Labor & Birth Process

Incomplete Breech

In a footling or incomplete breech one or both legs are presenting.

System Analgesia

Route: Typically administered parenterally through existing I.V. line. Drugs: Opioids such as butorphanol, nalbuphine, meperidine, fetanyl. Ataractics such as hydroxyzine, promethazine. Benzodiazepines such as diazepam, midazolam.

Criteria for Using Continuous: Internal Monitoring of the FHR

Ruptured membranes. Cervical dilation of at least 2 cm. Present fetal part low enough to allow placement of the scalp electrode. Skilled practitioner available to insert spiral electrode.

Absent

fluctuation range undetectable

Two weeks after a vaginal birth, a client presents with low-grade fever. The client also reports a loss of appetite and low energy levels. The health care provider suspects an infection of the episiotomy. What sign or symptom is most indicative of an episiotomy infection?

foul-smelling vaginal discharge.

Dilation

0 cm: external cervical os is closed. 5 cm: external cervical os is halfway dilated. 10 cm: external os is fully dilated and ready for birth passages.

Effacement

0%: cervical canal is 2 cm long. 50%: cervical canal is 1 cm long. 100%: cervical canal is obliterated.

False Pelvis

Above linea terminalis. Upper flared parts of two iliac bones and concavities. Wings of base of sacrum.

Key Terms Related to Fetal Heart Rate

Accelerations. Artifact. Baseline fetal heart rate. Baseline variability. Deceleration. Electronic fetal monitoring. Periodic baseline changes.

What would the nurse use to monitor the effectiveness of intravenous anticoagulant therapy for a postpartum woman with deep vein thrombosis?

Activated partial thromboplastin time. The activated partial thromboplastin time is used to monitor the effectiveness of intravenous anticoagulant therapy, most commonly heparin.

android

male-shaped, not favorable

Cephalic (Vertex)

military, brow, face.

Platypelloid

not favorable

True Pelvis

Below linea terminalis. inlet, midpelvis, outlet (pelvic measurements).

Passageway: Bony Pelvis

Linea terminalis. True pelvis. False pelvis.

Four Categories of Baseline Variability

absent, minimal, moderate, marked

Second Stage of Labor

cervix 10 cm dilated to birth of baby.

The injection of a local anesthetic to block specific nerve pathways is referred to as:

pudendal block. A pudendal block is a form of regional anesthesia that successfully blocks pain sensation in a designated body part, in this case the the pudendal nerve.

A woman telephones the prenatal clinic and reports that her water just broke. Which suggestion by the nurse would be most appropriate?

"Come to the clinic or emergency department for an evaluation." When the amniotic sac ruptures, the barrier to infection is gone, and there is the danger of cord prolapse if engagement has not occurred. Therefore, the nurse should suggest that the woman come in for an evaluation.

Cardinal Movements of Labor

1. Engagement. 2. Descent. 3. Flexion. 4. Internal Rotation. 5. Extension. 6. External Rotation. 7. Expulsion.

The first stage of labor is often a time of introspection. In light of this, which information would guide the nurse's plan of care?

A woman may spend time thinking about what is happening to her. Women need a support person with them during all stages of labor.

Fetal Assessment During Labor & Birth

Amniotic fluid analysis. Fetal heart rate monitoring: Handheld versus electronic; intermittent versus continuous; external versus internal. Fetal heart rate patterns: Baseline, baseline variability, periodic changes. Other assessment methods: Fetal scalp sampling, pulse oximetry, stimulation.

A nurse is caring for woman in labor. The woman's membranes just ruptured. The nurse assesses the characteristics of the fluid. Which finding would the nurse identify as normal?

Amniotic fluid should be clear when the membranes rupture.

The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize?

Assess the woman's fundus. The nurse should prioritize assessing the uterine fundus to eliminate it as a source of the bleeding.

Nursing Management of Laboring Women

Assessment. Comfort measures. Emotional support. Information and instruction. Advocacy. Support for the partner.

Passenger: Fetal Presentation

Cephalic (vertex). Military. Brow. Face. Breech. Frank. Full or complete. Footling or incomplete. Shoulder.

Premonitory Signs of Labor

Cervical changes. Lightening. Increased energy level. Bloody show. Braxton Hicks contractions. Spontaneous rupture of membranes.

Position: Maternal

Change Position: Squatting, Kneeling on all fours. Supine, with or without use of stirrups. Side lying.

A nurse is monitoring the fetal heart rate (FHR) of a client in labor using an electronic fetal monitor. The reading shows a late deceleration. Which intervention will the nurse implement?

Change maternal position to side-lying position.

Non-pharmacologic measures for pain management

Continuous labor support. Hydrotherapy. Ambulation and position changes. Acupuncture and Acupressure. Attention focusing and imagery. Therapeutic Touch and Massage; Effleurage. Breathing techniques.

Continuous Electronic External Fetal Monitoring

Contraction monitor sensor. Fetal heart rate sensor.

The nurse is caring for a client who is experiencing a non eventful labor process. Which assessment findings may occur as the client progresses through the stages of labor?

Dry mucous membranes. Nausea. Increased white blood cell count. Increased urine specific gravity. Hyperventilation. The nurse is correct to identify that normal changes occur during the labor process. Due to mouth breathing and drinking limited fluids, if any, dehydration with dry mucous membranes and elevated urine specific gravity are common. Since labor prolongs gastric emptying, client may experience nausea. An increase in white blood cell stemming from immune response is common.

General Anesthesia

Emergency cesarean birth or woman with contraindication to use of regional anesthesia. I.V. injection, inhalation, or both. Commonly, first thiopental IV to produce unconsciousness Next, muscle relaxant. Then intubation, followed by administration of nitrous oxide and oxygen; volatile halogenated agent also possible to produce amnesia.

Regional Analgesia/Anesthesia

Epidural block: continuous infusion or intermittent injection; usually started when dilation >5 cm. Combined spinal-epidural block aka walking epidural. Patient-controlled epidural. Local infiltration that is usually for episiotomy or laceration repair. Pudendal block, usually for 2nd stage, episiotomy, or operative vaginal birth. Intrathecal, spinal analgesia/anesthesia, during labor and cesarean birth.

Breech

FRANK : BUTT presents at cervix, most common type of breech. FULL/Complete breech: Reversal of cephalic, BUTT and FEET present at cervix. Footling breech: one or both feet present first. Indicates Cesarean: ESPECIALLY WHEN TRANSVERSE WITH SHOULDER PRESENTING TO CERVIX.

Psychological Response

Factors influencing a positive birth experience: Clear information on procedures. Support, not being alone. Sense of mastery, self confidence. Trust in staff caring for her. Positive reaction to the pregnancy. Personal control over breathing. Preparation for the childbirth experience.

False Labor

False: Irregular rhythm, not close together. Abdominal pain, felt in the front of abdomen, decreases with ambulation. Drink fluids, walk to see any change in intensity of the contractions. If contractions diminish, stay home.

The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned?

Fetal position. When documenting the ROA, this is the right occiput anterior or the relationship of the fetal position to the mother using the maternal pelvis as the point of reference.

Passenger

Fetal skull. Fetal attitude. Fetal lie. Fetal presentation. Fetal position. Fetal station. Fetal engagement.

Pelvic Shape

Gynecoid. Android. Anthropoid. Platypelloid.

A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention?

Help the woman change positions.

Physiologic Responses to Labor: Maternal

Increased heart rate, cardiac output, blood pressure, during contractions. Increased white blood cell count. Increased respiratory rate and oxygen consumption. Decreased gastric motility and food absorption. Decreased gastric emptying and gastric pH. Slight temperature elevation. Muscle Aches and Cramps. Increased BMR. Decreased blood glucose levels.

A nurse is caring for a client with a postpartum laceration. Which nursing diagnoses would be most appropriate?

Ineffective tissue perfusion. Risk for injury. Impaired tissue integrity

Guidelines for Assessing Fetal Heart Rate

Initial 10 to 20 minute continuous FHR assessment on entry into labor/birth area. Completion of a prenatal and labor risk assessment on all clients. Intermittent auscultation every 30 minutes during active labor for low-risk women and every 15 minutes for high-risk women. During second stage of labor intermittent auscultation every 15 minutes for low-risk women and every 5 minutes for high-risk women.

Continuous Electronic Internal Fetal Monitoring

Intrauterine pressure catheter. Internal fetal monitor. Electrode.

The nurse is caring for a client whose fetus is noted to be in the position shown. For which fetal lie would the nurse provide client teaching?

Longitudinal. The picture shows the fetus parallel to the maternal spine, which denotes the longitudinal lie.

A woman presents to the clinic at 1-month postpartum and reports her left breast has a painful, reddened area. On assessment, the nurse discovers a localized red and warm area. The nurse predicts the client has developed which disorder?

Mastitis. Mastitis usually occurs 2 to 3 weeks after birth and is noted to be unilateral. Assessment should reveal a localized reddened area that is warm and painful to palpation.

Maternal Assessment During Labor & Birth

Maternal status, vital signs, pain, prenatal record review. Vaginal examination, cervical dilation, effacement, membrane status, fetal descent, and presentation. Rupture of membranes. Uterine contractions. Leopold maneuvers.

The nurse is monitoring a client who has given birth and is now bonding with her infant. Which finding should the nurse prioritize and report immediately for intervention?

Maternal tachycardia and falling blood pressure

Moderate

Normal fluctuation range from 6 to 25 bpm.

Comfort & Pain Management

Pain as universal experience; intensity highly variable. Mandate for pain assessment in all clients admitted to health care facility. Numerous non-pharmacologic and pharmacologic choices available.

Passenger: Fetal Engagement

Presenting part reaching 0 station. Floating: no engagement; presenting part freely movable about pelvic inlet.

A nurse is coaching a woman during the second stage of labor. Which action should the nurse encourage the client to do at this time?

Push with contractions and rest between them.

Which neonatal assessment is the highest priority if the mother received meperidine during labor?

Respiratory rate. The fetal respiratory rate immediately after delivery assessed as respiratory depression is a side effect of the maternal dose of meperidine.

Signs of Placental Separation

The uterus rises upward. The umbilical cord lengthens. A sudden trickle of blood is released from the vaginal opening. The uterus changes its shape to globular.

TACO

Time. Amount. Color. Odor.

A nurse is a caring for a postpartum client. What instruction should the nurse provide to the client as a precautionary measure to prevent thromboembolic complications?

To help prevent the occurrence of postpartum thromboembolic complications, the nurse should instruct the client to avoid sitting or standing in one position for long periods of time.

A client comes to the emergency department reporting strong contractions that have lasted for the past 2 hours. Which assessment will indicate to the nurse that the client is in true labor?

True labor is defined as the onset of regular uterine contractions that cause progressive cervical dilation (dilatation) and effacement.

First Stage of Labor

True labor to complete cervical dilation, 10 cm. Longest of all stages. Two phases: latent phase, 0 to 6 cm. Active phase, 6 to 9 cm.

True labor

True: regular, rhythmic contractions that intensify with ambulation, close together 4 to 6 minutes apart, lasting 30 to 60 seconds. Pain in abdomen sweeping around from back, cervical changes.

continuous electronic fetal monitoring

Uses a machine to produce a continuous tracing of the FHR. Produce a graphic record of the FHR pattern. 110 to 160 bpm. 2 types: internal and external. Primary objective. To provide information about fetal oxygenation and prevent fetal injury from impaired oxygenation. To detect fetal heart rate changes early before they are prolonged and profound.

The nursing instructor is leading a discussion exploring the various conditions that can result in postpartum hemorrhage. The instructor determines the session is successful when the students correctly choose which condition is most frequently the cause of postpartum hemorrhage?

Uterine atony

Powers

Uterine contractions, primary stimulus. Intra-abdominal pressure from mother pushing and bearing down. Contractions: involuntary: thin and dilate cervix. Three parameters: Frequency, Duration, Intensity.

Factors Influencing the Onset of Labor

Uterine stretch. Progesterone withdrawal. Increased oxytocin sensitivity. Increased release of prostaglandins.

A nurse is reviewing the fetal heart rate pattern and observes abrupt decreases in FHR below the baseline, appearing as a U-shape. The nurse interprets these changes as reflecting which type of deceleration?

Variable decelerations present as visually apparent abrupt decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions.

Veal Chop

Variable, Early, Acceleration, Late, Cord Compression, Head Compression, Ok, Placental Insufficiency.

A nurse is assessing the perineum of a postpartum woman using the REEDA scale. The woman is one day postpartum. The nurse notes that the woman has serous discharge. Which score would the nurse assign this finding?

When using REEDA score, each component is assigned a score 0 to 3. Serous discharge would be given a score of 1. A score of 0 would be used if no discharge was present. A score of 2 is assigned if there is serosanguinous discharge present. A score of 3 is assigned if there is bloody, purulent discharge present.

Periodic Baseline Changes

accelerations and decelerations.

Third Stage of Labor

birth of infant to placental separation. Placental separation. Placental expulsion.

Passageway: Soft Tissues

cervix. pelvic floor muscles. vagina.

linea terminalis

division of false and true pelvis

The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at 0 station. When questioned by the client as to what has happened, the nurse should point out which event has occurred?

engagement. The movement of the fetus into the pelvis from the upper uterus is engagement. This is the first cardinal movement of the fetus in preparation for the spontaneous vaginal delivery.

gynecoid

favorable for vaginal delivery

Marked

fluctuation range >25 beats per minute.

Minimal

fluctuation range observed at < 5 bpm.

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?

occiput. With a vertex presentation, a type of cephalic presentation, the fetal presenting part is the occiput.

Passenger: Fetal Attitude

relation of fetal body parts to each other head flexed is good, head extended is bad.

Passenger: Fetal Lie

relationship of long axis of fetus with long axis of mom : termed longitudinal or transverse.

Which assessment finding in a client reporting uterine contractions would be most consistent as an indicator of approaching labor?

rupture of amniotic membranes

Cervix

thins through effacement to allow presenting part to descent into vagina.

A woman's primary care provider has told her he wants to use an episiotomy for birth. She asks the nurse what the purpose of this is. Which answer would be best?

"It relieves pressure on the fetal head."

Critical Factors Affecting Labor and Birth: 5 P's

Passageway: birth canal: pelvis & soft tissues. Passenger: fetus and placenta. Powers: contractions. Position: maternal. Psychological response.

Physiologic Responses to Labor: Fetal

Periodic FHR accelerations and slight decelerations. Decrease in circulation and perfusion. Increase in arterial carbon dioxide pressure. Decrease in fetal breathing movements. Decrease in fetal oxygen pressure; decrease in partial pressure of oxygen.

Five Additional Factors Affecting the Labor Process

Philosophy: Low Tech, High Touch. Partners: Support Caregivers. Patients: Natural Timing. Patient Preparation: Childbirth Knowledge Base. Pain Control: Comfort Measures.

A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client?

Postpartum hemorrhage is defined as blood loss of 500 ml or more after a vaginal birth and 1000 ml or more after a cesarean birth.

pelvic floor muscles

Separate the pelvic cavity from the perineum. Support organs of pelvis.

A new mother is holding her infant after a feeding. Which behavior by the mother would be concerning to the nurse related to malattachment?

She refers to the infant as "it" instead of saying the infant's name.

Pharmacologic Measures for Pain Management

System Analgesia. Regional or local anesthesia. Neuraxial Analgesia/Anesthesia techniques: use of analgesic or anesthetic, continuously or intermittently into epidural or intrathecal space. Shift in pain management: woman as an active participant during labor.

Upon examination of a postpartal client's perineum, the nurse notes a large hematoma. The client does not report any pain, and lochia is dark red and moderate in amount. Which factor would most likely contribute to the nurse not discovering the perineal hematoma prior to the examination?

The client has a history of epidural anesthesia. If a client has an epidural, her sensation of pain is decreased, so nurses cannot rely on client reports of pain as a symptom of a perineal hematoma.

Full or complete breech

The full or complete breech occurs when the fetus sits crossed-legged above the cervix.

What is a risk factor for developing a postpartum infection?

type 1 diabetes. prolonged labor. cesarean birth

anthropoid

usually adequate

Fourth Stage of Labor

1 to 4 hours following delivery.

Epidural vs spinal block

Epidural goes into epidural space & spinal block goes into cerebral spinal fluid.

Passenger: Fetal Position

Landmarks: Occipital bone O: vertex presentation. Chin: mentum M: face presentation. Buttocks: sacrum S: breech presentation. Scapula: acromion process A: shoulder presentation. Three-letter abbreviation for identification.

Passenger: Fetal Skull

Largest and least compressible structure. Sutures: allow for overlapping and changes in shape (molding); help identify position of fetal head. Fontanels: intersections of sutures; help in identifying position of fetal head and in molding. Diameters: occipitofrontal, occipitomental, suboccipitobregmatic, and biparietal.

Which client outcome during the active phase labor is best?

The client will practice breathing techniques during contractions. Being tense works against cervical dilation (dilatation) and fetal descent. For that reason, the client is encouraged to practice breathing techniques.

A nurse is assessing a female client in the labor admission unit. The client has been having contractions every 5 minutes for the past 6 hours. Which finding would the nurse use to determine if the client is experiencing true labor?

The client's cervix has changes of effacement and dilation (dilatation).

A nurse is caring for a postpartum client who has a history of thrombosis during pregnancy and is at high risk of developing a pulmonary embolism. For which sign or symptom should the nurse monitor the client to prevent the occurrence of pulmonary embolism?

calf swelling. The nurse should monitor the client for swelling in the calf. Swelling in the calf, erythema, and pedal edema are early manifestations of deep vein thrombosis, which may lead to pulmonary embolism if not prevented at an early stage.

A 19-year-old female presents in advanced labor. Examination reveals the fetus is in frank breech position. The nurse interprets this finding as indicating:

the buttocks are presenting first with both legs extended up toward the face. In a frank breech position, the buttocks present first with both legs extended up toward the face.