NUR 413 Exam 3

Stages & Phases of labor: assessments & intervention

1st stage Onset of regular contractions to full (10cm) dilatation & effacement dilation/effacement Early labor: 1st phase 0-4cm Active labor: 2nd phase 4-7cm Transition: 3rd phase 8-10cm 2nd Full dilatation & effacement of the cervix to delivery of fetus Begins with full (10cm) dilation: Cervix no longer palpable Ends with delivery of newborn A woman may Bear down, have increased bloody show, vomit Become Restless, shaky, sweaty Cardinal movements of labor Engagement/descent, flexion, internal rotation, extension, external rotation, expulsion Birth sequence Descent: measured by station Crowning: visualization of the head Extension: delivery of the head/suction M-N External rotation: Delivery of the shoulders Spontaneous vaginal delivery: vertex presentation, occiput anterior 3rd Delivery of the fetus to delivery of the placenta Shiny Shultz: inside to outside margins Dirty Duncan: outside margins to inside, greater risk of retained placenta

3rd Stage Delivery of the Placenta: nursing interventions and risks associated

5-30 minutes following delivery of newborn Uterus contracts reducing surface area and force separation of Placenta Decreased estrogen and progesterone Accompanied by bleeding Efforts to reduce bleeding include Maintain uterine contractions Oxytocin 10U IM or IV Fundal massage Breastfeeding/kangaroo care Ensure all products of conception are delivered Examine placenta Site healed by 6 weeks

VBAC: Vaginal birth after Cesarean - criteria for this and when and when is this not a possibility

Indications for primary cesarean birth compatible Non-reoccuring situations Breech presentation Fetal distress Previous incision low-transverse Not compatible CPD Classic vertical incision Facility must be able to have anesthesia & OR available within 30 min Risk of uterine rupture isk of Uterine Rupture (0.9%) OB EMERGENCY Uterine trauma: accidents, surge

Group Beta Strep - clinical indications and tx

Maternal group beta streptococcus 10 to 40% of women GU, GI tract reservoir Culture 35-37 wks Vaginal, rectal ABX tx IV during labor Penicillin at least 1 dose, 4 hr prior to delivery Preferably 2 Clindamycin if risk of anaphylaxis w/PCN Challenge q6-8hr dosing Untreated or insufficient tx NB observation x 48hr for s/sx of infections

Assessing fetal well-being during labor: accelerations, variability, decels (Early, late, & Variable decelerations) and when

Baseline - reassuring Variability - reassuring Accelerations - reassuring Decelerations -variable/cord compression

Role of the RN in the non-medically indicated induction of labor (Slide about AWHONN article)

Be familiar with Medical indications for induction and augmentation of labor Post-term, gestational diabetes, preeclampsia Associated risks C/S Contraindications CPD, placenta previa Benefits of spontaneous labor Education For women and families Use effective communication BRAIN Benefits, Risks, Alternatives, Intuition, Not Now? Benefits of spontaneous labor Fetal maturity Passage of immune globulins peaks Cascade of hormones prepares mother and fetus Less stress on the mother Efficient contractions, less discomfort, expel placenta Less stress on the baby Easier transition to extrauterine life Clear fetal lung fluid More breastfeeding= Less illness

Medications for preterm labor. Ex: terbutaline, magnesium, nifedipine (uses, side effects, when and when not to administer)

Betamethasone SC: terbutaline, more commonly used Relaxes smooth muscle, inhibits UCs, causes bronchoconstriction Monitor for maternal pulmonary edema Maternal cardiac and metabolic risks of beta-mimetic therapy are Tachycardia, arrythmias, heart palpitations, jiterry, hydration, pulmonary edema Withhold if HR >120 Magnesium sulfate IV: relaxes smooth muscles Baseline observations include Urine output greater than 30 mL/hr Vital signs Alertness, cranial nerve examination, deep tendon reflexes (DTRs) Auscultation of lung fields The dose is 4-6 g IV over 20-30 mins, followed with a maintenance dose of 1-4 g/hr Therapy continued for 12 hrs after UCs have stopped Short term use (48 hrs) to allow for steroid prophylaxis Pt will feel flushing, warmth, HA, dizzy, dry mouth Monitor for Mag toxicity: Calcium gluconate rescue med Withhold if resp 12 or below, reflexes diminished, crackles, min. Output Nifedipine PO: procardia, calcium channel blocker Lowers intracellular Ca to inhibit UCs, give for 48 hrs or less Side effects: flushing, HA, tachycardia, palpitations, nausea, hypotension Indomethacin (indocin): NSAID Relaxes uterine smooth muscles by inhibiting prostaglandins. May be a better first-line tocolytic for early preterm labor (<32 wk) Preterm labor associated with polyhydramnios The renal effects of indomethacin may be beneficial to reduce polyhydramnios

Spontaneous rupture of membranes vs. artificial rupture of membranes, risks associated with AROM

Breaking-open of the amniotic membranes, releasing amniotic fluid. Rupture may be PROM (premature), SROM (spontaneous), or AROM (artificial). AROM risks: prolapsed cord, placental abruption, infection if labor doesn't begin with 12-24 hours, compression and molding of fetal head, fetal injury, bleeding, severe variable decelerations, increase in pain, and amniotic fluid embolism, inspect discharge

Pelvic dystocia & other factors that can impede labor (meds, bladder, etc)

Cesarean delivery: emergent, repeat Trial of labor after cesarean Fetal intolerance: non reassuring response to labor Failure to progress: dystocia Ineffective contractions, power Ineffective positioning of the passenger Ineffective fit, passageway Preterm: too early Emergencies Bleeding, shoulder dystocia, prolapsed cord, amniotic fluid embolism Breech Presentation A: Frank breech B: Incomplete (Footling) breech C: Complete breech in left sacral anterior (LSA) position D: On vaginal examination, the nurse may feel the anal sphincter. The tissue of the fetal buttocks feels soft Shoulder dystocia Head is born, but anterior shoulder cannot pass under public arch Newborn Birth injuries Mother Excessive blood loss, lacerations, extension of episiotomy, endometritis Bladder distension can cause a harder time when delivering the newborn since the mother will have a harder time applying pressure on the cervix during labor Some medications can also slow down the rate of contractions during labor

Benefits of childbirth preparation, positioning, breathing, & relaxation

Childbirth preparation offers several advantages. It helps a pregnant woman and her support person understand the choices in the birth setting, promotes awareness of available options, and provides tools for them to use during labor and birth. Another advantage is the satisfaction of the parents, for whom childbirth becomes a shared and profound emotional experience. In addition, each method has been shown to shorten labor. All nurses should know how these techniques differ, so that they can support each birth experience effectively. women who receive continuous support during labor require less analgesia, have fewer cesarean and instrument births, and experience a shorter period of labor. the need to provide ongoing support of the woman's partner/support person during the labor and birth process. Positioning Reduced muscle tension, improved relaxation, improved comfort, improved progression of labor by using gravity (ambulating, rocking, squatting). Breathing Distraction, improved oxygenation of both mom and baby

How to assess amniotic fluid. Interventions if amniotic fluid is meconium-stained

Color: clear, straw, white flecks, watery Is the fluid stained or discolored, indicating possible meconium contamination? Greenish brown meconium in fluid Yellow-stained fetal hemolytic disease, intrauterine infection Port wine- bleeding from abruptio placentae If meconium stained, neonatal resuscitation may need to begin (suctioning, establishing patent airway, etc.) Odor: earthy, fleshy, human Any unusual smell? Malodorous Amount (norm: 500-1200 mL) Has there been a sudden gush of fluid or a constant leakage? When was the last time the mother felt the baby move? Time When did the membrane rupture occur?

Prolapsed umbilical cord: assessment and interventions

Cord presentation/compression Variable decelerations, hypoxia ROM (PROM & PPROM) Assess FHR Move fetus off cord Keep cord damp w/sterile saline gauze Stay in place to OR Reposition patient knee chest or modified Sim's OB emergency Call OR team and prep for surgery Note pressure of presenting part on umbilical cord, which endangers fetal circulation Occult (hidden) prolapse of cord Complete prolapse of cord. Note that membranes are intact Cord presenting in front of fetal head may be seen in vagina Frank breech presentation with prolapsed cord Arrows indicate direction of pressure against presenting part to relieve compression of prolapsed umbilical cord Pressure exerted by examiner's fingers in Vertex presentation Breech presentation Arrows indicate direction of pressure against presenting part to relieve compression of prolapsed umbilical cord Gravity relieves pressure when woman is in modified Sim's position with hips elevated as high as possible with pillows Knee chest positions

Fetal lie, attitude, positions and presentation

Fetal attitude: relation of the fetal parts to one another General flexion Fetal lie: relationship of maternal and fetal spine Longitudinal, transverse Fetal presentation: the part of the body that enters the birth canal first Cephalic: 97% Vertex: the area between the fontanels Shoulder Scapula Breech Sacrum

Assessing intensity of contractions

Fingertips on fundus Mild Easy to indent, like tip of nose Moderate Difficult to indent, like chin Strong Rigid, board like, impossible to indent, like forehead

External cephalic version (ECV). When is this used and when should it not be used

Done on L&D around 37th week U/S done ahead of time Non-stress test (NST) Gentle, constant pressure on abdomen MgSo4 or terbutaline Prevents UCs Rh - women get Rhogam Must occur without force Buttocks pushed out of pelvic inlet while head is pushed towards it It is used to revert fetus from breech position to cephalic position prior to birth C/S delivery is planned if not successful

Characteristics of high functioning interdisciplinary teams (Slide about AWHONN article)

Effective communication Women, family, and members of care team Body language, nonverbal cues, courtesy, prior experience w/team Sleep Skills Listening, coping Teamwork Leadership, mutual performance monitoring, mutual support, respect, adaptability, avoidance of hierarchy, effective communication

Assessment of laboring patient

Maternal vital signs and assess systems Med/OB history and prenatal records (STIs, labs, GTPAL, etc) Labor status: CTXs, dilatation, effacement, membranes, station Fetal status: FHR, presentation, position, activity Labs: Type and cross, urinalysis (glucose, protein, ketones, UDS) Psychosocial: preparation, coping/response to labor, support Admission to L&D for labor Normal labor 4 cm dilated Active phase of the 1st stage ROM Risk of cord prolapse Risk of infection Collect urine Urine drug screen Protein 1+ or greater Pre-eclampsia Ketones Nutritional staus Glucose 1+ to 2+ or greater Diabetes Contractions 511 contraction pattern 5 minutes apart Lasting 1 minute Pattern persists for 1 hour Interview pt in between ctx's How to time contractions Duration: beginning to end of one contraction Frequency: beginning of one contraction to the beginning of the next contraction Intensity and palpation of uterine contractions Fingertips on fundus Mild Easy to indent, like tip of nose Moderate Difficult to indent, like chin Strong Rigid, board like, impossible to indent, like forehead Evaluation of CTXs Frequency Duration Wavelike pattern Increment, acme, decrement Normal gradient Stronger at the fundus Minimal at the cervix Leads to Cervical dilation, effacement, delivery of fetus Cervical exam Using sterile gloves and lubricant, perform a vaginal exam and determine the dilatation and effacement of the cervix

Shoulder dystocia: interventions, assessment of fetus post interventions

Note in the crib Proper positioning Shoulder and arm are adducted and internally rotated Erb's: passive ROM exercises Fracture: limit movements, splints Dress the injured arm first When undressing: do uninjured arm first then injured arm

Five P's

Passenger (fetus and placenta) Passageway (birth canal) Powers (contractions) Position of mother Psychological response

S/S & types of placenta previa and placental abruption

Placenta previa Painless Question induction orders Inquire about C/S More common African-American women Prior C/S Other risk factors Increased gravidity Parity Age Hx abortions Smoking tobacco Male fetus Low lying placenta Patient may labor and proceed with vaginal delivery B & C are partial and complete C/S required Placental abruption (Pain) Premature separation of placenta Leading cause of perinatal mortality Risk factors Increased maternal age Increased parity Use of tobacco Cocaine abuse= uterine rupture Trauma, HTN, previous abruption, rapid decompression of uterus (hydramnios), multiple gestation, PPROM, fibroids Three types of abruptio placentae A marginal abruption with external hemorrhage B central abruption with concealed hemorrhage C complete separation

Epidural placement: positioning, side effects, nursing interventions

Positioning for patients electing for an epidural sit upright, laying down side lying, with back curled and staying perfectly still Side effects of epidurals include: the inability to void, maternal hypotension and non-reassuring fetal heart rate patterns, decreased motor sensation in the lower extremities, and the need to stay in bed. Nursing interventions: use of foley catheter, IV lactated ringers, and oxytocin

Signs and symptoms of preterm labor: interventions

S/Sx preterm labor may be subtle, including Uterine contractions or menstrual like cramps Cervix is 1cm 80% or more effaced 4 ctx in 20 mins 8 ctx in 60 mins The feeling of pelvic pressure Increase in vaginal discharge Cramps with or without diarrhea Low, dull backache Inpatient management Pt is admitted to labor and delivery IV fluids Lt/Rt lateral recumbent position, bedrest Labs: CBC, C reactive protein, vaginal cultures and urine culture obtained NST 50% will stop contracting when treated with Hydration, bedrest Risk related to long term bedrest Isolation, DVT, constipation, muscle loss Gradual return to limited activity is planned if the labor has been arrested Administer tocolytics Drugs used to inhibit uterine contractions Treat and stop preterm labor Promote uterine quiescence-relaxation for external cephalic version To slow labor for maternal transport to a tertiary care facility Treat uterine hyperstimulation To buy time to implement other treatment modalities Begin administering antenatal glucocorticoids (steroids) Accelerate fetal lung maturity Reduce severity of sequelae in preterm births A gain of 24 hrs to several days is the best outcome Promote fetal lung maturity Betamethasone at 12.5 mg IM every 12-24 hrs for 2 doses Dexamethasone at 6 mg IM every 6 hrs for 4 doses is recommended Delivery must be delayed a minimum of 12 hours The benefits are proven to last 7 days Prophylactic steroids should not delay the delivery of an acutely distressed fetus

Use of Leopold's maneuver: purpose and what this can tell the nurse. How does the nurse perform the maneuvers

Series of four maneuvers designed to provide a systematic approach whereby the examiner may determine fetal presentation and position.

Use of Stadol and effects on fetal and maternal v.s.

Stadol is a narcotic analgesic medication and an opioid agonist-antagonist.2 Doctors may prescribe this medication to treat migraine headaches, relieve pain after surgery, or help with the pain during labor. Effects on moms and infants Moms Pain at the injection site Nausea and vomiting Drowsiness or sedation Dizziness Muscle weakness Itching Urinary retention Increased blood pressure Infants Apnea Slow breathing in the baby Sleepiness Poor feeding or breastfeeding Apnea Increased risk of sinusoidal fetal heart rate pattern

C/S: preparation/positioning for OR

Steps for surgical delivery Informed consent, Foley catheter, IV access, anesthesia, abdominal prep, hip wedge for the OR table Positioning: During caesarean section mothers can be in different positions. Theatre tables could be tilted laterally, upwards, downwards or flexed and wedges or cushions could be used.

Fetal fibronectin test

Symptomatic or at risk pts At 24-34 wks whose membranes have not ruptured Posterior vaginal swab Protein located in fetal membranes Produced by the placenta and membranes Is a predictor of the likelihood of preterm birth If negative: 99% of women will not go into labor in 1-2 weeks If positive: 15-20% will go into labor

Precipitous birth nursing interventions

The nurse manages precipitous birth in the hospital by encouraging the woman to assume a comfortable position. If time permits, the nurse scrubs both hands with soap and water and puts on sterile gloves. Sterile drapes are placed under the woman's buttocks. At all times during the birth, the nurse gives clear instructions to the woman, supports her efforts, and provides reassurance. The nurse needs to remain calm and proceed in a slow, confident manner A precip pak should also be on site during the delivery Small drape that can be placed under the woman's buttocks to provide a sterile field Bulb syringe to clear mucus from the newborn's mouth Two sterile clamps (Kelly or Rochester) to clamp the umbilical cord before applying a cord clamp Sterile scissors to cut the umbilical cord Sterile umbilical cord clamp, either Hesseltine or Hollister Baby blanket to wrap the newborn in after birth Package of sterile gloves

Early labor: S/Sx

The signs and symptoms of preterm labor may be subtle, including Uterine contractions or menstrual like cramps Cervix is 1cm 80% or more effaced 4 ctx in 20 mins 8 ctx in 60 mins The feeling of pelvic pressure Increase in vaginal discharge Cramps with or without diarrhea Low, dull backache Premonitory signs of labor Lightening Fetus settles into pelvis Engagement Easier breathing Pain, pressure, voiding, discharge Braxton Hicks contractions Irregular, "warm up" Cervical changes Effacing, dilation Bloody show Mucous plug Rupture of membranes 12% before onset of ctx Sudden burst of energy Nesting Wt loss (1-3 lbs) Backache &/or sacroiliac pressure GI: Diarrhea, N&V, indigestion

Signs and symptoms of true labor vs. false labor

True: Contractions Regular pattern, intervals gradually shorten, discomfort radiates from back to abdomen, intensify w/ambulation Do not decrease with Rest/relaxation (warm bath), fluids, voiding Cervical dilation Progressive change False: Contractions Irregular pattern, discomfort in abdomen only Lessen with Ambulation, rest, fluids, voiding Cervical dilation No change

When is a classical uterine incision made for C-Section. Risks associated with this.

Vertical incision is used for: Emergencies: faster Associated risks: Risk of uterine rupture