Chapter 16

What can we do to comfort patient during active phase? [8]

Position changes Semirecumbent Lateral Upright Hands/knees Massage Effleurage Use counterpressure

How do we do Fundal Checks? How should fundus remain?

Position woman with knees flexed and head flat The fundus remains contracted in the midline of the abdomen

When does labor begin? How does this occur? What can help this to occur?

When contractions are presented: - Contractions cause naturally by mom producing hormone - Baby produced hormones during this phase from fetal adrenal gland Labor can be induced by oxytocin

What happen in the 2 stage of birth?

- Prepare delivery bed , position patient for delivery, equipment set up, perineal scrub performed, Turn warmer on - Perineum bulges and flattens - stool may pass - UC q 1-3" Strong, woman may feel out of control - Ferguson's reflex-Women pushes-uncontrollably - Ring of Fire- crowning - Episiotomy if needed - Birth of Head-Ritgen maneuver - Delivery of Infant- note time

What does a sterile vaginal exam determine? When do we do this exam? Such as? (4) Why? Who is this contraindicated in? [3]

1. Status of Amniotic membranes (intact, bulging) 2. Status of Cervix- (soft, firm, anterior or posterior) 3. Dilation- 0cm (closed) to 10 cm (complete) 4. Effacement- (0% long and thick up to100% completely thin/gone) 5. Fetal station- where is the presenting part in 6. Fetal Presentation- The presenting part (head, breech, shoulders) and The position (left, right, anterior, posterior, transverse) relation to the ischial spines 7. Engagement- well applied to cervix, or floating in abdomen Only when indicated: 1. Upon admission 2. Before administering Meds 3. Significant changes in contractions or FHR 4. Women complains of pressure - risk for infection - Placenta previa - abruptio placentae [rupturing of placenta] - preterm premature rupture of membranes (PPROM)

What is a contraction lasting over 90 secs? Why? What should we do?

A emergency can cause fetal distress - If we were administering potosin we would want to slow the rate and manage/monitor for this

__________ labor can last longer in certain women, but should not be alarming unless there are signs of distress.

Active

When the perineum bulges and flattens, what do that indicate? Where do we typically see this?

Delivery is about to occur 2nd stage of labor

When does the placenta come out? What will we see prior to placenta coming out? [5] Once we see these sign have mom do what? What do we need to do once placenta is out? [2] What do we need to assess for? [2]

Duration 5-30 minutes after birth - Do NOT rush this - Contractions- intermittent , mild to moderate - Firmly contracting fundus- size of grapefruit - Change in shape of uterus - Sudden gush of dark blood from introitus - Apparent lengthening of umbilical cord Ask mom to push once again --> Vaginal fullness --> Placenta expelled - Note exact time on clock - Start 20 units of Pitocin - Obtain Cord Blood Start this after placenta comes out Excessive blood loss Alteration in vital signs and consciousness

What is placenta previa? What is abruptio placentae? These are both what?

It is a condition in which the placenta develops over and covers the cervix. - improperly implanted premature separation of the placenta from the uterine wall [rupturing of the placenta] contraindicated for SVE

How long is 1st stage, active phase typically? How long will mom be in the 1st stage, active phase if nulliparas? Multiparas? How much is she dilating ?

Nulliparas- 5-7 hrs 1cm/hr approx. Multiparas- 2-4 hrs. 1.5cm/hr

How long is 1st stage, transition phase typically? How long will mom be in the 1st stage, transition phase if nulliparas? Multiparas? How much is she dilating?

Nulliparas- 5-7 hrs 1cm/hr approx. Multiparas- 2-4 hrs. 1.5cm/hr

Sometimes with SROM, the umbilical cord can do what? What should we do?

Prolapse - monitor FHR closely for abnormals

Why do we not want PROM?

Risk for bacteria infection r/t baby being out of placenta TOO long

Different techniques to confirm ROM:

Speculum exam Nitrazine paper: if urine is wont change color Ferning: get a swab and put on glass and look at with a microscope AmniSure testing kit

The multigravida mother with a history of rapid labor who is in active labor calls out to the nurse, "The baby is coming!" which of the following would be the nurse's first action? a. Inspect the perineum b. Time the contractions c. Auscultate the fetal heart rate d. Contact the birth attendant

a. Inspect the perineum

The client's vaginal examination reveals: 3 cm dilated, 80% effaced, vertex at -1 station. The woman is talkative and appears excited. The nurse determines the client to be in which stage and phase of labor? a.1st stage, active phase b.1st stage, latent phase c.2nd stage latent phase d.3rd stage, transition

b. 1st stage, latent phase

Mrs. Adams is awakened one morning by a sudden gush of fluid from the vagina. Ms. Adams was experiencing: a. bloody show b. spontaneous rupture of membranes c. dilatation of the cervix d. effacement of the cervix

b. spontaneous rupture of membranes

The nurse would assist the laboring woman into a hands-and-knees position when: the occiput of the fetus is in a posterior position. the fetus is at or above the ischial spines. the fetus is in a vertex presentation. the membranes rupture.

the occiput of the fetus is in a posterior position.

What is APGAR?

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)

How to time contractions:

Must document the frequency, duration, and strength

What can cause n/v in pregnant woman? What can we do to help this?

Slowing of gastric motility - ice chips

If pregnancy history isn't presented, what do we need to do?

scan uterus

What is lochia?

vaginal discharge after childbirth

Nursing Interventions in Second Stage of labor:

1. Get Mom into a good pushing position 2. Sterile Table Set up 3. Perform a Perineal scrub 4. Turn Infant Warmer on-Check Infant Resuscitation equipment -oxygen, laryngoscope, suction 5. Implement Periods of Push and Rest. To avoid excessive fatigue, implement rest periods during second-stage pushing efforts.

How long is 1st stage, latent phase typically? How long will mom be in the 1st stage, latent phase if nulliparas? Multiparas? How are contractions presented her?

4-6 hours Nulliparas- 8 1⁄2 hours Multiparas - 5 hours * Irregular contractions

If mom expresses the ned to defacate, what should we assess?

Cervical dilation --> may mean she's about to go into labor

Watch for Bladder distention-especially with epidural. Why?

Epidural decreases sensation of urine sensation

When pushing, encourage pt NOT to do this:

Hold their breath

A pregnant woman on IV fluids should be monitored for what?

I&O to see if fluid overload [hypervolemia] is occurring - pregnant women tend to retain fluid

What is the 4th stage of labor? What is considered normal blood loss in this stage? If more than this? What needs to be assessed? How often? [5]

THE RECOVERY STAGE: 1st 4hrs after delivery of placenta. - At least 2 hours 250-500mL - more than 500mL = hemorrhage Assess Vital signs, fundus, bladder, lochia, perineum every 15 minutes

When trying to decide if patients contractions are true or false, have them to what?

Walk

Once water in broken, we need baby out by what time?

by 24 hours after water broke

Ms. Adams also notes a pinkish discharge. This is called the a. lochia b. labor c. strep B discharge d. bloody show

d. bloody show

What do with infant as soon as they're born?

- Place infant under radiant warmer, Stimulate, dry infant, assess Apgar's, attach heart, temp monitor to infant - Obtain cord blood - Apply bands, footprint, cord sensor to infant [protects baby from getting stolen] - Apgar: 1 and 5 minutes, VS q15 after Apgar assessed

Want them to be _________ dilated before we do epidural.

4cm

TACO is used for what? What does it stand for?

Assessing membrane rupture Time Amount Color - if green and chunky = meconium has occur early which indicates baby was stressed <-- NOT good Odor - should smell sweet = amniotic fluid

What diet restriction will mom be on when admitted?

Clear liquids or NPO