NUR 221 EXAM 2

Cesarean Birth pre op considerations

NPO Foley SCD's prophylactic abx Allergies Labs Consent Teaching Shave area

Eclampsia

patient with preeclampsia starts having seizures as well. -may occur postpartum -have to delivery baby -50% of seizures occur during labor 25% before and 25% after ma

Frequency of contractions are measured from the...

peak of one contraction to the peak of the next contraction (or beginning to beginning)

newborn thermoregulation

Normal temp- 97.7-99.5 -After delivery put the baby on mom to regulate temp -Newborns can't shiver -Newborn has thin SQ fat layers and brown fat -Check bs levels, babies with low bs are cold -Composed of more body water than adults -Abdominal wall defect can lose heat easily -Rewarm baby slowly -Wrap baby in blanket and put on hat -Take temp axillary (under arm)

POISON stands for

P- position change (to left side) O- oxytocin off I- increase IV rate (give extra fluids) S- sterile vaginal exam O- oxygen (10 L nonrebreather) N- notify MD or CNM

APGAR

Score 2, 1, 0 Appearance (all pink, pink and blue, blue (pale) Pulse (>100, <100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent) Normal RR 30-60 Resuscitate if pulse <100 ventilate, <60 compress Complete this test at 1 and 5 minutes after birth and then every 5 minutes if score is less than 6 Interventions: 7-10 routine post delivery care 4-6 some resuscitation- O2, suction, stimulation/rub baby 0-3 full resuscitation

Fourth stage of labor

Recovery stage Begins after the delivery of the placenta and continues for one to four hours after the delivery. **Nursing right after birth will help the uterus to contract and will decrease the amount of bleeding Check vitals at least every 15 minutes for the first 2 hours Fundal check Newborn exam Apgar score

Second stage of labor

Stage of Expulsion Begins with complete cervical dilation and ends with delivery of fetus **Baby is moving through the birth canal Forceful contractions (Somatic Pain) PUSHING STAGE

Augmentation of labor

Stimulation of ineffective uterine contractions after labor has started spontaneously but is not progressing satisfactorily Cervical changes are happening but no contractions Invasive: oxytocin, amniotomy Noninvasive: ambulation, emptying bladder, change position, hydration, nourishment, relation techniques Operative: Forceps, Vacuum assisted

neonatal pain management

Swaddling Rocking Sucrose Skin to skin Breastfeeding Pacifier Low light Low noise Tylenol Opioids

What is normal FHR?

110-160 bpm newborn is the same

Stadol (butorphanol)

-used for Pain management -narcan DOES NOT reverse Stadol effects -Can be used throughout labor [should not be given within 1 hour before delivery]

Oxytocin (Pitocin)

-Chemical cervical ripening method -Hormone normally produced by the pituitary gland -Stimulates uterine contractions -helps promote aid breast milk production (letdown) -Used for induction of labor (speeds up labor process) Maternal Hazards: Uterine rupture, postpartum hemorrhage, placenta abruption, infection, unnecessary c-section d/t abnormal FHR patterns Fetal Hazards: hypoxemia, acidemia may have late decels and minimal absent variability (POISON MOM) Nursing Considerations: Assess FHR frequently, monitor contractions and mothers status, frequent vitals Uterine tachysystole can occur (5 contractions in 10 minutes) stop or slow down infusion

Preeclampsia risk factors

-Nulliparity -Age >40 or <18 -interpregnancy interval >7 yrs -family history of preeclampsia -woman born small for gestational age -obesity/gestational DM -preeclampsia in previous pregnancy -poor outcome in previous pregnancy -preexisting medical conditions -chronic htn -renal disease -type 1 DM -factor V leiden mutation -mulitfetal pregnancy -African American

Non-stress test (NST)

-ultra sound record movement, doppler measures fetal HR, assess fetal well being -Reactive if 2 or more acceleration with 15bpm lasting 15 seconds for 20 min with return to baseline -if less than 32 weeks 10 bpm lasting 10 seconds -if the test is nonreactive the patient should have a biophysical profile (BPP)

Minimal FHR variability

1-5 bpm

Moderate FHR variability

6-25 bpm what we want

bradycardia FHR and causes

<110 bpm due to perfusion issues, body is in distress

Tachycardia FHR and causes

>160 bpm if mom is tachy too could be due to infection

Marked FHR variability

>25 bpm

chronic hypertension

A blood pressure that is equal to or greater than 140/90 mm Hg, which exists prior to pregnancy, occurs before the 20th week of pregnancy, or continues to persist postpartum. Risk factors: African American Obese Primary HTN High Risk For: superimposed preeclampsia, stroke, acute kidney injury, heart failure, placental abruption, and death Fetal Risks: IUGR, death, preterm birth Tx: Antihypertensive drugs, Labetelol, nifedipine, methydopa, and thiazide diuretics **Methyldopa and Labetelol are the drug of choice for breastfeeding moms

Assessment Tests for Fetal Well-Being (ALONE)

A- Amniocentesis L- L/S Ratio (2:1) O - Oxytocin Test N - Non-Stress Test E - Estriol Level

Category 3 FHR tracing

Absent Variability 0 bpm sinusoidal pattern tachycardia bradycardia late decels variable decels TX: DELIVERY

Nubain (Nalbuphine)

Analgesic, Opioid agonist- antagonist Pain relief during labor- MOST COMMON IV PUSH SLOW

Magnesium Sulfate

Anticonvulsant Given with preeclampsia to prevent seizures and also helps to slow everything down and lower BP. Helps neurologically with the fetus and can help prevent cerebral palsy or other defects. -Given IV, give a loading dose 4-6 grams in 100mL IV fluid over 15-20 mins and then a maintenance amount of 40 Gms in 1000 mL with LR IV 2 grams per hour -Maintain serum Mg level of 4-8 -Antidote: calcium gluconate Assess for: Respirations <12 Maternal Oximeter reading <95% Hyporeflexia or DTR (Patella) Urinary Output <30 mL/hr Toxic serum level >8 mg/dL Fetal Distress or drop in FHR A significant drop in maternal pulse or BP

Methyldopa (Aldomet)

Antihypertensive S/E: sleepiness, postural hypotension, constipation, anemia, hepatic dysfunction Can take while breastfeeding

Factors that influence pain response

Anxiety Culture Previous Experience Expectations Physiologic Factors Environment Gate Control Theory Comfort

Cesarean Birth Post op considerations

Assess vitals often Assess s/s infections NPO until pass gas Assess incision Splint incision Ambulation (as often as you can) Stool Softeners Pain Relief Management Incentive Spirometer Do not use straws Rock in a rocking chair Lie on left side to help expel gas

Baseline FHR

Average FHR in 10 minute window. Does not include accelerations or decelerations and it must be in between contractions. There must be at least 2 minutes of identifiable baseline.

Category 1 FHR tracing

Baseline FHR 110-160 Moderate Variability 6-25 bpm NO late or variable decels early decels accelerations 15x15 (2 in 20 minutes reactive)

neonatal pain assessment

CRIES pain scale score each category 0-2 Crying Require O2 sat >95 Increased vitals Expression Sleepless NIPS used for age 0-1

Maternal adaptation to labor

Cardiac output increases 10-50% in first stage: 30-50% in second stage Heart rate increases slightly blood pressure increases during contractions WBC count increases RR increases Temp may be elevated slightly proteinuria may occur gastric motility and absorption of solid food are decreased: N/V may occur Blood glucose level decreases

Neonatal Pain S/S

Diaphoresis Crying Increase or Decrease in vitals Clinching fists Hyperglycemia Whimpering Groaning Grimace Chin quiver Eyes closed tightly Brows furrowed Rigidity Limb withdrawal Irritable Changes in feeding pattern

Nonpharmacologic Pain Management

Dick-Read method Lamaze method Bradley method hypno-birthing Relaxation techniques imagery and visualization Breathing techniques Effleurage Counterpressure touch and massage heat/cold therapy acupressure/acupuncture TENS intradermal water block aromatherapy hypnosis biofeedback music

Cytotec (misoprostol)

Drug class: Prostaglandin E1 (PGE1) Preinduction Cervical Ripening Given before Oxytocin to induce labor Usual dose/route: 100 or 200 mcg tablet which is prepared in pharmacy to ensure proper dosage. Initial dose is 25mcg inserted transvaginally into the posterior of the vaginal fornix using the tips of the index and middle fingers WITHOUT lubricant. Repeat every 3-6 hours up to 6 doses in a 24 hour period or until and effective contraction pattern is established, the cervix ripens (Bishop score of 8 or more) or adverse reactions occur. Side effects: higher doses more likely to cause nausea vomiting, diarrhea, fever, uterine tachysystole, with or without an abnormal FHR and patterns or fetal passage of meconium. The risk for adverse reactions is reduced with lower doses at longer intervals between doses. Use in obstetrics: Used to ripen the cervix making it softer and causing it to begin to dilate and efface, stimulating contractions. Do not give if woman has a hx of previous cesasarian birth or other major uterine surgery. Patient teaching: explain procedure to patient and family. Void before insertion, must maintain a supine with lateral tilt or side-lying position for 30-40 min after insertion. Avoid taking antacids

Cervadil (Dinoprostone)

Drug class: Prostaglandin E2 -Preinduction cervical ripening -Given before oxytocin to induce labor Dosage/Route: 10 mg inserted transvaginally. left in place for 12 hours or at the onset of active labor or earlier if tachystole or abnormal FHR pattern occur Gel: 0.5 mg administer through cath interested in cervical canal just below internal cervical OS. may be repeated every 6 hours up to 24 hours. S/E: N/V/D, fever, uterine tachysystole, abnormal FHR, fetal passage of meconium Nursing Considerations: Avoid use in women with asthma, glaucoma, and hypo/hyper tension. Do not give if previous C-section or other major uterine surgery. Assess labor status, Assess fetal status Pt teaching: instruct woman to void before insertion, maintain supine position or lateral tilt for 30-40 min after insertion

cesarean anesthetic protocols

Educate mom on risks Spinal, epidural, general are all used after anesthesia is given 5 minutes to get baby out

Preeclampsia precautionary measures

Environment -Quiet, non-stimulating, lighting subdued Seizure Precautions -suction equipment tested and ready to use -oxygen administration equipment tested and ready to use -call button within easy reach Emergency Medications Available on the Unit -Hydralazine -Labetalol -Nifedipine -Mag Sulfate -Calcium Gluconate Emergency birth pack easily accessible

Mechanisms of Labor (Cardinal Movements)

Every = Engagement Darn = Descent Fool = Flexion In = Internal Rotation Egypt = Extension Eats Raw = External Rotation Eggs = Expulsion

Fetal adaptation to labor

FHR- normal 110-160 early decels normal during labor circulation- affected by many factors, maternal position, uterine contractions, blood pressure, and umbilical cord blood flow. No blood flow at peak of a contraction Respiration- Fetal lung fluid is cleared from the air passages as the infant passes through the birth canal, fetal oxygen pressure decreases, arterial carbon dioxide pressure increases, arterial pH decreases, bicarb level decreases, fetal respiratory movement decrease

What is TOCO?

For uterine activity palpate uterus for contraction Apply over fundus- make sure there is contact GOES ON TOP tells frequency and duration of contractions

Kick counts (fetal movement counting)

How many kicks in a 1 hour period of time should be the same time each day should be after eating don't do it when the baby is sleeping - notify dr. if less than 10 kicks in 1 hour period

Postpartum vaginal considerations

Ice therapy Peri care Sitz bath numbing spray Stool softeners Pt education- different types of lochia, stay on top of pain, peri care (clean front to back, pat dry)

Maternal cardiac disease

Impaired cardiac function usually results from a congential defect or history of rheumatic heart disease with valve prolapse or stenosis; dangerous because of plasma volume increase that accompanies pregnancy. Can happen up to 5 months postpartum. Risk Factors: Have prior heart disease >40 yo Have preeclampsia or HTN African American obese S/S: Extreme swelling or weight gain Extreme fatigue Fainting Persistent cough chest pain or fast heart beat severe SOB crackles orthopnea rapid respirations cyanosis moist, frequent cough Tx: Antepartum- decrease stress on heart intrapartum- watch O2, pulmonary artery cath, ECG, fetal HR, elevate head & shoulders, side lying position, epidural, prefer vaginal birth Don't deliver flat in stirrups/ No Valsalva maneuver

Signs preceding labor

Lightening return of urinary frequency backache stronger braxton hicks contractions weight loss 1-3.5 lbs surge of energy bloody show cervical ripening possible rupture of membranes

Cesarean Birth Indications

Maternal cardiac diseases Nonreassuring fetal status Malpresentation of fetus (breech or traverse lie) Active maternal herpes infection Cephalopelvic disproportion Placental abruption Placenta previa History of previous cesarean birth Cesarean birth on maternal request

Category 2 FHR tracing

Minimal variability 1-5 bpm Marked variability >25 bpm tachycardia bradycardia late decels variable decels

VEAL CHOP MINE

Mnemonic for decelerations Variable Decels Cord Compression Move Mom Early Decels Head Compression Identify labor progress Accelerations Okay No action Late Decels Placental insufficiency Emergency POISON

5 P's affecting labor and birth

Passenger: Fetal Head: size & fontanels Fetal Lie: relation to mothers spine Fetal attitude: relation to fetus body parts Fetal presentation: what part of body is in inlet Fetal position: presenting part of baby head in pelvis Passageway: birth canal Anatomy of pelvis Powers: Effacement Dilation need both dilation and effacement for true labor Contractions Position: Position can affect the woman physiologic adaption to labor How is the mother laying Psychologic Response: Place of birth Preparation Type of provider Nursing care Procedures

Third stage of labor

Placental stage Begins immediately after the fetus is born and ends when the placenta is delivered Placenta usually delivered 5-15 minutes after baby arrives. (Visceral pain similar to first stage)

What is Leopolds maneuver?

Purpose: to determine presentation and position of fetus and aid in knowing where to position FHR monitor Method: explain procedure to pt, have woman empty bladder, wash hands, stand beside, facing woman's head 4 maneuvers

First stage of labor

This is the stage of cervical dilation Begins with onset of regular contractions and ends with complete dilation Latent stage- 0-6 cm can last about 20 hours, irregular contractions from 0-3 cm dilation every 5-30 minutes lasting about 30 seconds. regular contractions from 3-6 cm dilated every 3-5 minutes lasting 1 minute plus may be 30-80% effaced Active stage- 7-10 cm intense contractions every 0.5-2 minutes lasting 60-90 seconds 100% effaced (Visceral Pain) **Longest stage of labor

Version

Turning the fetus from one presentation to another before birth, usually from breech to cephalic.

Cesarean Birth Complications and Risks

UTI Infection Poor Wound Healing Hemorrhage Anesthesia risks Atelectasis Bowel/Bladder issues Wound Dehiscence Fetal Asphyxia

Hydralazine

Vasodilator; Antihypertensive S/E: HA, flushing tachycardia, palpitations, N/V, decrease in uteroplacental blood flow Fetal S/E: tachycardia, late decels Contraindicated in maternal tachycardia Can take while breastfeeding

preeclampsia S/S & Tx

a complication of pregnancy characterized by hypertension >140/90, edema, and proteinuria -after 20 weeks gestation Severe htn > 160/110 S/S: edema above the waist, hyperactive deep tendon reflexes 3/4+, clonus present, proteinuria, HTN -Risk for seizures: assess for mental status changes, vision changes, worsening headache Labs: >300 mg protein in 24 hour urine specimen Protein/creatinine ratio > 0.3 >+1 on urine dipstick Random urine must have 2 samples at least 6 hours apart >30 mg/dL of protein in both samples CBC, BUN, creatinine, AST, ALT Biophysical profile needs to be done once or twice weekly to determine fetal wellbeing deliver fetus around 37 weeks S/S fetus: not a lot of movement, poor placental perfusion, late decels (POISON MOM) Tx: Foley (to assess organ perfusion) Seizure precautions, Deliver fetus, mothers bp should return to normal after the baby is delivered. teach mom to continue her current medication regimen after delivery and follow up with physician. -Diet: limit salt intake, increase protein, increase fluids

Absent FHR variability

amplitude range undetected

Accelerations in FHR

an apparent, abrupt increase in the FHR above baseline. -Greater than or equal to 32 weeks gestation -The increase from onset to peak in <30 seconds -The peak must be at least 15 bpm and last at least 15 seconds -If <32 weeks gestation at least 10 bpm for 10 seconds This is a normal good finding... Just document and continue to monitor.

Pudendal block

anesthetic administered to block sensation around the lower vagina and perineum for episiotomy or tearing, mom can still feel contractions

Variable decelerations- Fetal Heart Rate

are an abrupt onset of decreased FHR below baseline that may occur with or after a contraction -Is usually due to cord compression and may be associated with fetal acidosis. Intervention- Put mom on left side. Administer 10 L O2 nonrebreather

Amniotomy (AROM)

artificial rupture of membranes -performed by a physician or midwife during a vaginal exam, amnihook makes small hole in membrane -usually labor begins within 12 hours of rupture Nursing Considerations Record time of rupture Record how well mom handled procedure Check for s/s infection S/S bleeding Check FHR Assess fluid for color, odor, consistency Check meconium Assess temp every 2 hours

What should you do before giving pain medication?

assess for addiction Mother will likely experience withdrawal symptoms if given opioids and is/has been an addict

When is the only time the baby is being perfused while in labor?

at rest (between contractions)

Mechanical and Physical labor induction methods

balloon catheter hydroscopic dilators amniotic membrane stripping or sweeping sexual intercourse nipple stimulation walking

Labetalol (Trandate)

beta-blocker, antihypertensive S/E: lethargy fatigue, sleep disturbance, orthostatic hypotension Contraindicated in women with asthma, heart disease, and CHF

Nifedipine (Procardia)

calcium channel blocker, antihypertensive S/E: HA, flushing tachycardia, may interfere with labor AVOID USING WITH MAG SULFATE

Alternative methods of labor induction

castor oil evening primrose acupuncture blue cohosh

How can you tell the intensity of a contraction by feeling?

cheek= resting nose= mild chin= moderate forehead= strong

induction of labor

chemical or mechanical initiation of uterine contractions before their spontaneous onset for the purpose of bringing about birth Indications: Preeclampsia/Eclampsia, PROM, fetal death, chorioamnionitis, IUGR Contraindications: acute fetal distress, shoulder/breech presentation, uncontrolled hemorrhage, placenta previa

placenta previa

placenta implanted in lower uterine segment near or over internal cervical os 3 different types: complete, marginal, low lying -1 in 200 pregnancies Risk factors: Asian Age >40 or <18 smoking previous pregnancy uterine scarring high altitude S/S: PAINLESS bright red bleeding in the 2nd or 3rd trimester Dx: Transvaginal US Mgmt: Labs (H&H), bed rest, NST/BPP (maybe once/twice per week), if <34 wks give betamethasone to mom, pelvic rest, limit vaginal exams,

sinusoidal pattern- Fetal Heart Rate

differs from variability in that it is a smooth wave-like pattern of regular frequency and amplitude. -Has cycle frequency of 3-5 minutes and lasts for 20 minutes of longer. Intervention- Deliver fetus

Prolonged deceleration- Fetal heart rate

greater than 15 bpm and lasts 2-10 minutes from onset to return to baseline -a prolonged decel that lasts >10 minutes is considered a change in baseline

What is tachysystole?

greater than 5 contractions in 10 minutes and there is fetal tachycardia or late decelerations

Early Decelerations - Fetal Heart Rate

have a shape that is symmetrical, with a gradual decrease and return of FHR to baseline in association with a contraction -Means Head compression-normal labor process **gradual decrease **mirror image of contraction JUST OBSERVE-prepare for delivery, document normal labor

Late decelerations - Fetal Heart Rate

have a shape that is symmetrical. with a gradual decrease and return of FHR to baseline in association with a contraction -is usually due to uteroplacental insufficiency and fetal hypoxia -Although acidosis is not always present, may be associated with fetal acidosis (EMERGENCY, THIS IS THE WORST DECEL) -Intervention: POISON

HELLP syndrome

hemolysis, elevated liver enzymes, low platelet count -DISRUPTS PLACENTAL PERFUSION -10-20% of women with severe preeclampsia develop this -Appears more frequently in caucasian women. -Mortality rate 7.4-34% -Rate of preterm birth 70%, 15% before 28 weeks S/S: usually develops antepartum period most women report hx of malaise, flu-like symptoms, epigastric RUQ pain, headache, change is loc, vision changessymptoms worse at night and improve during the daytime. Dx: abnormal lab levels AST -10-30 ALT -10-40 Platelets 150-400k Dx for HELLP increases risk for DIC, placental abruption, liver hemorrhage or failure, ARDS, sepsis, stroke

Duramorph

morphine sulfate Opioid analgesic IV most common given after C section

Epidural

most effective pharmacologic pain relief method for labor that is available. -Injection is made between fourth and fifth lumbar vertebrae ** Give IV bolus before administration to help with hypotension -Vitals every 5 minutes -Foley -Spinal Headache can occur -Risk for spinal fluid leak (may need blood patch) -Assess FHR for impaired placental perfusion -Contraindicated with low BP, hemorrhage, bleeding disorders, cardiac problems -Call anesthesia to reverse drug if problem arises

Gestational hypertension

onset of hypertension without proteinuria or other systemic findings after 20 week gestation. BP >140/90. --Has to be recorded on 2 occasions at least 4 hours apart after 20 weeks gestation with a previously normal blood pressure. -About 25-50% of women with gestational Htn go on to develop preeclampsia Tx: Antihypertensive medications -Usually resolves first week postpartum

Placenta Abruption

premature separation of the placenta from the wall of the uterus, can be partial or complete detachment Risk Factors: cocaine use HTN smoking PROM multifetal pregnancy Trauma Hx of abruption anything that affects perfusion Dx: Transvaginal US (about 50%) others are diagnosed by clots found in the placenta S/S: Pain at site of detachment painful dark red vaginal bleeding boardlike abdomen can have blue discoloration uterine tenderness Maternal complications: DIC hypovolemic shock renal failure Fetal complications: IUGR preterm birth neurological defects MGMT: depends on degree of detachment if stable: monitor, assess fetus regularly (NST, BPP), betamethasone, serial labs (to check for hemorrhage), urine output, if stable VAGINAL DELIVERY if unstable or complete abruption: emergency C-SECTION, monitor vitals

Duration of contractions are measured from the...

start to finish of one contraction

Intensity of contractions

strength of contraction at its peak (mild, moderate, strong)

nadir

the lowest point after the onset of an early/late deceleration and variable

Biophysical Profile (BPP)

uses a real-time ultrasound for visualization of physical and physiological characteristics of a fetus. 5 variables assessed 1. Fetal breathing -Score 2- at least one episode of fetal breathing movements of at least 30 second duration in a 30 minute observation -Score 0- Absent fetal breathing or less than 30 seconds in 30 minutes 2. Fetal movements -Score 2- at least 3 trunk/limb movements in 30 minutes -Score 0- Fewer than 3 episodes of trunk/limb movements 3. Fetal tone -Score 2- at least 1 episode of active extension with return to flexion of fetal limb or trunk; opening and closing of hand considered normal tone -Score 0- Absence or movement or slow extension/flexion 4.Amniotic fluid index -Score 2- deepest vertical pocket >2 cm -Score 0- deepest vertical pocket <2 cm 5. NST -Score 2- Reactive -Score 0- Nonreactive Management Score 8-10- No interventions Score 6- need further testing Score 0-4 deliver fetus