one full minute after rupture.
What is your first priority when the bag of water ruptures?
Assess the fetal HR for one full minute. You want to make sure that the cord doesn't' prolapse. Next, vaginal exam, do you see the cord protruding out of the mother?
Explain why lochia flow may increase temporarily when the mom first gets out of bed:
Because gravity allows blood that has pooled in the vagina during the hours of rest to flow freely when she stands.
Why does the L & D unit always have Narcan available?
Because it is a narcotic antagonist. Antidote for overdose, reduces respiratory depression induced by opioids, and reverses pruritus from epidural opioids.
What should normal amniotic fluid look like? What if it is brownish green? What if it is yellow?
Brownish green- indicates meconium staining which can be associated with fetal compromise. Yellow- suggests infection Normal- clear, possibly containing flecks of white vernix.
Explain the postpartum changes in the cervix and the vagina:
Cervix- formless, flabby, and opened wide. Small tears and lacerations can be present and is often edematous. Healing is rapid and can harden in 1 week. Vagina- the walls appear edematous with small lacerations. Very few vaginal folds are present. The hymen is torn. It will take 6-10 weeks for the vagina to complete involution and gin approximately the same size and contour that it had before pregnancy.
Pitocin or Cytotec are frequently used for labor induction and promotion of progress. How are these two different?
Cytotec is popular for preinduction cervical ripening and labor because of its low cost's stability and ease of use. It is a synthetic prostaglandin tablet. Pitocin is a synthetic form of oxytocin and is administered via IV. It is a synthetic version of naturally occurring hormone (oxytocin).
Explain why we might offer Judy a DTP vaccine prior to discharge.
DTP is safe during and after pregnancy. This can help prevent her baby from getting whooping cough. (pertussis). Generally, need every 3-5 years.
What is the clinical indication/concern for each of the patterns you defined in #55?
Early- mirror images of the contractions, return to FHR baseline by the end of the contraction, associated with fetal head compression. Late- look like early decelerations but begin after the contraction begins often near the peak, may not fall far from the baseline, nursing intervention is to improve placental blood flow and fetal oxygen supply. Variable- may be nonperiodic occurring at times unrelated to contractions. Their shape, duration, and degree of fall below baseline are variable.
Judy is close to delivering her baby. She has leg tremors, is nauseated, and very irritable. What stage is she probably in?
End of stage 1 (transition stage)
True or False. Episiotomies should be routinely performed to reduce tearing. (An incision of the perineum just before birth)
False
True or False. Fundal checks are not required for a mother who had a c-birth.
False
True or False. Tearing doesn't occur if an episiotomy is performed.
False
True or False? An episiotomy should be routinely done to prevent tearing during delivery.
False
What are the benefits of an epidural over general anesthesia?
General anesthesia is more of a systemic pain control and involves the loss of consciousness, unlike an epidural. General anesthesia is not used for vaginal births. Mom has control of her own airway with epidural. No chance of aspiration with general anesthesia. Biggest risk for epidural is hypotension!! If so, then push bolus of fluid! 2,000ml to prevent hypotension!
Why is a vaginal birth preferred over a c-birth (think of implications for both the mother and the child):
Having a C-section is a major surgery. A mother can lose up to 1,000ml of blood versus vaginal birth which is 500ml. There is higher risk for bleeding, scars, infection. If the mother has a vaginal birth, it is likely the mom and baby will have sooner contact with each other, the hospital stay may be shorter, the woman is likely to have other C-sections for future children. Baby's get squished so their amniotic fluid filled lungs can come out.
Why is it important to have your patient void regularly when in labor?
Having a full bladder can make delivery difficult and can prevent the baby from exiting.
The leading cause of maternal postpartum mortality is
Hemorrhage
1. Your patient is dilated to 10 cm with a paper-thin cervix. She does not feel the urge to push yet. What should you do?
If the mom has had spinal block, it may be possible that she won't be able to push. Otherwise, I would give it just a little more time until she feels the bear- down urge. ** Yes, just let the mom rest - called LABORING DOWN Paper thin cervix-ready to go.
How does the nurse determine if the vaginal drainage is in fact amniotic fluid?
If the woman lays on her side and it pools, that is amniotic fluid. After laying on her side it will all rush out at once. If it was urine, then it would be a continuous trickle. **Vaginal exam to check discharge against pH paper or a fern test( most reliable)
Explain the importance of waiting until your patient is dilated to a full 10 cm before she starts to push:
If you do not wait, the baby will not be able to come out. It needs to be at least 10 cm dilated. Otherwise, it can be harmful to both mom and baby. **Increased likelihood of mom to teat, edema can increase difficulty
Judy calls the L & D unit. She is 38.2. She thinks she might be in labor. What questions would you ask her to differentiate between true and false labor (Braxton Hicks):
If you get up and walk around, do the contractions stop? If so, then it is Braxton Hicks contractions. Is the contraction from front to back or back to front?
Are there any risks with labor induction? Yes/no and explain.
Induction and augmentation of labor can be associated with risks of spontaneous labor and have added risks from the procedure itself. This can include uterine tachysystole (hyperstimulation) which reduces placental perfusion and fetal oxygen caused by excessive duration and frequency of contractions. Uterine rupture that occurs with overdistention. Maternal water intoxication caused by oxytocin antidiuretic effects. Greater risk for chorioamnionitis and caesarean birth. More so with Cytotec vs ptosin Ptosin secrets anti diuretic hormone so mom will have swollen ankles and fluid retention.
Explain the difference between intermittent auscultation of fetal heart rate versus electronic fetal monitoring.
Intermittent is measured at regular intervals Electronic- continuous
Explain the changes that happen to the uterus in the first 6 weeks after birth:
Involution of the uterus. This entails 3 processes 1. Contraction of the muscle fibers 2. Catabolism (the process of converting cells into simpler compounds) 3. Regeneration of uterine epithelium Involution begins immediately after delivery of the placenta.
List two reasons why a physician may perform an amniotomy.
It is a superficial rupture of the amniotic sac. Done with a hook 1. Inducing or expediting labor 2. The placement of internal monitors- scalp electrode which tells us baby's HR. Other monitor used is for contractions to check strength it is called IUPC intra uterine, but most be dilated at least 2cm and amniotic sac has to be broken to get probes in.
The doctor orders prn Benadryl for your patient who got an epidural. What side effect is she experiencing?
Itching
Retained placenta fragments can cause what?
Late postpartum hemorrhage. This is usually preventable. HCP will inspect placenta to see if it is intact, otherwise will manually remove fragments. Infection.
Your patient is in stage 4 of delivery. Her pulse is increasing, her blood pressure is dropping, she has soaked a peri pad in 15 minutes, and her fundus is soft. What is the first thing you as a nurse will do?
Massage the fundus
A laboring mom's temperature is checked every 2 hours after the bag of water is ruptured. Why?
Maternal fever increases the fetal temperature and fetal oxygen requirements.
When Judy delivers, she complains of a chill, and she is shaking. Do you need to notify the doctor? Yes/no and explain your answer.
No, I would not alert the doctor. This is common after delivery; it usually lasts about 20 minutes and will subside spontaneously. A warm blanket of hot soup can help. Assure the mom that this is okay.
Why is postpartum depression now called "peripartum" depression?
Peripartum recognizes that depression related to pregnancy can occur before the baby is even born.
What can the Dr give to help stimulate contractions?
Pitocin or cytotek
Explain how excessive pain can compromise both the unborn baby and the labor process:
Poorly relieved pain lessens the pleasure of this extraordinary life event for both partners. The mother may find that it is difficult to interact with her infant because she is depleted from a painful exhausting labor. It can affect placental blood flow, Contractions can become shorter, less frequent, and less effective slowing the process of labor.
What can the Dr give to help with cervix thinning and dilating?
Prostaglandin
1Explain how the fetus maintains adequate circulation even though maternal blood flow to the fetus stops during contractions:
The baby's hemoglobin is high (14/15/16) and oxygen is in the intervillous space. When mom has contraction the baby is fine for a min or two because of its extra oxygen carrying capacity.
Explain why the HCP may look for the score of the Bishop Scale before starting an induction***
The bishop score uses five factors estimate cervical readiness for labor which include cervical readiness for labor, cervical dilation, effacement, cervical consistency, position, and fetal station (we want to be a positive number in relation to ischial spine). This remains popular due to its ability to predict probable success with of induction. The likelihood of vaginal birth is like that of spontaneous labor if the score is greater than 8.
Are there any risks with the use of Pitocin? Yes/no and explain.
The contractions may become too strong (hypertonic).
Is there any risk to the newborn when a HCP uses a vacuum during delivery? Yes/no and explain
The infant may come out with ecchymoses, circular scalp edema, redness and bruising called a chignon but can resolve quickly after birth. vacuuming can cause inter cranial bleeding which can lead to mental retardation
You palpate the fundus of your patient and find it +2 and off to the side. What action do you take?
The nurse should massage it and have the mother urinate as that suggests a full bladder. It should be firm, never soft. Help the mom urinate if she cannot then a catheter should be placed.
Would a woman at station -2 be closer to delivery than a woman at +2 station? Explain your answer.
The woman at +2 is closer because this indicates the baby is further out. If the baby were a -2, it indicates that the baby is still high up in the mom.
What is the only contraindicated position for your patient to be in during labor? Explain your answer.
The woman should avoid supine position with no side tilt. It is best for the woman to be in upright positions as it adds the force of gravity to fetal descent.
What is the greatest risks for a pregnancy that extends past 40 weeks
There is an increased risk for a stillborn baby and fetal death.
Explain why a laboring mother could have an elevated white blood cell count (as high as 25,000):
This can be related to stress from pregnancy and is expected to be higher. However, in a healthy person who is not pregnant his would indicate and infection. 5-10K is normal. Releases catecholamine! Would be normal to have this elevation for up to a week.
Explain each of the following: lochia rubra, lochia serosa, and lochia alba.
This can provide information about whether involution is progressing normally. Rubia- For the first 3 days of childbirth the lochia consists mostly of blood. It has a red/brown color. The amount decreases by the 4th ay. Serosa- composed of serous exudate, erythrocytes, leukocytes, and cervical mucus. By the 11th day the erythrocyte component decreases. Alba- white, crème or light yellow in color. It contains leukocytes, fat, cervical mucus etc. This is present in many women until the 3rd week but can last up to 6 weeks.
Why is it important to determine if the bag of water has ruptured when the woman presents to the L & D unit? If it was already ruptured, what questions would you ask the patient?
This is important to know because if the bag of water has ruptured, labor will begin soon after. It is also important because the umbilical cord could be displaced. If it was already ruptured I could ask, when did it happen? Was it a gush or a trickle?
Why does the HCP order 1000-2000 ml of IV fluid to be infused prior to an epidural block?
This is infused to prevent hypotension with regional anesthesia.
We like to see "moderate variability" (defined as fetal heart rate changes of 6-25 beats per minute) for the fetal heart rate during labor. What does this indicate?
This is usually a re-assuring sign that reflecting that the fetus has a responsive central nervous system.
Judy delivered her son two days ago. She has diastasis recti. What does she need to know about this?
This is when the longitudinal muscles of the abdomen separate. It can be minimal or severe. The mother can benefit from gentle exercises to strengthen the abdominal wall. This usually resolves in 6 weeks.
What should the nurse do when she determines that there is a prolapsed umbilical cord?
This is when the umbilical cord slips down after the membranes rupture, subjecting it to compression between the fetus and the pelvis. The priority intervention id to relieve pressure on the cord to restore blood flow. The doctor should be contacted immediately and prepare for birth. Meanwhile the nurse can: Position the hips higher than her head to shift the presentation, knee chest position, Trendelenburg position or hips elevated with pillows. If elevating the hips do not work then vaginal elevation of the presenting part using sterile gloved hand may be required.
Judy has RH negative blood. The son that she just delivered is RH positive. Explain to Judy why she needs a Rhogam injection prior to discharge:
This keeps the immune system from making permeant antibodies to Rh- positive blood. I'd explain Judy that she will get this during each pregnancy. She is Rh negative which just means that she has no protein on red blood cells. Her baby is Rh positive, so it has protein on its red blood cells. Rhogam helps with future pregnancies.
Explain why we might offer Judy a rubella vaccine before she leaves the hospital:
This vaccine was not safe to take while Jenny was pregnant. MMR vaccine will help prevent, measles, mumps, rubella, and varicella. She can only get this after pregnancy, not during because this is a live vaccine. Should not get pregnant for a month after rubella shot. Recommended after childbirth to prevent abnormalities in future children as well. If mom gets rubella during pregnancy, then development problems for baby.
True or False. A mediolateral episiotomy decreases the risk of a tear into the anal area.
True
True or False. Any drug taken by the woman during labor may affect her fetus.
True
True or False. Drugs may affect the course and length of labor
True
True or False: most woman experience some degree of "baby blues" during the postpartum period.
True
True or False: post-partum psychosis is always a medical emergency.
True
True or False? The best incision for a c/s is a horizontal incision as it decreases chances of uterine rupture during a subsequent pregnancy.
True
True or False: anaphylactoid syndrome is life threatening. Explain
True (Amniotic fluid embolism) is rare but very serious. It can cause a widespread, proinflammatory, anaphylactic like reaction of the amniotic fluid enters maternal circulation.
True or False: a placenta accreta could be a medical emergency. Explain:
True This means that the placenta has grown too deeply into the uterine wall. It can cause severe blood loss after delivery.
Are there any risks with the use of Cytotec? Yes/no and explain.
Uterine rupture, maternal hemorrhage, tachysystole.
What is the greatest risk for a mother undergoing a VBAC?
Uterine rupture. Because mom has incision and could pop open
Why would a HCP not do a version on a woman who has a planned C-section?
Version is used to try and a void a C-section. If she has a planned C-section there is likely a reason. Some of these reasons can include uterine malformations that limit the room available to perform the version, previous cesarean birth, disproportion between fetal size and maternal pelvic size, fetal size 4,000 g or larger.
What are the priorities for the newborn immediately after birth?
Vital signs every 15 min, making sure the baby is adjusting to birth, stays warm and bonds with the mother. ABC baby, DRYING infant off!! (hypothermia is a huge problem with babies)
What are the priorities for the mother immediately after birth?
Vital signs every 15 min, monitor peritoneum and vaginal area for bleeding, tears, trauma and swelling. Bladder assessment. Monitor the fundus (it should be always firm to prevent excess bleeding). Amount and character of lochia expect rubra lichia, less than 1 pad per hour. Ice pack for mom 24 hours, then heat and soaking in the tub.
Judy states that she lost about 3 pounds the last week of her pregnancy. Is this normal? What can cause this?
Yes, this is normal because of the changing levels of estrogen and progesterone cause excretion of some of the extra fluid that accumulates during pregnancy.
You need to order a breakfast tray for your patient in labor. What will you probably order?
You don't want the mother to drink a lot of fluid or eat anything heavy. Id likely order jello, applesauce, moderate amount of liquids, maybe even toast.
Review again:
a. Bishop score: a score of 8 or greater means a better chance of having a vaginal birth. Less than 6 need cervical ripening. The highest score is 13. If doing an induction, the higher bishop score to start the better chance of successful vaginal delivery. b. Nagele's rule: is used to determine the baby's EDD. You take the last day of the mom's last menstrual period, minus 3 months, add 7 days. c. Frequency versus duration of contractions: frequency is how OFTEN (start to start) and duration is HOW LONG. d. 4 stages of labor: First stage/3 phases: *Latent phase: cervix 0-3cm. The patient is social and easy to distract. *Active phase: cervix 4-7 cm. more intense regular contractions. Patient needs breathing and active relaxation. *Transition phase: cervix 8-10 cm. Most intense phase, the mom often feels out of control and wants to give up. Second stage: from full dilation to delivery of the neonate. Third stage: from delivery of the neonate to delivery of the placenta Fourth stage: the first 4 hours after delivery of the placenta as the woman recovers
Explain the effect of labor on each of these body systems:
a. Cardiovascular system: during each uterine contraction, blood flow to the placenta gradually decreases causing a relative increase in the woman's blood volume. Will increase blood pressure slightly and lower the woman's pulse. Vital signs will best be addressed during contractions. The mother should be encouraged to rest in positions other than supine to promote blood return to her heart and therefore enhance blood flow to the placenta and promote fetal oxygenation. b. Respiratory system: Depth and rate of respirations increase. Breathing rapidly and deeply may cause symptoms of hyperventilation if she exhales too much carbon dioxide. Help the mom slow her breathing. Breathing in a paper bag can help. c. Gastrointestinal system: Gastric motility is reduced. Most women not hungry but thirsty and gave a dry mouth. Food and large volumes of liquid are usually limited to reduce the risk of vomiting and aspiration if unexpected surgery is needed. **Continue drinking fluids d. Urinary system: reduced sensation of a full bladder. A full bladder can inhibit the fetus from exiting. Fluid retention is normal during pregnancy but reverts to normal after delivery. Urine is excreted in large quantities and the bladder will fill rapidly the first few days after birth. ** Void every 2-3 hours e. Hematopoietic system/normal blood loss: 500ml is the average blood loss, 1,000 for C section. Levels of several clotting factors may be higher during labor and after delivery. Fibrinolysis (clot breakdown) decreases during labor to promote coagulation at the placental site. Risk for venous thrombosis increases during pregnancy and after birth. **1g drop in hemoglobin is normal to 8 or 9. Prior to delivery it is thicker d/t clotting factors, placenta will be separating. Blood is more hypercoagulable leading to DVT/blood clots
Define the following:
a. Contraction Frequency: How often-you measure from the beginning of one contraction to the beginning of the next. b. Contraction duration: How long-the length of the contraction beginning to end. c. Contraction intensity: How strong- mild (nose), moderate (chin), strong (forehead) d. Effacement: the cervix must efface, or thin and dilate in order for the baby to pass through the vagina. Efface means that it gets thinner. This is the only thing that shows true progressive labor (cervical dilation and effacement) e. Dilation: the opening. A major cervical change during labor. Dilation and effacement occur together during labor but at different rates. As the cervix is pulled upwards and the fetus is pushed downward, the cervix dilates. f. The 4 "P's" of labor: Powers, Passage, Passenger, Psyche- all of these have to be in working order for the mom to deliver. Muscles on top of uterus are stronger than the bottom. g. Cephalic presentation: The baby's head is down. You want this position. h. Breech presentation: Occurs when the baby's butt or feet enter the pelvis first. This is a big disadvantage. i. Braxton Hicks contractions: false labor contractions. Irregular mild contractions. j. Lightening: when the baby drops. 2-3 weeks before delivery. k. Bloody show: a mixture of thick mucus and pink or dark brown blood may occur as the cervix begins to soften, dilate, and efface slightly. (the plug) can lose earlier during pregnancy, can have multiple plugs. l. Energy spurt: happens to most women before they go into labor. m. Fontanels: 2 soft spots on the baby's head. The anterior fontanel is diamond shaped and closes at 18 months. The posterior fontanel is a triangular shape and closes in 2-3 months. The plates of skull can override to allow for birth. n. Leopold maneuvers: is when you feel the position of the baby and try to move the baby if it is not in the right position. You'd first feel the fundus to tell if it's the baby's head or butt, then feel down the side to see what side the baby's back is, feel for the head or butt above the suprapubic area. This is only done if head down to check head flexion. o. SROM: spontaneous rupture of membrane (breaks on its own) p. AROM: artificial rupture of membrane (with the use of a hook) q. Apgar score: this is a test for newborns after birth and given twice. Right away and 5 min after birth. This checks the baby's heart rate, reflex response, color, respiratory effort, and muscle tone. Lose points typically on color (acrocyanosis is very common) r. Fundus: the top part of the uterus, opposite from the cervix.
Define:
a. Early decelerations: fetal head compression for any reason increases intercranial pressure, causing the vagus nerve to slow the heart rate. Early decelerations are not associated with fetal compromise and require no further intervention. b. Late decelerations: impaired exchange of oxygen and waste products in the placenta. The fetus may develop acidemia which can depress cardiac function because of poor oxygenation. c. Variables: conditions that reduce flow through the umbilical cord result in variable decelerations. Fall and rise abruptly in 30 seconds.
1. Explain the treatment for: Mastitis, Endometriosis
a. Endometritis: IV antibiotics is the initial treatment. Other medications can include antipyretics. Women may be given a single prophylactic IV dose to anyone having a c-section. b. Mastitis: occurs 2-4 weeks after childbirth but can develop anytime during breast feeding. Treated with antibiotic therapy and continued emptying of the breast as the first line of treatment.
Explain the function of each:
a. Fetal scalp electrode - detects electrical signals from the fetal heart b. Intrauterine pressure catheter (IUPC): there are two different kinds and can be used to measure uterine activity including contraction intensity and resting tone.
Explains what occurs in each of the stages of labor:
a. First stage/3 phases: dilation of cervix 0-10, irritability 1. Latent phase: cervix 0-3cm. The patient is social and easy to distract. 2. Active phase: cervix 4-7 cm. more intense regular contractions. Patient needs breathing and active relaxation. 3. Transition phase: cervix 8-10 cm. Most intense phase, the mom often feels out of control and wants to give up. b. Second stage: from full dilation to delivery of the neonate. c. Third stage: from delivery of the neonate to delivery of the placenta d. Fourth stage: the first 4 hours after delivery of the placenta as the woman recovers
Explain what happens to each of the following body systems during the postpartum period
a. Gastrointestinal system: shortly after childbirth digestion begins and the mother is usually hungry. Constipation is a common problem after giving birth. Intestinal tones were diminished during pregnancy. Perineal trauma and hemorrhoids can cause discomfort. Normal bladder and bowel function can normally resume 8-14 days after birth. b. Urinary system: the urethra, bladder and tissue around the urinary meatus become edematous and traumatized. The bladder will fill rapidly because of diuresis. Many new mothers do not have the sensation to void. Urinary retention an overdistention of the bladder can cause UTI's. Stress incontinence can get better after 3 weeks. c. Musculoskeletal system: the mother may experience muscle fatigue for 1-2 days after giving birth. Warmth and gentle massage can increase circulation. Ligaments and cartilage of the pelvis start to resume to their normal positions. Correct posture and good body mechanics are important. d. Integumentary system: many skin changes occur due to hormones. Hyperpigmentation begins to recede. Stretch marks fade to silver lines but usually do not disappear. Hair loos will begin 4- 20 weeks after delivery and can be regrown in 4-6 moths for most women. Otherwise, it can take upwards to 15 months. e. Endocrine system: rapid decline in placental hormones. HgC is present for 3-4 weeks. If the mother is not breast feeding, then the pituitary hormone prolactin which stimulates milk secretion returns to non-pregnant levels in 14 days.
Define the following:
a. Hypertonic contractions: occur during the latent phase of labor, uncoordinated and erratic in frequency, duration, and intensity. b. Placenta abruption: premature separation of the normally implanted placenta. c. Placental infarcts: results from a interruption of blood supply to a part of the placenta which causes the cells to die. d. Nuchal cord: when the umbilical cord becomes wrapped around the neck of the fetus all the way. e. Oligohydramnios: too little of amniotic fluid around the baby during pregnancy.
Explain how each of the following influence pain perception and/or tolerance:
a. Intensity and length of labor: the woman who has a short, intense labor often complains of severe pain because each contraction does so much work. A rapid labor may limit her options for pharmacological pain relief. b. Cervical readiness: if pre- labor cervical changes (softening with some dilation and effacement) are incomplete, the cervix does not open as easily. More contractions are needed to achieve dilation and effacement resulting in a longer labor and greater fatigue. c. Fetal position: an occiput posterior fetal position is a common variant seen in otherwise normal labors. This can cause intense back discomfort. d. Characteristics of the pelvis: the size and shape of a woman's pelvis influence the course and length of her labor. Abnormalities can cause a longer labor and fetal malpresentation or position. e. Cultural differences: can influence how the mother interprets and responds to pain during childbirth. f. Previous experiences with pain: a woman who has been through childbirth before has a different perspective. They may be aware of normal labor sensations and is less likely to associate them with injury or abnormality. g. How prepared mom is for childbirth: preparation reduces anxiety and fear of the unknown. It allows a woman to rehearse for labor and learn a variety of skills to master as labor progresses. h. Planned versus unplanned pregnancy: planned pregnancies give the mom more time to prepare. The mom may have a better support system from the spouse if it was planned.
Explain each of the following drugs that could be used for intrapartum pain management:
a. Meperidine: adjunct to epidural anesthesia, may be repeated every hour by PCA. b. Fentanyl: onset is quick (5 min for IV administration), but the duration is short. c. Nubain: 5-10 mg may be given to relieve pruritus associated with epidural narcotics. d. Nitrous oxide: the woman does not become unconscious, helps to relax the mother and does not cause harm to the baby.
Postpartum hemorrhage can be treated with the following medications. Explain the effect of each:
a. Pitocin: increases uterine tone and controls bleeding. Rapid via IV. b. Methergine: may be given IM but can increase blood pressure so if she is hypertensive this is not an option. IV can be used in a life-threatening emergency. It stimulates sustained contraction of the uterus and cause arterial vasoconstriction. c. Cytotec: increases uterine tone and helps to control bleeding. d. Hemabate: is a form of prostaglandin. It is used to treat post-partum hemorrhage and can be given IM.
List 3 potential reasons for each of the following: Postpartum hemorrhage and infection
a. Postpartum hemorrhage: retained placenta, 5 or more children, rapid or prolonged labor, uterine fibroids, preeclampsia, coagulation defects. b. Postpartum infection: operative procedures like a c-section, multiple cervical examinations, prolonged labor, diabetes, catheterization, manual extraction or retained fragments, premature use of tampons and sexual activity, contaminating pads (washing hands well when changing pads).
Explain an epidural block:
an injection given in the woman's back to cause numbness to the lower half of the body.
Explain why diuresis and diaphoresis are common for post-partum women
because the body is retaining a lot of water.
What are the factors of the bishop score? ****
cervical dilation, effacement, cervical consistency, position, and fetal station (we want to be a positive number in relation to ischial spine)
Why might the HCP insert a prostaglandin in the cervix of a pregnant woman
prostaglandin helps with cervix thinning and dilating. doesn't stimulate contractions (Pitocin or Cytotec are used for this)
A common mnemonic to help us remember what each of the patterns mean is VEAL CHOP. Define
these acronyms are used for fetal acceleration and decelerations. Variable (look like random dips, sharp, come back to baseline quickly. Do not correlate with mom's contractions) ----Cord Compression (first thing you want to do is reposition mom) Early (looks like a mirror of the contraction)----Head compression (the contraction itself is pushing on the baby's head) Don't need to do anything about these. Acceleration (baby's HR accelerating when mom has contraction)----OK (do nothing it is ok) Late (begin after the contraction starts) ---- Placental Insufficiency (most concerning, can't support life anymore, turn mom, increase fluids, stop ptosin, if it doesn't get better then C-section)
A mother who received Pitocin during her labor has a significant amount of postpartum ankle swelling. Could the Pitocin have played a part in this?
when Pitocin is administered, it triggers the release of ADH