Exam #2 - Process 2
What is a variable deceleration?
-Defined as abrupt decrease below FHR of 15bpm or more, lasting 15 seconds and then returning to baseline in less than 2 minutes from onset -Shape: V or U can occur with or without contractions -Causes: umbilical cord compression, prolapsed umbilical cord, nuchal cord, cord entanglement -Management: relieve pressure on umbilical cord (d/c pitocin, change maternal position, perform vaginal exam, amnioinfusion, 500cc bolus, consider oxygen, notify provider
Describe nursing interventions when membranes rupture in pregnant woman
-Monitor FHR and pattern for several minutes after rupture and document findings -Monitor maternal temp and discharge every 1-2 hours
What is a nitrazine test?
-Used to detect the presence of amniotic fluid. -Vaginal secretions have a pH of 4.5-5.5 and do not affect the Nitrazine strip or swab. -Amniotic fluid has a pH of 7-7.5 and turns the Nitrazine strip blue.
What happens with contractions in true labor?
-can begin irregularly but become regular in frequency, stronger, last longer, and are more frequent -felt in lower back, radiating to abdomen -walking can increase contractions intensity
What happens to the cervix in false labor?
-no significant changes in dilation or effacement (thinning of the tissue) -often remains in the posterior position -no significant bloody show
What happens with contractions in false labor?
-painless, irregular frequency, and intermittent -decreases in frequency, duration and intensity with walking or position changes -felt in lower back or abdomen above the umbilicus -often stop with rest or comfort measures such as oral hydration or emptying of the bladder
What happens to the fetus in true labor?
-presenting part engages in the pelvis
What happens to fetus in false labor?
-presenting part is not engaged in pelvis
What happens to the cervix in true labor?
-progressive change in dilation and effacement -bloody show -moves to anterior position
What is a late deceleration?
-symmetrical gradual decrease and return to the baseline FHR associated with UC -Shape: usually symmetrical -Management: discontinue pitocin, change maternal position, 500cc iv bolus, consider oxygen, notify provider
Describe the latent phase of labor
0-3 cm of dilation; mild to moderate irregular contractions ranging from 5-30 minutes apart lasting 30-45 seconds (similar to pushing on nose); Assess by palpating the abdomen; these patients are able to carry on a conversation and are able to ambulate; this is the best time to educate patient, review birth plan, review breathing techniques, do they want an epidural or not.
What does a Nitrazine test
1. A Nitrazine test strip is used to detect presence of amniotic fluid in vaginal secretions. 2. Vaginal secretions have a pH of 4.5 to 5.5; they do not affect yellow color of Nitrazine strip or swab 3. Amniotic fluid has a pH of 6.5 to 7.5 and turn yellow Nitrazine strip or swab a blue color. 4. Interventions a. Place client in dorsal lithotomy position b. Touch test tape to fluid c. Asses test tape for a blue-green, blue-gray, or deep blue color, which indicates that membranes are probably ruptured.
what is a normal fetal heart rate for term baby?
110-160 bpm
What is used to describe fetal position?
3 letters 1st letter: indicates location of presenting part in right or left side of mothers pelvis 2nd letter: specific presenting part (Occiput, Sacrum, Mentum, SC for sacrum) 3rd letter: location of presenting part in relation to anterior, posterior, or transverse portion of maternal pelvis
Describe the active phase of labor
4-7 cm of dilation; moderate to strong contractions ranging 3-5 minutes apart and lasting for 40-70 seconds; (push on your chin for moderate contractions and push on forehead for strong contractions); palpation is really the only way to assess intensity unless we have an internal monitor in place to detect pressure with each uterine contraction; The patient will start getting anxious at this time trying to breathe through contractions; will possibly request analgesic at this time; support person may start to feel helpless
Describe the transition phase of labor
8-10 cm of dilation; strong to very strong contractions ranging from 2-3 minutes apart and lasting 45-90 seconds each; this is the most painful phase because the largest diameter of the head is passing through the birth canal; big change in mother's disposition if she doesn't have epidural; mom can be very agitated and irritable; support can't do anything right; nauseated; increased bloody show; feeling the urge to push; shaking; coach mom to breathe if not fully dilated; DON'T push unless fully dilated because that could cause trauma to perineum; increased swelling; swelling will impede the delivery
Describe the 2nd stage of labor
Begins with full cervical dilation; complete effacement; ends with baby' birth; so it lasts from full dilation to birth of the infant; This is when mother starts pushing; She has the urge to push because the presenting part is pushing down on the pelvic floor; most mothers will deliver in the lithotomy position
what is physiologic response?
Fetal response: heart rate, circulation, respiratory movement from certain changes that stimulate chemoreceptors in the aorta and carotid bodies to prepare for initiating fetus breaths, the squeezing of vaginal birth helps to clear fluid and passageways of fetus Maternal response: lightening, urinary frequency, back discomfort, braxton hicks, weight loss, surge of energy, increase vaginal discharge, bloody show, cervical ripening or softening, rupture of membranes
labor and delivery
L&D
Describe the 3rd stage of labor
Lasts from the infant's birth until the separation and expulsion of the placenta; the placenta is usually expelled within 10-15 minutes after birth; if not detached by 30 minutes the placenta is considered retained; SIGNS of placental separation include firmly contracted uterus, change in the uterus from a discoid to a globular ovoid shape as the placenta moves into the lower uterine segment, sudden gush of dark blood from the vagina, and apparent lengthening of the umbilical cord as the placenta descends into the vagina; the provider will examine the placenta and membranes for intactness
Examples of fetal positions with letters
ROT: right occipitoltransverse ROP: right occipitoposterior LOP: left occiciptal posterior LOT: left occipital transverse ROA: right occipitol anterior LOA: left occipitol anterior
Describe the 4th stage of labor
The 4th stage includes the first 2 hours after birth; it includes post anesthesia recovery, interactions with newborn, care of the newborn, care of the family, and family-newborn relationships; Nurse should assess maternal BP and pulse every 15 mins for the first 2 hours and determine the temp at beginning of recovery, then assess every 4 hours for the 8 hours after birth, then at least every 8 hours. Nurse should assess fundus and lochia every 15 mins for the first hour and then according to facility protocol. Encourage voiding to mother. After bonding, mom may take a nap.
What are the factors affecting labor?
The 5 P's -passenger -passageway -powers -position -psychological response
What is an early deceleration?
Visually apparent usually symmetrical gradual decrease and return of the FHR associated w/ a UC Gradual FHR decrease- onset to nadir of >=30 secs *the nadir of the decel occurs at the same time as the peak of the UC* Caused by *fetal head compression* (increased intracranial pressure causing the vagus nerve to slow the HR) Shape: gradual and usually symmetrical Timing: mirrors the contraction associated with: vertex presentation, active phase, large fetus for pelvic size
what are the levels of variablity in fetal heart rate?
absent: amplitude undetectable minimal: less than or equal to 5 bpm moderate: 6-25 bpm marked: greater than or equal to 25 bpm
What is position?
affects the womens anatomic and physiologic adaptations to labor frequent changes in position relieve fatigue, increase comfort, and improve circulation
Describe the admission process for laboring woman
assess EDD, membranes, start frequency and duration of contractions, temp every 1-2 hrs if membranes have ruptured, vital signs, weight, UA, blood lab draw, assess abdomen and place fetal monitor assess that baby is head down position (Leopold/s maneuver), deep tendon reflexes (normal is 2+), vaginal exam (dilation, effacement and station), test fluid for amniotic or urine
what are we worried about if mom has too many contractions?
baby not getting enough oxyge
What is the definition of frequency in contractions?
beginning of one contraction to the beginning of another -we want to see less than or equal to 5 contractions in 10 mins, averaged over a 30 min window
what is the definition of duration with contractions?
beginning of one contraction to the end of the contraction -normal duration generally ranges from 45-90 seconds
Describe what happens in the first stage of labor
begins with the onset of regular uterine contractions and ends with full cervical effacement and dilation. It has 3 phases: latent, active, and transition
signs of true labor
bloody show lightening dilation effacement regular contractions that dont go away with rest
when talking about fetal heart rate, a baseline less than 110 bpm is fetal ___________
bradycardia
what kind of presentation is it when the sacrum comes out first?
breech presentation
what kind of presentation is the most common birth presentation of baby?
cephalic presentation documented as vertex
nitrazine test used for what
check for amniotic fluid 6.5-7.5 pH
What is powers?
contractions Primary powers- involuntary contractions responsible for effacement and dilation of cervix and descent of the fetus stretch receptors in the posterior vagina release endogenous oxytocin that triggers the maternal urge to bear down, or the Ferguson reflex Secondary powers- the bearing down efforts to aid in expulsion of fetus as patient contracts her diaphragm and abdominal muscles and pushes
during labor, GI motility and absorption of solid foods are _________ and stomach emptying time is ______.
decreased and slowed
what types of decelerations are there
early, late, variable, and prolonged
non-pharmacological interventions for pain in laboring mom
focusing and relaxation breathing techniques imagery and visualization effleurage and counter pressure music water therapy (hydrotherapy) TENS unit acupressure and acupuncture application of heat and cold touch and massage hypnosis biofeedback aromatherapy intradermal water block
what is the definition of intensity with contractions?
how strong they are: milkd, moderate, or strong -must palpate unless we use intrauterine catheter in place -palpate between contractions to assess resting tone
Cardiac output __________ due to contractions causeing increased blood volume being pushed from the uterus into the maternal vascular system.
increases HR increase BP slight increase Respirations increase
what is important to know about the bladder in labor
it needs to be empty to avoid bladder injury
what helps to identify what kind of deceleration it is?
shape, timing in relation to contractions, and duration
what kind of presentation is it when the scapula comes out first?
shoulder presentation
how do we find frequency of contraction pattern?
start of one contraction to start of another contraction
Describe stations of fetus
station 0 is at the level of the ischial spines birth is imminent when the presenting part is at +4 to +5
When talking about fetal heart rate, a baseline greater than 160 bpm is considered fetal ____________
tachycardia
What is lightening?
the presenting part of the fetus becomes engaged into the pelvis
what is the definition of lie relating to baby?
the relation of the long axis or spine of the fetus to the spine of the mother
What is the definition of attitude relation to mother and baby?
the relationship of the fetal body parts to each other
what is the definition of station relating to mother and baby?
the relationship of the presenting part of the fetus to an imaginary line drawn between the maternal ischial spines and is a measure of the degree of descent of the presenting part of the fetus through the birth canal. This is measured in cm above or below the ischial spine.
duration is
the start to end of one contraction
why do active laboring moms only get ice chips?
this decreases episodes of vomiting and the risk of aspiration just in case they would need to go into surgery.
What does the passenger have to go through with birth?
this include the fetus and placenta -factors: size of fetal head, fetal presentation, fetal lie, fetal attitude, fetal position, and placenta
why does wbc increase with labor and birth?
this is thought to occur because of physical and emotional stress or tissue trauma
What is the passageway?
this is what the fetus and placenta have to pass through which includes the pelvis, lower uterine segment, cervix, pelvic floor muscles, vagina, and external opening of the vagina.
Class 4-7
vhjgggy
what is a good nonstress test result
we want a reactive test showing cns is well oxygenated normal heart rate 110-160 atleast 2 accelerations 2 30 min tests
Signs of labor
weight loss lightening braxton hicks bloody show energy burst rupture of membranes