OB: Chapter 14 Nursing Management During Labor and Birth, Health Promotion: Labor and Delivery C6- EXAM
LABOR AND DELIVERY: Part 4
Preliminary Signs of Labor
Nursing Care During the SECOND Stage of labor
Preparing the place of birth Positioning for birth Promoting effective pushing Perineal cleaning Episiotomy Birth Cutting and clamping the cord Introducing the infant
What is the nursing priority if the meconium fluid is thick? Thin?
Thick: call the MD & CFM, FHT Thin: CFM
What does it mean if the meconium fluid is thin? Thick?
Thin: not as serious - fetal monitor Thick: very serious - notify MD
T/F: Epidurals cause a lower rate of spontaneous vaginal delivery
True
T/F: Epidurals cause higher rates of fever
True
LABOR AND DELIVERY: Part 5
True Signs of Labor
A client has been in labor for 10 hours and is 6 cm dilated. She has already expressed a desire to use nonpharmacologic pain management techniques. For the past hour, she has been lying in bed with her doula rubbing her back. Now, she has begun to moan loudly, grit her teeth, and bear down with each contraction. She rates her pain as 8 out of 10 with each contraction. What should the nurse do first?
Assess for labor progression. Performing breathing exercises, ambulating, changing position, and emptying the bladder all can help the client experience a reduction in pain. However, the best first step is to assess the client for labor progress before assisting her otherwise. Bearing down can be a sign that the client is 10 cm dilated. pg 451
Preliminary Signs of Labor When does lightning occur?
1st Time Mom: 10-14 days prior to labor Multipara: May not experience lightning until active labor
A client asks why she should learn breathing patterns for labor. After instruction is given, the nurse determines teaching has been effective when the client states:
"Breathing patterns are distraction techniques taught to decrease pain in labor." Breathing techniques are largely distraction techniques taught in birth classes and are well documented to decrease pain in labor. pg 471
A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states:
"Effleurage is light abdominal massage used to displace pain." Effleurage is a light abdominal massage used to keep the laboring woman's focus on the massage instead of the pain of labor. pg 470
A woman states that she does not want any medication for pain relief during labor. Her primary care provider has approved this for her. What the nurse's best response to her concerning this choice?
"I respect your preference whether it is to have medication or not." Individualizing care to meet women's specific needs is a nursing responsibility. pg 464
Opioids are often used in labor for pharmacologic pain management. A client in the transition phase of labor is requesting fentanyl for pain. How should the nurse respond to her request?
"Pain medication given now might cause the baby to have slow respirations and is not recommended; let's try to focus and breathe." Once the woman has entered into the transition phase of labor, she is considered to be imminent for birth. Any opioid medication might pass to the fetus and is not recommended due to the effects of respiratory compromise. The nurse will need to encourage nonpharmacologic methods at this point and should not consult the provider. The nurse should also remain supportive of the mother.
A woman refuses to have an epidural block because she does not want to have a spinal headache after birth. What would be the nurse's best response?
"Spinal headache is not a usual complication of epidural blocks." Because epidural anesthesia does not enter the cerebral spinal fluid space, it is unlikely to cause a "spinal headache."
A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which would be the most appropriate response by the nurse?
"The injection is given in the space outside the spinal cord." An epidural block, as the name implies, does not enter the spinal cord but only the epidural space outside the cord.pg 474
Fourth Stage of Labor
(Maternal Homeostatic Stabilization Phase) Begins after the delivery of the placenta and continues 1-4 hours after delivery
Third Stage of Labor
(Placental Stage) birth of infant until delivery of placenta -Placental separation: lengthening of cord, sudden gush of vaginal blood, change in the shape of the uterus -Placental expulsion
The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is:
7.15 or less. In the hypoxic fetus, the pH will fall below 7.2, which is indicative of fetal distress. pg 464
The nurse is reviewing the uterine contraction pattern and identifies the peak intensity, documenting this as which phase of the contraction?
Acme The acme is the peak intensity of a contraction. The increment refers to the building up of the contraction. The decrement refers to the letting down of the contraction. Diastole refers to the relaxation phase of a contraction pg 453
What is the regional anesthetic that is powerful, long acting, crosses the placenta, can be measured in fetal circulation and will effect the fetus for a long time afterward?
Amids: Marcaine and Xylocaine
What is the best way for a nurse to assess cultural considerations for laboring mom and family?
Ask! "What would be important to you?"
During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor?
Assess amount of cervical dilation. If vaginal bleeding is absent during admission assessment, the nurse should perform vaginal examination to assess the amount of cervical dilation. Hydration status is monitored as part of the physical examination. A urine specimen is obtained for urinalysis to obtain a baseline. Vital signs are monitored frequently throughout the maternal assessment. pg 451
False Contractions
Begin and remain irregular Felt first abdominaly, and remains in abdomen and groin Disappears with ambulation and sleep No increase in duration, frequency, intensity No cervical dilation
True Contractions
Begin irregular, become regular and predictable Felt first in lower back, sweeps around to abdomen Not changed by level of activity Increase in duration, frequency and intensity Achieve cervical dilation
Preliminary Signs of Labor Cervical Changes Prior to Labor
Cervix begins to soften and weaken (ripening) results from breakdown of collagen which produce a decrease in tissue binding capacity. consists of effacement and softening of the cervix, which can help hasten the beginning of labor, or shorten the course of labor
The nurse is preparing a young couple for the upcoming birth of their child, and the mother expresses concern for needing pain medications and the effects on the fetus. When counseling the couple about pain relief, the nurse would incorporate which information in the teaching about measures to help to decrease the requests for pain medication?
Continuous support through the labor process helps decrease the need for pain medication. Continuous labor support involves offering a sustained presence to the laboring woman. A support person can assist and provide aid with acupressure, massage, music therapy, or therapeutic touch. Research has validated the value of continuous labor support versus intermittent support in terms of lower operative deliveries, cesarean births, and request for pain medication. pg 465
When to be admitted during pregnancy
Contractions Ruptured membranes Bleeding other than bloody show Decreased fetal movement Any other concerns
Labor and Delivery: Part 6
Contractions and Labor
Mechanisms of Labor / Cardinal Movements (7)
Descent Engagement Flexion Internal rotation Extension External rotation Expulsion
A 39-week-gestation client presents to the labor and birth unit reporting abdominal pain. What should the nurse do first?
Determine if the client is in true or false labor. When a nurse first comes in contact with a pregnant client, it is important to first ascertain whether the woman is in true or false labor. Information regarding the number of pregnancies or history of drug allergy is not important criteria for admitting the client. The healthcare provider should be notified once the nurse knows the client's current status. pg 478
On examination, the nurse determines the client is at 50% effacement. This means: the cervical canal is 1 cm long.
Effacement refers to the length of the cervical canal. At 0%, the cervical canal is 2 cm long; at 50%, 1 cm long; and at 100%, the cervical canal is obliterated.
Dilation
Enlargement of the cervix 10cm is complete, Uterine contractions increase the diameter by pulling cervix up over presenting part
What is the regional anesthetic that is rapidly metabolized and doesn't cross the placenta easily?
Esters: Novocaine and Nesacaine
Levels of Station
F(-3)FLOATING High I(-2)In the right direction S(-1)settling in H(0)halfway there (ENGAGED) I(+1)inching out N(+2)nearly there G(+3)get the crown +4 is on the floor
LABOR AND DELIVERY: PART 1
HORMONES
A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority?
FHR When membranes rupture, the priority focus should be on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. Prolonged rupture can lead to an infection. Assessing the fetal position and maternal comfort are important but should not be the primary focus.
T/F: Baby stops moving at term
False: baby's movement does slow down though
Presentation-Cephalic
Head is the body part that first contacts the cervix: Vertex, brow, face, and military
Labor and Delivery: Part 3
Hospital Admission During Pregnancy
A nurse is teaching a couple about patterned breathing during their birth education. Which technique should the nurse suggest for slow-paced breathing? Inhale slowly through nose and exhale through pursed lips.
Inhale slowly through nose and exhale through pursed lips. For slow-paced breathing, the nurse should instruct the woman to inhale slowly through her nose and exhale through pursed lips.
A multigravida is admitted to the hospital in active labor. The client's and the fetus's condition have been good since admission. The client calls out to the nurse, "the baby is coming!" What is the first action of the nurse?
Inspect the perineum. The nurse needs to determine if birth is imminent and be prepared for birth. Once the nurse assesses the coming labor, the heart sounds, contraction rate, and contacting the primary care provider can all be done, if there is time.
Preliminary Signs of Labor Braxton Hicks Contractions
Irregular, intermittent contractions that occur during pregnancy that tone the uterus for birthing. Cause more discomfort closer to onset of labor DO NOT produce cervical changes
There are advantages and disadvantages to any kind of method used to control pain during labor and birth. What is an advantage of opioid administration?
It has the ability to be administered by the nurse Opioids are most frequently given by the intravenous (IV) route because this route provides fast onset and more consistent drug levels than do the subcutaneous or intramuscular routes.
Preliminary Signs of Labor
Lightening Braxton Hicks contractions Ripening of Cervix/Softening Sudden burst of energy Weight loss (1-3lb) Indigestion Nausea and vomiting Diarrhea
Latent Phase
Longest stage and most variable onset of contractions until 0-3 cervical dilation MOOD: Happy Able to cope Relieved/anxious Talkative Excited
Drugs Used During Labor and Delivery- Epidural Adverse Effects
Maternal hypotension and urinary retention
Fetal Attitudes: Sinciput
Moderate flexion, chin not touching the chest "military position"
HORMONES Endorphins
Natural analgesic hormone released by movement on birthing ball
True Signs of Labor: What should be used to confirm the presence of amniotic fluid once the clients water breaks?
Nitrazine paper should be used by a nurse to confirm that amniotic fluid is present. ☐ Amniotic fluid is alkaline: Nitrazine paper should be deep blue, indicating pH of 6.5 to 7.5.
Labor and Delivery: Part 2
Ongoing Fetal Assessments during labor with rationale
What is the regional anesthetic that causes puritis and relieves local pain
Opiates: Fentanyl and Morphine
Labor and Delivery: Part 10
Procedures Related to Labor and Delivery and Complications of L&D
Nursing Care During the FIRST Stage of labor
Respect contraction time Promote change in positions Promote voiding and provide bladder care Offer support Respect and promote the support person Support pain management efforts
True Signs of Labor: When is the Assessment of Amniotic Fluid Performed?
Should be performed after assessing FHR when membranes rupture/water breaks
Labor and Delivery: Part 7
Stages of Labor
Episiostomy
Surgical incision of perineal body to enlarge outlet - commonly used to avoid spontaneous laceration use has decreased tremendously: Research has shown: 1) An episiotomy makes it more likely the woman will have anal sphincter tears 2) perineal lacerations heal more quickly than deep perineal tears
A nurse is caring for a female client in labor who has chosen hydrotherapy as her pain management for labor. As the nurse prepares the client for this treatment, which procedure is recommended as the most appropriate consideration?
The client should be in active labor. Most recommendations for hydrotherapy, or water therapy, include active labor. If the client is not in active labor, the contractions could slow because of relaxation of muscles. There is no time limit for water therapy; it is provided for comfort. The water temperature should not be higher than the maternal body temperature, and water therapy can be used with intact or ruptured membranes.
True Signs of Labor include...(3)
Uterine contractions Bloody Show Rupture of the Membranes
There has been much research done on pain and the perception of pain. What is the result of research done on levels of satisfaction with the control of labor pain?
Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience. Research has shown that women report higher levels of satisfaction with their labor experience when they feel a high degree of control over the experience of pain (Stuebe & Barbieri, 2005). pg 464
Attitude
degree of flexion the fetus assumes...includes vertex sinciput brow face
When is it appropriate to reinforce teachings to mom during labor?
active stage
The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next?
administration of oxygen by mask The client should be administered oxygen by mask because the abnormal FHR pattern could be due to inadequate oxygen reserves in the fetus. Because the client is in preterm labor, it is not advisable to apply vibroacoustic stimulation, tactile stimulation, or fetal scalp stimulation. pg 460
What medical interventions can cause a prolapsed cord?
amniotomy (AROM)
What is an amniotomy?
artificial rupture of membranes
If mom is at risk for postpartum hemorrhage, what assessments should you make?
assess the fundus 24-48 hours after, know exactly where the fundus is
The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as:
baseline FHR. The baseline FHR averages 110 to 160 beats per minute over a 10-minute period. Fetal bradycardia occurs when the FHR is less than 110 beats per minute for 10 minutes or longer. Short-term variability is the beat-to-beat change in FHR. Baseline variability refers to the normal physiologic variations in the time intervals that elapse between each fetal heartbeat observed along the baseline in the absence of contractions, decelerations, and accelerations.
Active Phase
cervical dilation from 3-7 MOOD:Anxiety increases Fear loss of CTRL Coping mechanisms needed Increased introspection Increasing panic
What can the nurse do if imminent birth is occurring?
coach mom not to push, catch baby if baby is coming out, birth baby!
What are ways that nurses can promote physiologic labor care?
continuous labor support by being present at the bedside, giving low technology care by giving intermittent auscultation, patience with labor, allow labor to begin on its own, let mother freely move around
What can you pick up with intermittent auscultation?
decelerations/accelerations
What are the disadvantages for baby with an epidural?
decreased FHT, variability and presence of decelerations (lates)
A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth?
decreased alertness Morphine is a commonly used opioid for the management of pain during labor. It is associated with newborn respiratory depression, decreased alertness, inhibited sucking, and a delay in effective feeding. pg 473
What are the negative effects of using an epidural?
decreases oxytocin production (contractions) and breastfeeding success (coordination)
What are the effects of Nubain on mom and baby?
drowsiness, dizziness, crying, blurred vision, nausea, diaphoresis, urinary urgency
When is it appropriate to teach mom during labor?
early stage
A woman in early labor is using a variety of techniques to cope with her pain. When the nurse enters the room she notes that the woman is making light, circling movements with her fingertips across her abdomen. What technique is she using?
effleurage Effleurage is a form of touch that involves light circular fingertip movements on the abdomen and is a technique the woman can use in early labor. The theory is that light touch stimulates the nerve pathways to the brain and keeps them busy, thereby blocking the pain sensation. pg 470
A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as:
effleurage. Effleurage is a light, stroking, superficial touch of the abdomen in rhythm with breathing during contractions. Acupressure involves the application of a finger or massage at a trigger point to reduce the pain sensation. Patterned breathing involves controlled breathing techniques to reduce pain through a stimulus-response conditioning. Therapeutic touch involves light or firm touch to the energy field of the body using the hands to redirect the energy fields that lead to pain. pg 470
The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use?
external electronic fetal monitoring Analysis of the FHR using external electronic fetal monitoring is one of the primary evaluation tools used to determine fetal oxygen status indirectly. Fetal pulse oximetry measures fetal oxygen saturation directly and in real time. It is used with electronic fetal monitoring as an adjunct method of assessment when the FHR pattern is abnormal or inconclusive. Fetal scalp blood is obtained to measure the pH. The fetal position can be determined through ultrasonography or abdominal palpation but is not indicative of fetal oxygenation. pg 455
As a woman enters the second stage of labor, which would the nurse expect to assess?
feelings of being frightened by the change in contractions The nature of contractions changes so drastically to an urge to push that this can be frightening. pg 487
Presentation
fetal body part that will deliver first Cephalic Breech Shoulder
What is the main assessment during stage 2 & 3?
fetal descent
What are the advantages of Fentanyl?
has a rapid onset and limited placental crossing (needs repeated doses)
What are the nursing roles when a Spinal has been given?
have the patient lay flat for 6-12 hours after
What are the 2 signs of a breech baby?
heart beat is heard high on mom and you cant feel the presenting part during a vag exam
The nurse is assisting a client through labor, monitoring her closely, now that she has received an epidural. The nurse would report which finding to the anesthesiologist?
inability to push If she is not able to push, her epidural dose may be adjusted to decrease the impact on the sensory system. Dry lips indicate that she may need fluids, so the nurse should give her some ice chips or a drink of water. Urinary retention and rapidly progressing labor should be directly reported to the obstetrician, not the anesthesiologist.
Early in labor, a pregnant client asks why contractions hurt so much. Which answer should the nurse provide?
lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels During contractions, blood vessels constrict, reducing the blood supply to uterine and cervical cells, resulting in anoxia to muscle fibers. This anoxia can cause pain in the same way blockage of the cardiac arteries causes the pain of a heart attack. Endorphins are naturally occurring opiate-like substances that reduce pain, not cause it. Distraction and mechanical irritation of nerve fibers are also methods of reducing pain, not causes of pain.
What is the maximum amount of time mom should be holding her breath while pushing during labor?
less than 6 seconds
A nurse is caring for a client who has just received an epidural. Which side effect is the most common in epidural anesthesia?
maternal hypotension, which can lead to fetal bradycardia Epidural anesthesia conveys the risk of hypotension, especially if the client has not received an adequate amount of fluid before the procedure is performed. A sudden drop in maternal blood pressure can cause uterine hypoperfusion, which may result in fetal bradycardia. pg 474
Which episiotomy incision could go into the groin/leg area?
mediolateral/lateral
Which patients are more likely to have an episiotomy?
primigravida, large fetus, OP position, forceps, shoulder dystocia, white race
True Signs of Labor: Can water break too early?
prolonged rupture of membranes (greater than 24 hours prior to start of labor) increases chance of infection.
How often should you assess during stage 2 & 3?
q15 min
What are the advantages of mom being upright or side lying during stage 2?
speeds up stage 2, reduces need for episiotomies (causes small increase in 2nd degree lacerations), less pain
What are your priorities with vaginal bleeding?
status of the baby, put on CFM
What position should you discourage during stage 2 & 3? Why?
supine - changes uterine axis and directs head away from pelvic inlet & causes baby to work against gravity
A woman's perception of pain can differ according to all of the following except:
the presentation, lie, and attitude of the fetus. Fetal position can influence a client's perception of pain. Fetal attitude does not influence a client's perception of pain.
In shallow or modified-pace breathing,
the woman should inhale and exhale through her mouth at a rate of 4 breaths every 5 seconds
How could the nurse tell if there was a prolapsed cord?
there would be variable decelerations, you may be able to see it
Heart Rate Accelerations
transient increases in fetal heart rate normally caused by fetal movement - usually accompany uterine contractions due to fetal movement occurring in response to contractions
Presentation-Shoulder
transverse lie, the fetus is lying horizontally in the pelvis so long axis is perpendicualr to mother-C section is required.
How long can it take for the epidural to start working?
up to 30 min
While caring for a woman in labor, the nurse notes that the fetal heart monitor demonstrates late decelerations. The most common cause for their occurrence is:
uteroplacental insufficiency. Late decelerations are associated with uteroplacental insufficiency. They typically indicate decreased blood flow to the uterus during the contractions. Maternal hypotension and fatigue would not be observed on the fetal heart monitor. Cord compression would be marked by fetal tachycardia.
What causes a low risk mom to become a high risk mom?
vaginal bleeding, meconium fluid, absence of fetal mvmt or FHT, prolapsed cord, imminent birth
What can you not pick up with intermittent auscultation?
variability
What are the nursing interventions during stage 1 for a high risk mom?
vitals q15 min, monitor contractions q15 min, FHT q15 min, bladder assessment, teaching (labor progression, pain relief options, CFM), include family
What are the nursing interventions during stage 1 for a low risk mom?
vitals q30 min, monitor contractions q15-30 min, FHT q30 min, bladder assessment, teaching (labor progression and pain relief options)
What assessments would you make with vaginal bleeding? What assessment would you NOT do?
vitals, color of blood, LOC, diaphoretic? - NO vaginal exam! (it could be placenta previa = hemorrhage)
Should mom be grunting, groaning and exhaling during pushing?
yes
When are pudendals and locals given?
2nd stage only
Nonreassuring EFM Tracings
Severe variable decels (FHR<70 for longer than 30-45 seconds accompanied by rising BL, slow recovery or decreasing variability) Late decels of any magnitude Absent variability Prolonged deceleration (>60-90 seconds) Severe bradycardia (FHR baseline <70)
Fetal Heart Rate Range
Normal fetal heart rate ranges from 120 to 160 bpm
T/F: electronic fetal monitors increase c/s rates
True
A client in the first stage of labor is admitted to a health care center. The nurse caring for the client instructs her to rock on a birth ball. The nurse informs her that this causes the release of certain natural substances, which reduces the pain. To which substance is the nurse referring?
endorphins The nurse is referring to the release of endorphins, which are natural analgesic substances released by the movement of the client on the birth ball. The nurse should encourage the client to rock or sit on the birth ball. This causes the release of endorphins. The client's movement on the birth ball does not produce prostaglandins, progesterone, or relaxin.
Why is the initial interaction between nurse and laboring woman so important?
establishes trust, rapport and has been proven to have a positive effect on birthing process
How can the nurse decrease the need for an episiotomy?
not allowing recumbent (supine=posterior recumbant position) and lithotomy positioning (flat on back with feet up=guyno position), sustained breathing holding during pushing and not applying a timeframe to pushing
In pattern-paced breathing
the breathing is punctuated every few breaths by a forceful exhalation through pursed lips.
The nurse is assessing a woman in active labor. She notes a small mass above the symphysis pubis, rounded, distended, and nontender. What intervention should the nurse take next?
Check the chart for the last void. The most probable explanation of the mass is the bladder, which is full. The nurse should determine the last void by the client and offer to assist the client to void or prepare to catheterize the client to empty the bladder. This can be taken care of by the nurse. The client would not likely know if the mass was always present or not, given its location. If it were the uterus, it would be tender to the touch. pg 486
Early Decelerations
occur before onset of uterine contraction - uniform in shape, benign, and usually do not occur intervention; usually related to fetal head compression leading to vaginal stimulation
Heart Rate Decelerations
periodic decreases in fetal heart rate from baseline - can be early, late, and variable according to time of occurrence in contraction cycle
Does evidence support NPO during pregnancy? What does it suggest?
No - evidence suggests eating a low-residue, low-fat diet during labor
What are the nursing interventions for vaginal bleeding?
No bag exam! FHT, reposition mom, IV, count and weigh pads
Labor and Delivery: Part 8
Nonpharmalogical Pain Relief in Labor
Reassuring EFM Tracings
Normal baseline Accelerations with fetal movement Present short-term variability 3-5 cycles of long-term variability per minute Early decels may be present
What kind of nursing care is needed during stage 1?
P: position U: Urination R: Relaxation R: Respiration (breathing techniques) R: Rest R: Reassurance
The coach of a client in labor is holding the client's hand and appears to be intentionally applying pressure to the space between the first finger and thumb on the back of the hand. The nurse recognizes this as which form of therapy?
acupressure Acupressure is the application of pressure or massage at designated susceptible body points. A common point used for a woman in labor is Co4, which is located between the first finger and thumb on the back of the hand. Women may report their contractions feel lighter when a support person holds and squeezes their hand because the support person is accidentally triggering this point. Acupuncture involves insertion of needles into the same body points. Effleurage, the technique of gentle abdominal massage often taught with Lamaze in preparation for birth classes is a classic example of therapeutic touch. Biofeedback is based on the belief people have control and can regulate internal events such as heart rate and pain responses. pg 465
A client received IV meperidine for pain. An hour later a full-term neonate is born with respiratory depression. The nurse anticipates the neonate will require administration of which medication?
naloxone Naloxone is the drug used for reversal of opioids' adverse effects. If a narcotic is given too close to birth, the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be registered (respiratory depression, sleepiness) in the fetus for 2 to 3 hours after birth. Indomethacin is an analgesic and NSAID; ampicillin is an antibiotic; and epinephrine is a vasopressor. pg 471
What are some potential outcomes of meconium stained fluid?
possible respiratory issues but it doesn't mean there will always be a bad outcome
What is the main use of a Spinal?
c/s
What is the outcome of this event? (prolapsed cord event)
c/s, lower 1 minute APGAR
What are the effects of Demerol on baby?
can cause fetal depression if given too close to delivery, decreases fetal movements, variability and APGAR
A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency?
every 15 minutes During the first hour of the fourth stage of labor, the nurse would assess the woman's fundus every 15 minutes and then every 30 minutes for the next hour. pg 491
If mom comes in saying that there has been decreased or absent fetal movement, how should the nurse verify this report?
fetal monitoring and ausculations
A pregnant client with a history of spinal injury is being prepared for a cesarean birth. Which method of anesthesia is to be administered to the client?
general anesthesia General anesthesia is administered in emergency cesarean births. Local anesthetic is injected into the superficial perineal nerves to numb the perineal area generally before an episiotomy. Although an epidural block is used in cesarean births, it is contraindicated in clients with spinal injury. Regional anesthesia is contraindicated in cesarean births.
How would the nurse know that there is a presence of meconium stained fluid?
if fluid looks green or yellow
What are the advantages of a Spinal?
immediate effects (which is why its used during c/s), numbs mom from nipples down
A nurse is required to obtain the fetal heart rate (FHR) for a pregnant client. If the presentation is cephalic, which maternal site should the nurse monitor to hear the FHR clearly?
lower quadrant of the maternal abdomen In a cephalic presentation, the FHR is best heard in the lower quadrant of the maternal abdomen. In a breech presentation, it is heard at or above the level of the maternal umbilicus.
A client has presented in the early phase of labor. She is experiencing abdominal pain and shows signs of growing anxiety about the pain. What is the best pain management technique the nurse can suggest at this stage?
practicing effleurage on the abdomen In early labor, the less medication use the better; allow use of nonpharmacologic management and control the pain with gate theory. Sitting in a warm pool of water is relaxing and may lessen the pain, but it does not control the pain. Sedatives are not indicated as they may slow the birthing process. Opioids should be limited as they too may slow the progression of labor. pg 465
Lie
relationship of the long axis of the fetal body and the long axis of the maternal body (longitudinal vs. transverse)
Station
relationship of the presenting part of the fetus to the level of the ischial spines
Position
relationship of the presenting part to a specific quadrant of the woman's pelvis
What are the effects of Narcan on mom and baby?
reverses mild respiratory depression
How does the nurse assist with the administration of epidurals?
hold mom still and comfort her
What is the priority with a prolapsed cord?
hold the head up
If a woman with preeclampsia is given analgesia/anesthesia what are you on the look out for?
hypotension and fluid status
If a woman with bleeding complications is given analgesia/anesthesia what are you on the look out for?
hypotension, hypovolemia/shock = fetal hypoxia/acidosis
During stage 1, how should the baby be assessed?
identification of the station and presenting part & FHT
What complications do episiotomies cause?
increased blood loss, infection, perineal pain for days-weeks, painful intercourse
A client who requested "no drugs" in labor asks the nurse what other options are available for pain relief. The nurse reviews several options for nonpharmacologic pain relief, and the client thinks effleurage may help her manage the pain. This indicates that the nurse will:
instruct the client or her partner to perform light fingertip repetitive abdominal massage. The relaxation technique of visualization is used in hypnobirthing or focused meditation. Controlled chest breathing is a technique used in Lamaze breathing. Pressing on trigger points is an acupressure technique. pg 465
At which time during a woman's labor might the nurse assist with a pudendal block?
just before birth Pudendal block is a local block in the perineal area and is used to numb for birth. Application before labor begins or while it is in the early stages would be counterproductive, as the client would not have proper feeling and would have a harder time pushing. After birth it is pointless; the most painful part is over
What kind of teaching would you give during stage 1 for a low risk mom?
labor progression, pain relief options & a code word
What does research say about how long labor lasts for a first time mom (G1) with an epidural?
labor will last longer and increases rate of c/s
The student nurse is preparing to assess the fetal heart rate (FHR). She has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:
left lower quadrant. The best position to auscultate fetal heart tones in on the fetus back. In this position, the best place for the FHR monitor is on the left lower quadrant. pg 455
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." An episiotomy widens the vaginal opening, decreasing pressure on the fetal head. pg 483
First Stage of Labor
(Stage of Cervical Dilation) onset of contractions until cervix is completely dilated includes the latent, active, and transition sub phases
Second Stage of Labor
(Stage of Expulsion) full dilation until delivery of infant
What are the disadvantages for mom with an epidural?
(major side effect=HYPOTENSION), hot spots, pruitis, increase in core temperature, delayed onset, prolonged 1st and 2nd stages of labor, respiratory and cardiac arrest
Fetal Blood Sampling
- Scalp blood pH >7.25 is normal - Scalp blood pH 7.21 to 7.25, repeat in 30 minutes - Scalp blood pH below 7.20 is acidotic and recognized as a level of fetal distress
Contractions and Labor: Define: Intrapartum
-beginning of contractions that cause cervical dilation to the first 1 to 4 hours after delivery.
How long does it take for most all general anesthetic agents to reach baby?
2 minutes
Preliminary Signs of Labor How do you know lightning has occurred?
Mom reports... -Pressure on diaphragm relieved/decreased -increased abdominal/pelvic pressure (Clothes fit differently) -increased pressure on bladder (lotta bathroom breaks)
True Signs of Labor: What Nursing Assessment is performed immediately after the rupture of membranes?
Assess fetal FHR for abrupt decelerations which are indicative of cord compression secondary to cord prolapse.
A client has just received combined spinal epidural. Which nursing assessment should be performed first?
Assess vital signs. The most common side effect of spinal and epidural anesthesia is hypotension, which can lead to fetal bradycardia, decelerations, or fetal distress. Although each is important, this nursing assessment should be performed first.
A client has just had an epidural placed. Before the procedure, her vital signs were as follows: BP 120/70, P90 bmp, R18 per min, and O2 sat 98%. Now, 3 minutes after the procedure, the client says she feels light-headed and nauseous. Her vital signs are BP 80/40, P100 bmp, R20 per min, and O2 sat 96%. Which interventions should the nurse perform?
Assist the client to semi-Fowler's position, assess the fetal heart rate, start an IV bolus of 500 mL, and administer oxygen via face mask. In a pregnant woman, hypotension is best managed in the left lateral or semi-Fowler's position owing to risk of supine hypotension in the supine position and in Trendelenburg's position. The sitting position could exacerbate hypotension. Naloxone is administered for respiratory depression. When the mother experiences a change in vital signs, this may affect the fetal heart rate.
What are the teachings for a high risk mom during stage 1?
CFM, how it could impact baby and the assessments that need to be done
T/F: pharmacological interventions (like pain relief drugs) are a substitute for a supportive role
False
T/F: nurses are legally allowed to administer anesthetic agents
Falso
How does a woman who feels in control of the situation during labor influence her pain?
Feelings of control are inversely related to the client's report of pain. Studies reveal that women who feel in control of their situation are apt to report less pain than those who feel they have no control. pg 475
Preliminary Signs of Labor Lightning: What is it?
Fetal head descends/drops into pelvic inlet
Perineal Lacerations
First degree: vaginal mucous membrane and skin of the perineum to the fourchette Second degree: vagina, perineal skin, fascia, levator ani muscle and perineal body Third degree: entire perineum and reaches the external sphincter of the rectum Fourth degree: entire perineum, rectal sphincter, and some of the mucous membrane of the rectum
What color of meconium fluid is more dangerous?
Green
What does it mean if the meconium fluid is green? Yellow?
Green: just happened - worse Yellow: Happened a while ago - better
A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth?
Morphine is a commonly used opioid for the management of pain during labor. It is associated with newborn respiratory depression, decreased alertness, inhibited sucking, and a delay in effective feeding. pg 473
Transition Phase
Most difficult and shortest phase dilation continues from 7-10cm MOOD:anxiety / fear (worst here) Restless Tired Apprehensive Irritable Withdrawn Communication difficult for her May want limited touch or talk -encourage to refrain from pushing until fully dilated)
A client has asked that an opioid be kept on standby in case she needs it for pain control. As a precaution, the nurse will also have which of medication readily available to reverse the effects of that opioid? naloxone
Naloxone is an opioid antagonist that can be given to reverse the effects of the central nervous system depression, including respiratory depression, caused by opioids. It is also used to reverse the side effects of neuraxial opioids. Nalbuphine is an opioid. Hydroxyzine is an ataractic. Midazolam is a benzodiazepine. pg 473
General anesthesia is not used frequently in obstetrics because of the risks involved. There are physiologic changes that occur during pregnancy that make the risks of general anesthesia higher than it is in the general population. What is one of those risks?
Neonatal depression is possible. General anesthesia is not used frequently in obstetrics because of the risks involved. The pregnant woman is at higher risk for aspiration. It requires more skill to intubate a pregnant woman because of physiologic changes in the trachea and thorax. In addition, general anesthetic agents cross the placenta and can result in the birth of a severely depressed neonate who requires full resuscitation. pg 476
A woman who has just been admitted in labor indicates that her husband is parking the car and her doula is on her way. The nurse's best response would be:
OK, let me ask you some personal questions before she arrives." Doulas are birth coaches who provide one-on-one support in labor and throughout birth. A nurse would want to ask the client any personal questions before the doula arrives because the primary purpose of the doula is to be a continuous presence. A doula does not take the place of a nurse.
A woman in labor at the hospital has just received an epidural block. Which intervention is a priority before and during epidural placement?
Provide adequate IV fluids to maintain her blood pressure. The client will need to have a bolus of IV fluids prior to and then maintained during the epidural to be prepared in the event of the hypotensive episodes that may accompany epidural placement. The hypotensive event is transitory, and increasing oral hydration is unnecessary and may lead to nausea later. Monitor the mother's body temperature, but wait for instructions from the primary care provider as to when to administer medication. Bradycardia is not a common side effect of epidural medication. pg 474
A client has just arrived at the hospital, in early labor, showing signs of extreme anxiety over the birth to come. Why is it so important that the nurse help the client relax?
The client's anxiety can actually slow down the labor process and decrease the amount of oxygen reaching the uterus and the fetus. Anxiety out of control can decrease the oxygen of the mother by increasing her respiratory rate and increasing the demaEpidural Adverse Effectsnd on her body, and have a negative impact on the fetus. Encourage control of the anxiety. Anxiety will not negatively affect the action of the epidural. It is premature to be stern with the client. While it is preferable that she save her energy, it is not damaging to her or to the fetus if she does not sleep. pg464
The nurse is caring for a client who is considered low-risk and in active labor. During the second stage, the nurse would evaluate the client's FHR at which frequency?
The nurse is caring for a client who is considered low-risk and in active labor. During the second stage, the nurse would evaluate the client's FHR at which frequency? every 15 minutes It is recommended that the FHR be assessed during the second stage of labor every 15 minutes for the low-risk woman and every 5 minutes for the high-risk woman and during the pushing stag
True Signs of Labor: What would happen if Nitrazine paper was dipped in urine?
The paper would remain yellow since urine is slightly acidic
The laboring client who is at 3 cm dilation and 25% effaced is asking for analgesia. The nurse explains the analgesia usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice?
This may prolong labor and increase complications. Administration of pharmacologic agents too early in labor can stall the labor and lengthen the entire labor. The client should be offered nonpharmacologic options at this point until she is in active labor. pg 471
If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first?
Turn her or ask her to turn to her side. The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression. pg 463
True Signs of Labor: Bloody show
brownish or blood tinged mucus discharge caused by expulsion of cervical mucus plug resulting from onset of cervical effacement/dilation
In the US when does dilation slow and why?
btwn 4 - 6 cm bc uterus is a muscle that requires glucose but mom have been NPO
Presentation-Breech
buttock or feet are first ( frank, full (complete), footling)
When mom is in the transitional stage of labor how do you teach/lead her? Why
by only giving her essential information or commands - her perceptual field is narrowed
HORMONES Relaxin
causes backache during pregnancy by acting on the pelvic joints
What are the potential outcomes of decreased or absent fetal movement?
either baby would be fine or stillbirth
Which intervention would be least effective in caring for a woman who is in the transition phase of labor?
encouraging the woman to ambulate Although ambulating is beneficial during early and possibly even active labor, the strong and frequent contractions experienced and the urge to bear down may make ambulating quite difficult. During transition, women should continue to breathe with contractions and focus on one contraction at a time. Providing one-to-one support at this time helps the woman cope with the events of this phase, as well as help her maintain a sense of control over the situation. pg 481
A pregnant client in her 32nd week of gestation has been admitted to a health care center reporting decreased fetal movement. What should the nurse determine first before placing the fetoscope on the woman's abdomen, so as to auscultate the fetal heart sounds?
fetal back The nurse assessing the client should first determine the fetal back before placing the fetoscope on the client's abdomen. The fetal back is determined first because it is through the back that the heart signals are best transmitted. During labor, the fetal heart rate should be assessed to check for any variations indicating distress. Fetal heart rate is auscultated by placing a fetoscope on the client's abdomen in the area of the fetal back. Determining the fetal head, shoulders, and the buttocks would be of no help in localizing the heart sounds. pg 453
A woman in labor who is receiving an opioid for pain relief is to receive promethazine. The nurse determines that this drug is effective when the woman demonstrates which finding?
less anxiety Promethazine is used in combination with an opioid to decrease nausea and vomiting and lessen anxiety. It may also be used to increase sedation. It does not affect the progress of labor. Benzodiazepines are used to calm a woman who is out of control, allowing her to relax enough to participate effectively during labor.
HORMONES Prostaglandins
local hormones that bring about smooth muscle contractions in the uterus-
Before giving a systemic drug what is an important fetal assessment to make?
make sure baby has NO lates or variables, variability is present, reactive NST, FHT: 110-160
Which episiotomy incision tears into the rectal area more easily?
midline
What is a good advantage of Intermittent auscultation pertaining to the physiologic labor?
mom is not confined to a bed
What do laboring moms say their priority care needs are during labor verses what nurses think they are?
moms need a human presence and advice/advocacy and nurses think more about pain relief and skill in technology of care
A client has asked that an opioid be kept on standby in case she needs it for pain control. As a precaution, the nurse will also have which of medication readily available to reverse the effects of that opioid?
naloxone Naloxone is an opioid antagonist that can be given to reverse the effects of the central nervous system depression, including respiratory depression, caused by opioids. It is also used to reverse the side effects of neuraxial opioids. Nalbuphine is an opioid. Hydroxyzine is an ataractic. Midazolam is a benzodiazepine. pg 473
Where are the hot spots usually felt with an epidural and what should you do?
on her groin area, roll her on her the side where it is
Effacement
shortening and thinning of the cervix, normally 1-2 cm long, primips effacement takes place before dilatation
By promoting physiologic labor care, how does this affect the outcome of the labor and birth?
shorter birth, decreased use of pain drugs and oxytocin, decreased use of forceps and c/s
While waiting for the placenta to deliver during the third stage of labor the nurse must assess the new mother's vital signs every 15 minutes. What sign would indicate impending shock?
tachycardia and a falling blood pressure Monitor the woman's vital signs at least every 15 minutes during the third stage of labor. Tachycardia and a falling blood pressure are signs of impending shock; the nurse should immediately report these signs. pg 491
To assess the frequency of a woman's labor contractions, the nurse would time:
the beginning of one contraction to the beginning of the next. Measuring from the beginning of one contraction to the next marks the time between contractions. pg 453
Which position causes a small increase in 2nd degree lacerations?
upright
True Signs of Labor: When does a womans water usually break?
usually membranes rupture 24 hours prior to onset of labor, or anytime during labor (transition phase)
The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction?
uterine resting tone frequency of contractions intensity of contractions The nurse should assess the frequency of contractions, intensity of contractions, and uterine resting tone to monitor uterine contractions. Monitoring changes in temperature and blood pressure is part of the general physical examination and does not help to monitor uterine contraction.
How would you know imminent birth is about to happen?
you can see it! Baby could be crowning, perineum bulges out and labia spreads apart
Labor and Delivery: Part 11
Diseases/Disorders/Conditions that may Effect Labor and Delivery
Labor and Delivery: Part 9
Drugs Used During Labor and Delivery
Which moms should have a continuous fetal monitor? high risk moms only
high risk moms only
How can you prevent hypotension in moms receiving analgesia/anesthesia
give a bolus of fluids before (500-1000ml)
A woman presents in advanced labor, and birth appears imminent. What is the most important and appropriate aspect of admission for this woman?
taking her blood pressure and determining whether clonus or edema is present In advanced labor the most important assessments must be completed first. The assessment for signs or symptoms of preeclampsia must be assessed first. The history can be obtained after the birth of the baby or if labor slows down. Plans for the newborn can be figured out later. Blood tests can be run as soon as a sample can be taken from the mother.
True Signs of Labor: Characteristics of Amniotic Fluid
■ Should be watery, clear, and pale- to straw-yellow in color. ■ Odor should not be foul. ■ Volume is between 500 and 1,200 mL.
A nurse is monitoring the FHR of a client in labor using an electronic fetal monitor. The reading shows a late deceleration. Which intervention should the nurse implement?
Change maternal position to an upright or side lying position. To intervene with late decelerations, the nurse should change maternal position to an upright or side lying posture. Late deceleration in the fetus indicates insufficient uteroplacental perfusion. Changing the maternal position improves the maternal venous return. In upright position, the uterine activity becomes more efficient. Attempts should be made to increase the uteroplacental perfusion and fetal circulation. Administering oxytocin and encouraging Valsalva maneuver (extended breath holding) may augment the uteroplacental insufficiency. In late deceleration, the nurse should administer oxygen through nasal cannula and discontinue administration of oxytocin. Placing the client in the lithotomy position contributes to poor placental circulation pg 463
The laboring client is on continuous fetal monitoring when the nurse notes a decrease in the fetal heart rate with variable deceleration to 75 bpm. What is the initial nursing intervention?
Change the position of the client. Variable decelerations often indicate a type of cord compression. The initial response is to change the position and try to release the cord compression. If this does not work, apply oxygen while using the call light to alert others. If this continues, her fluid status needs to be assessed before increasing her IV rate. pg 460
The client is in the second stage of labor and is at 2+ station and in anticipation of birth within the hour. Her epidural did not work, and she is begging for meperidine. Which is the most appropriate action by the nurse?
Encourage her through the contractions, and explain why she is not receiving the meperidine. At this point, any medication would be contraindicated as it would pass to the fetus and may cause respiratory depression. The nurse will have to work with the mother through the contractions and pushing. The client has progressed too far to retry the epidural medication. No meperidine should be given due to the risk to the fetus.
Nursing Interventions for Nonreassuring FHR
Optimize maternal positioning Monitor maternal v/s for hypotension and treat Administer IV fluids as needed Give supplemental oxygen if indicated Consider discontinuing oxytocin Initiate continuous monitoring Place internal monitors as appropriate Perform vaginal exam to assess for prolapsed cord or labor progress Assist physician with fetal blood sampling Prepare for expeditious birth Provide client and family with explanation Administer tocolytic as ordered
A client is in active labor. As one of the nursing diagnoses is "Risk for trauma to the woman or fetus related to intrapartum complications or a full bladder," what would be appropriate for the nurse to do in order to achieve the goal of "no complications due to a full bladder"?
Palpate the area above the symphysis pubis every two hours. Another source of trauma that can interfere with the progress of labor is a full bladder. Every two hours the nurse should palpate the area just above the symphysis pubis feeling for a rounded area of distention, which indicates the bladder is full. pg 481
Passage
Passage is the route the fetus must travel from the uterus through the cervix and vagina to the external perineum. Must pass through the pelvic inlet and outlet. Need to determine the adequacy of the pelvic size: Diagonal conjugate is the AP diameter of the inlet At the pelvic inlet the : AP diameter is the narrowest At the outlet: The transverse diameter is the narrowest If cephlopelvic disproportion: Tell the parents that the pelvis too small for the way the baby is coming through. If say the head is too big-may think it is abnormal
What are the differences between Oxytocin and Pitocin?
Pitocin doesn't cross the BBB, and turns off oxytocin production, Oxytocin increases pain threshold, trust and decreases stress
Nursing Care during the THIRD & FOURTH stage of labor
Placenta delivery Oxytocin Perineal repair Immediate postpartum assessment and care
Bishops Score
can help to determine how favorable, or how ready a cervix is for induction. A low bishops score would indicate that this person may need a medication for cervical ripening to get started
How can hypotension from an epidural be life threatening?
causes decreased perfusion to the baby, bradycardia and lates
What are the effects of Demerol on mom? When is it okay to give it?
causes mom to have N/V, itching, urinary retention & respiratory depression - its okay to give well before labor begins
HORMONES Progesterone**
causes relaxation of smooth muscle tissue hormone involved in maintaining pregnancy
HORMONES Estrogen**
causes stimulation of uterine muscle contractions
How does general anesthesia affect the uterus? Why is that bad?
causes uterine relaxation - increased risk for postpartum hemorrhage
A woman is experiencing back labor and reports intense pain in the lower back. Which is the most effective nursing intervention to relieve this type of pain?
counter pressure against the sacrum Counter pressure against the sacrum is a way to provide support and comfort for a women having intense back labor. Effleurage is ineffective for true back labor, as is conscious relaxation. Breathing will not diminish the pain of back labor. pg 483
What should you do if you give Demerol and labor begins shortly after? (within an hour)
give Narcan to baby to reverse respiratory depression
Fetal Attitudes: Vertex
good(complete flexion) , head bowed forward and body flexed so chin touches the sternum and arms folded on chest and thighs flexed on abd "fetal position"
A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia?
headache following anesthesia The nurse should inform the client and her family about the possibility of headache after spinal anesthesia. The drug is retained in the mother's body and not passed to the fetus. There may be uterine atony, and not excessive uterine contractions, following spinal anesthesia. Spinal anesthesia may lead to bladder atony, and not an increased frequency of micturition.
If a woman with diabetes is given analgesia/anesthesia what are you on the look out for? What shouldn't you give her?
hypotension - don't give dextrose fluid
Fetal Attitudes: Brow
partial extension, presents the brow of the head
What are pudendals and locals used for?
perineal stretching and episiotomy
Fetal Attitudes: Face
poor flexion, back is arched and neck extended and fetus complete extensio
A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next?
respiratory rate The nurse must monitor for respiratory depression. Monitoring the client's respiratory rate will be the best indicator of respiratory depression. pg 474
What are the effects of Stadol on mom and baby? When is it okay to give it?
reverses effects of other narcotics in mom and causes withdrawal, maternal and fetal respiratory depression - its okay to give when baby is in utero (mom is doing the breathing, but monitor mom)
The expected fetal heart rate response in an active fetus is:
acceleration of at least 15 bpm for 15 seconds. A reassuring active fetal heart rate is a change in baseline by increase of 15 bpm for 15 seconds. This is a positive and reassuring periodic change in fetal heart rates as a response to fetal movement.
