NURS 247 Ch 14 Nursing Management during labor and birth
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: Pharmacologic measures regional analgesia/anesthesia: (pain relief c/out loss of consciousness) c or c/out opioids: combined spinal-epidural analgesia
"walking epidural" -inserting epidural needle into the epidural space and subsequently inserting a small-gauge spinal needle through the epidural needle into the subarachnoid space -rapid onset of pain relief (3-5 min) lasts up to 3 hours -pushing reflex is not lost, motor power remains intact -complications include: maternal hypotension intravascular injection accidental intrathecal blockade postural puncture H/A inadequate or failed block maternal fever pruritus -hypotension and assc FHR changes managed with maternal positioning (semi-fowler's position), IV hydration, supplemental oxygen
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: Pharmacologic measures SYSTEMIC ANALGESIA: opioids: Fentanyl (Sublimaze) 50-100 mcg IV
- given IV or epidurally -can cause maternal hypotension, maternal and fetal respiratory depression -rapidly crosses placenta
determining fetal heart rate patterns category II
-is not predictive of abnormal fetal acid-base status and but does require evaluation and continued monitoring
The admission assessment: physical examination
1. pain level 2. uterine activity (contraction freq, duration, intensity) 3. Fetal status, HR, positioning, satin 4. cervical dilation + degree of effacement 5. status of membranes 6. vital signs 7. perform leopold maneuvers to determine fetal lie 8. fundal height measurement 9. ability to ambulate safely
summary of assessments during the 2-4th stages of labor: bearing down
2nd stage of labor (birth of neonate): assist c q effort 3rd stage of labor (placenta expulsion): none 4th stage of labor (recovery): none
summary of assessments during the 2-4th stages of labor: vaginal discharge
2nd stage of labor (birth of neonate): observe for signs of descent- buldging of perineum, crowning 3rd stage of labor (placenta expulsion): assess bleeding after expulsion 4th stage of labor (recovery): assess q 15 min with funds firmness
summary of assessments during the 2-4th stages of labor: behavior/psychosocial
2nd stage of labor (birth of neonate): observe q 15 min: cooperative, focus is on work of pushing newborn out 3rd stage of labor (placenta expulsion): observe q 15 min; often feelings of relief after hearing newborn crying, calmer 4th stage of labor (recovery): observe q 15 min, usually excited, talkative, awake; needs to hold newborn, be close and inspect body
Resting tone is normally between
5 and 10 mm Hg in early labor and between 12 and 18 mm Hg in active labor
The nurse is analyzing the readout on the EFM and determines the FHR pattern is reassuring based on which recording?
Acceleration of at least 15 bpm for 15 seconds
analysis of amniotic fluid
Green fluid- fetus has passed meconium secondary to transient hypoxia prolonged pregnancy cord compression intrauterine growth restriction (IUGR) maternal hypertension diabetes, or chorioamnionitis; however, it is considered a normal occurrence if the fetus is in a breech presentation.
Baseline variability is defined as irregular fluctuations in the baseline FHR, which is measured as the amplitude of the peak to trough in bpm
fluctuation range undetectable fluctuation range observed at <5 bpm fluctuation range from 6 to 25 bpm fluctuation range >25 bpm
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: Pharmacologic measures SYSTEMIC ANALGESIA
Involves the use of one or more drugs administered orally, IM, IV; they distribute throughout body via circulatory system *** complication: respiratory depression -opioids given at the time of birth can cause CNS depression in newborn, necessitating use of Narcan (naloxone) several drug categories can be used: opioids: typically IV, butorphanol (Stadol), nalbuphine (Nubain), meperidine (Demerol), morphine or fentanyl (sublimaze). Assc c respiratory depression, inhibited sucking, delay in effective feeding, decr alertness Ataractics: hydroxyzine (Vistaril), promethazine (Phenergan), prochlorperazine (Compazine) Benzodiazepines: diazepam (Valium), midazolam (Versed) SYSTEMIC analgesics typically administered parenterally, through IV
Leopold maneuvers are a method for determining the presentation, position, and lie of the fetus through the use of four specific steps.
Maneuver 1: What fetal part (head or buttocks) is located in the fundus (top of the uterus)? Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the back of the fetus.) Maneuver 3: What is the presenting part? Maneuver 4: Is the fetal head flexed and engaged in the pelvis?
a pain assessment tool named coping with labor algorithm
Plan, Do, Check, Act provides mechanism for pain documentation and links it to nursing care intervention
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: Pharmacologic measures includes systemic analgesia + regional/local anesthesia NEURAXIAL ANALGESIA/ANESTHESIA
admin of analgesic (opioids) or anesthetic (capable of producing a loss of sensation in an area of the body) agents, either continuously or intermittently, into the epidural or intrathecal space to relieve pain
The purpose of performing a vaginal examination is to assess
assess the amount of cervical dilation cervical effacement fetal membrane status presentation, position, station, degree of fetal head flexion, and presence of fetal skull swelling or molding
periodic baseline changes fetal decelerations -late
associated with uteroplacental insufficiency, which occurs when blood flow within the intervillous space is decreased to the extent that fetal hypoxia or myocardial depression exists -Conditions that may decrease uteroplacental perfusion with resultant decelerations include: maternal hypotension gestational hypertension placental aging secondary to diabetes and postmaturity hyperstimulation via oxytocin infusion maternal smoking anemia cardiac disease.
intermittent FHR monitoring
auscultation via a fetoscope or a handheld Doppler device that uses ultrasound waves that bounce off the fetal heart, producing echoes or clicks that reflect the rate of the fetal heart
The normal baseline FHR can be obtained by
auscultation, ultrasound, or Doppler, or by a continuous internal direct fetal electrode.
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: appalachian women
believe placing a hatchet under bed will cut pain
the membranes are probably ruptured if the ninrazine turns
blue-green to deep blue, with pH ranging from 6.5 to 7.5
late decelerations imply some degree of fetal hypoxia, recurrent or intermittent late decelerations are always category ???
category II (indeterminate) or category III (abnormal)
Baseline variability of FHR absent or minimal
caused by fetal acidemia secondary to uteroplacental insufficiency cord compression a preterm fetus maternal hypotension uterine hyperstimulation abruptio placenta fetal dysrhythmia. Interventions to improve uteroplacental blood flow and perfusion through the umbilical cord include lateral positioning of the mother increasing the IV fluid rate to improve maternal circulation administering oxygen at 8 to 10 L/min by mask considering internal fetal monitoring documenting findings and reporting to the health care provider.
Uterine contractions with intensity of 30 mm Hg or greater
cervical dilation
assessing uterine contractions
contraction (systole) relaxation (diastole) Each contraction starts with a building up (increment), gradually reaching an acme (peak intensity), and then a letting down (decrement). -At the acme (peak) of the contraction, the entire uterus is contracting, with the greatest intensity in the fundal area. The relaxation phase follows and occurs simultaneously throughout the uterus. - Assessment of the contractions includes frequency duration intensity uterine resting tone
Continuous Electronic Fetal Monitoring (EFM)
detects the fetal pulse by sensing and analyzing tissue movements via Doppler ultrasound. - recommended method of intrapartum fetal surveillance for high-risk pregnancies. -primary objective; to provide information about fetal oxygenation and prevent fetal injury that could result from impaired fetal oxygenation during labor -there is a continuous record of the FHR: no gaps exist, as they do with intermittent auscultation. -. On the downside, however, using continuous monitoring can limit maternal movement and encourages the woman to lie in the supine position, which reduces placental perfusion.
can do what other test if ninrazine test inconclusive
fern test can confirm rupture of membranes
FHR variability is an important clinical indicator that is predictive of
fetal acid-base balance and cerebral tissue perfusion. -It is influenced by fetal oxygenation status, cardiac output, and drug effects -As the CNS is desensitized by hypoxia and acidosis, FHR decreases until a smooth baseline pattern appears. Loss of variability may be associated with a poor outcome.
nursing management during the second stage of labor: perineal lacerations
first degree laceration: extends through the skin 2nd degree: extends through the muscles of the perineal body 3rd degree: continues through the anal sphincter muscle 4th degree: involves the anterior rectal wall; special consideration for these because they can cause fecal incontinence lacerations should be repaired during third stage of labor
continuous internal monitoring -indicated for high risk mom/fetus -possible conditions might include
multiple gestation decreased fetal movement abnormal FHR on auscultation IUGR maternal fever preeclampsia dysfunctional labor preterm birth, or medical conditions such as diabetes or hypertension. -It involves the placement of a spiral electrode into the fetal presenting part, usually the head, to assess FHR, and a pressure transducer placed internally within the uterus to record uterine contractions
To ensure that the maternal heart rate is not confused with the FHR,
palpate the client's radial pulse simultaneously while the FHR is being auscultated through the abdomen.
Summarize assessment data collected on admission to the prenatal unit priorities are?
upon admission priorities are: true/falso labor send her home or no? assessing FHR assessing cervical dilation/effacement have membranes ruptured?
External electronic fetal monitoring cannot assess
variability accurately. Therefore, if external monitoring shows a baseline that is smoothing out, use of an internal spiral electrode should be considered to gain a more accurate picture of the fetal health status.
Intermittent FHR auscultation can be used to detect FHR baseline and rhythm and changes from baseline. However, it cannot detect
variability and types of decelerations, as electronic fetal monitoring (EFM) can
periodic baseline changes fetal decelerations -variable
most common pattern, transient and correctable -associated with cord compression -category II or III
determining fetal heart rate patterns category III
- is predictive of abnormal fetal acid-base status at the time of observation and requires prompt evaluation and interventions such as giving maternal oxygen changing maternal position discontinuing labor augmentation medication treating maternal hypotension
periodic baseline changes fetal accelerations
- transitory abrupt increases in the FHR above the baseline that last <30 seconds from onset to peak -assoc c sympathetic nervous system stimulation -elevations of FHR of more than 15 bpm above the baseline, and their duration is >15 seconds, but less than 2 minutes -considered reassuring and require no interventions. Accelerations denote fetal movement and fetal well-being and are the basis for nonstress testing.
Maternal assessment
-Assess maternal vital signs, BP, temp, pulse, resp, and pain -review prenatal record to identify risk factors that may contribute to a decrease in uteroplacental circulation during labor. If no vaginal bleeding on admission, perform vaginal examination to assess cervical dilation
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: Pharmacologic measures SYSTEMIC ANALGESIA: opioids: Nalbuphine (Nubain) 10-20 mg IV
-IV -causes less maternal nausea and vomiting -decreases FHR variability, fetal bradycardia, respiratory depression
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: Pharmacologic measures SYSTEMIC ANALGESIA: opioids: meperidine (Demerol) 25-75 mg IV
-IV, intrathecally, epidurally with max fetal uptake 2-3 hr after admin -can cause CNS depression - decreases FHR variability
GUIDELINES FOR ASSESSING FETAL HEART RATE
-Initial 10- to 20-minute continuous FHR assessment on entry into labor/birth area -Completion of a prenatal and labor risk assessment on all clients -Intermittent auscultation every 30 minutes during active labor for a low-risk woman and every 15 minutes for a high-risk woman -During the second stage of labor, every 15 minutes for the low-risk woman and every 5 minutes for the high-risk
continuous internal monitoring criteria
-Ruptured membranes -Cervical dilation of at least 2 cm -Presenting fetal part low enough to allow placement of the scalp electrode -Skilled practitioner available to insert spiral electrode
Fetal Descent and Presenting Part
-The ischial spines serve as landmarks ( zero station) -If presenting part is palpated higher than the maternal ischial spines, a negative number is assigned; -if the presenting fetal part is felt below the maternal ischial spines, a plus number is assigned, denoting how many centimeters below zero station -Progressive fetal descent (-5 to +4) is the expected norm during labor—moving downward from the negative stations to zero station to the positive stations in a timely manner.
periodic baseline changes fetal decelerations -prolonged decelerations
-abrupt FHR declines of at least 15 bpm that last longer than 2 min, but less than 10 minutes -associated with: prolonge cord compression abruptioplacenta cord prolapse supine maternal position vaginal examination fetal blood sampling maternal seizures regional anesthesia uterine rupture
assessments during the 4th stage of labor: fundus
-assess height, position, firmness, q 15 min during first hour following birth -needs to remain firm to prevent postpartum bleeding (should feel size and consistency of grapefruit) -located midline and below umbilicus -if not firm (boggy) gently massage it until it is, once firmness obtained stop it
nursing management during the fourth stage of labor
-begins after the placenta is expelled -lasts up to 4 hrs after birth, during which time recovery takes place -focus is : observation for hemorrhage, comfort measures, and promotion of family attachment
interventions for category III patterns
-call DR get orders -discontinue oxytocin -turn client on left or right lateral, knee-chest, or hands and knees to increase placental perfusion or relieve cord compression -administer oxygen via nonrebreather face mask to increase fetal oxygenation -increase the iV fluid rate to improve intravascular volume and correct maternal hypotension -assess the client for underlying contributing causes -modify pushing in the sec stage of labor to improve fetal oxygenation -prepare for an expeditious surgical birth if pattern is not corrected in 30 minutes
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: nonpharmacologic measures simple safe inexpensive gate control theory
-continuous labor support -hydrotherapy -hypnosis -ambulation -maternal position changes -transcutaneous electrical nerve stimulation (TENS) -acupuncture -acupressure -attention focusing imagery -therapeutic touch and massage -breathing techniques -effleurage- light stroking touch of abdomen in rhythm c breathing during contractions -application of heat/cold
assessments during the 4th stage of labor what will you see in vitals
-decrease in BP may indicate uterine hemorrhage -incr in BP may indicate preclampsia -pulse slower than in labor (60-70 bpm) -elevated pulse - early sign of blood loss -fever indicative of dehydration (less than 100.4 or 38 C) or infection, which may involve GI tract -RR usually 16-24 bpm and regular, should be unlabored
nursing interventions for third stage of labor
-describe placenta separation to couple -instruct woman to push when signs of separation are apparent -give oxytocin if ordered and indicated after placental expulsion -provide info on laceration or episiotomy if applicable -cleaning and assisting into comfortable position -assess knowledge of breastfeeding -instruct about latching on, positioning, infant sucking and swallowing -warm blankets -ice to perineal area -explaining assessments -ascertaining any needs -monitoring maternal physical status: -vaginal bleeding; Amt, consistency, color -vital signs -uterine fundus, which should be firm in the midline and at level of umbilicus -recovering all birthing stats and securing primary caregivers name -documenting birthing event in the birth book
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: Pharmacologic measures SYSTEMIC ANALGESIA: antiemetics: Hydroxyzine (Vistaril) 50-100 mg IM
-does not relieve pain but reduces anxiety and potentiates opioid analgesic effects, CANNOT BE GIVEN IV -decreases nausea and vomiting
umbilical cord blood acid-base analysis
-drawn at birth, helps evaluate intrapartum hypoxia and acidemia. -normal mean pH value 7.2-7.3 useful for interventions with newborns with low 5 min APGAR scores severe FGR category II/III patterns during labor umbilical cord prolapse uterine rupture maternal fever placental abruption meconium-stained amniotic fluid postterm births
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: Pharmacologic measures SYSTEMIC ANALGESIA: benzodiazepines: Diazepam (Valium) 2-5 mg IV
-enhances pain relief of opioid and causes sedation -may be used to stop eclamptic seizures -decreases nausea and vomiting -can cause newborn depression; therefore lowest dose possible should be used
assessments during the 4th stage of labor
-focus: vital signs status of uterine fundus and perineal area -comfort level -lochia amount -bladder status
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: Pharmacologic measures SYSTEMIC ANALGESIA: antiemetics: Prochlorperazine (Compazine) 5-10 mg IV or IM
-frequently given c morphine sulfate for sleep during prolonged latent phase; counteracts the nausea that opioids can produce
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: Pharmacologic measures SYSTEMIC ANALGESIA: opioids: butorphanol (Stadol) 1-2 mg IV q2-4h
-given IV -rapidly transferred across placenta -can cause neonatal respiratory depression
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: Pharmacologic measures SYSTEMIC ANALGESIA: opioids: morphine 2-5 mg IV
-given IV or epidurally -rapidly crosses placenta, causes decrease in FHR variability -can cause maternal/neonatal depression -decreases uterine contractions
rupture of membranes
-if intact, the membranes will be felt as a soft bulge that is more prominent during a contraction. -If the membranes have ruptured- sudden gush of fluid. Membrane rupture also may occur as a slow trickle of fluid. -When membranes rupture, the priority focus; assessing fetal heart rate (FHR) first to identify a deceleration, might indicate cord compression secondary to cord prolapse
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: Pharmacologic measures Inhaled analgesics
-in labor half nitrous oxide gas (50%) is mixed with half oxygen (50%) and breathed in through a mask/mouthpeice -self administered -no FHR abnormalities have been reported
fetal scalp stimulation
-indirect method to evaluate fetal oxygenation and acid base balance to identify fetal hypoxia by fetal scalp stimulation or vibroacoustic stimulation -vibroacoustic stimulator (artificial larynx) applied to the womens lower abdomen and turned on for 3-5 sec to produce sound and vibration or by placing a gloved finger on the fetal scalp and applying firm pressure -a well-oxygenated fetus will respond when stimulated by moving in conjunction with an acceleration of 15 bpm above the baseline heart rate that lasts at least 15 sec.
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: Pharmacologic measures regional analgesia/anesthesia: (pain relief c/out loss of consciousness) c or c/out opioids: patient controlled epidural analgesia
-indwelling epidural catheter with an infusion of medication and a programmed pump that allows woman to control dosing
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: Pharmacologic measures regional analgesia/anesthesia: (pain relief c/out loss of consciousness) c or c/out opioids: local infiltration
-injection of a local anesthetic, such as lidocaine, into the superficial perineal nerves to numb perineal area. -done by Physician or midwife before performing an episiotomy or before suturing a laceration -does not alter pain of uterine contractions, but numbs immediate area of episiotomy or laceration -no side effects for woman or newborn
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: Pharmacologic measures regional analgesia/anesthesia: (pain relief c/out loss of consciousness) c or c/out opioids: spinal (intrathecal) analgesia/anesthesia
-injection of anesthetic "caine" agent, c our c/out opioids, into the subarachnoid space to provide pain relief during labor/cesarean birth. -frequently used for elective or emergent cesarean births -reactions include: hypotension and spinal H/A -given during the active phase of labor (more than 5 cm of dilation) - do not cause motor blockade, rapid-onset pain relief, less likely to cause newborn respiratory depression
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: Pharmacologic measures regional analgesia/anesthesia: (pain relief c/out loss of consciousness) c or c/out opioids: pudendal nerve block
-injection of local anesthetic agent (bupivacaine, ropivacaine) into the pudendal nerves near each ischial spine -provides pain relief in lower vagina, vulva, perineum -used for second stage of labor, an episiotomy or an operative vaginal birth with outlet forceps or vacuum extractor
The FHR is heard most clearly at the fetal back. -In a cephalic presentation, the FHR is best heard in the ------ -In a breech presentation, it is heard -----
-lower quadrant of the maternal abdomen. -at or above the level of the maternal umbilicus
assessment during the third stage of labor
-monitoring placental separation by noting: firmly contracting uterus change in uterine shape from discoid to globular ovoid sudden rush of dark blood lengthening of umbilical cord -examining placenta for the second time -assessing for perineal trauma -firm fundus c bright red blood trickling; laceration -boggy fundus c red blood flowing: uterine atony -boggy fundus c dark blood and clots: retained placenta -inspecting the perineum for condition of episiotomy, if performed -assessing for perineal lacerations and ensuring repair by birth attendant
Baseline variability of FHR marked variability
-occurs when there are more than 25 beats of fluctuation in the FHR baseline. -Causes of this include cord prolapse or compression maternal hypotension uterine hyperstimulation and abruptio placenta. -Interventions include determining the cause if possible lateral positioning increasing intravenous fluid rate administering oxygen at 8 to 10 L/min by mask discontinuing oxytocin infusion observing for changes in tracing considering internal fetal monitoring -communicating an abnormal pattern to the health care provider, and preparing for a surgical birth if no change
immediate care of newborn (third stage)
-place under warmer/dried assessed -placed on moms abdomen -apgar score at 1 and 5 min -secure identification bands on baby and parents -electronic sensors
nursing management during third stage of labor
-stage is complete when placenta is expelled -nursin care primarily focuses on immediate newborn care and assessment and observing for signs of placental separation -recording time of expulsion -inspecting for intactness -nurse should also be assessing by palpating the uterus before and after placental expulsion
determining fetal heart rate patterns category 1
-strongly predictive of normal fetal acid-base status at the time of observation and needs no intervention
nursing interventions during 4th stage of labor
-support/info on episiotomy repair + related pain relief -ice pack to perineum -assiting with hygiene/perineal care -monitoring for return of sensation and ability to void -motinoring vital signs, fundal/lochial status, q 15 min -assessing for postpartum hemorrhage +urinary retention -offering analgesia/warm blankets -fluids/nourishment -encourage parent/infant attachment -be sensitive to typical cultural practices after birth -encourage mother to nurse -teach woman how to assess fundus for firmness and massage it if its boggy -describe lochia flowing normal parameters to observe postpartum -teaching safety about newborn abduction -teach portable sits bath as comfort measure for women c laceration/episiotomy -assist c ambulation -give info on routine on the mother-baby unit -observe for signs of early-parent infant attachment -
periodic baseline changes fetal decelerations -early
-transient fall in FHR caused by stimulation of the parasympathetic nervous system -classified early, late, variable -Early decelerations: -onset, nadir, and recovery of deceleration occur at the same time as the onset, peak, and recovery of the contraction -They rarely decrease more than 30 to 40 bpm below the baseline. -not indicative of fetal distress and do not require intervention.
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: Pharmacologic measures GENERAL ANESTHESIA
-typically reserved for emergency cesarean births when no time to provide spinal.epidural anesthesia or if woman has a contraindication to use of regional anesthesia -rapid loss of consciousness -give IV, inhalation or both -commonly given are thiopental or propofol -this is followed by muscle relaxant -then woman is intubated and given nitrous oxide + oxygen -primary complication: fetal depression, uterine relaxation, potential maternal vomiting and aspiration
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: Pharmacologic measures SYSTEMIC ANALGESIA: antiemetics: Promethazine (Phenergan) 25-50 mg IV or IM
-used for antiemetic effect when combined with opioids -causes sedation + reduces apprehension -may cause maternal hypotension + neonatal depression
assessments during the 4th stage of labor: vagina
-will be stretched and edematous -assess episiotomy if present for possible hematoma formation -suspect hematoma if woman reports excruciating pain or cannot void or mass is noted at perineal area -assess for hemrrhoids -pain should be less than 3 -assess vaginal discharge q 15 min for first hour and q 30 min for the next hour -palpate bladder for fullness, should produce large ants of urine -a full bladder will displace the uterus to either side of the midline and potentiate uterine hemorrhage secondary to bogginess
cervical dilation
0 cm: external cervical os is closed 5 cm: external cervical os is halfway dilated 10 cm: external os is fully dilated and ready for birth passage
Cervical Effacement
0%: cervical canal is 2 cm long 50%: cervical canal is 1 cm long 100%: cervical canal is obliterated
3 hormones play important roles in third stage
1. oxytocin - causes uterine contractions, helps enact instinctive mothering behaviors (holding baby close to body, 2. endorphins aka body natural opiates, produced altered state of consciousness and help block pain 3. adrenalin- the drop in adrenalin level from second stage, which had kept baby alert at first contact, causes women to get cold
summary of assessments during the 2-4th stages of labor: contractions/uterus
2nd stage of labor (birth of neonate): palpate every one 3rd stage of labor (placenta expulsion): observe for placental separation 4th stage of labor (recovery): palpating for firmness and position q 15 min for first hour
summary of assessments during the 2-4th stages of labor: vital signs
2nd stage of labor (birth of neonate): q 15 min 3rd stage of labor (placenta expulsion):q 15 min 4th stage of labor (recovery): q 15 min
summary of assessments during the 2-4th stages of labor: fetal heart rate
2nd stage of labor (birth of neonate): q 15 min by doppler or cont by EFM 3rd stage of labor (placenta expulsion): apgar scoring at 1 & 5 min 4th stage of labor (recovery): newborn- complete head to toe assessment, vita signs q 15 min until stable
During active labor, the intensity usually reaches
50 to 80 mm Hg.
continuous external monitoring
In external or indirect monitoring, two ultrasound transducers, each of which is attached to a belt, are applied around the woman's abdomen. -One transducer is called a tocotransducer, a pressure-sensitive device that is applied against the uterine fundus; detects changes in uterine pressure + converts the pressure registered into an electronic signal that is recorded on graph paper -placed over the uterine fundus in the area of greatest contractility to monitor uterine contractions. -other ultrasound transducer records the baseline FHR, long-term variability, accelerations, and decelerations. -positioned on the maternal abdomen in the midline between the umbilicus and the symphysis pubis. -The diaphragm of the ultrasound transducer is moved to either side of the abdomen to obtain a stronger sound and is then attached to the second elastic belt -This transducer converts the fetal heart movements into beeping sounds and records them on graph paper
PrepU The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8oF, contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize?
Meconium in the fluid
PrepU 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.
The admission assessment: lab values
include: urinalysis via clean catch urine specimen complete blood count blood typing/Rh factor analysis if following test results are not included in maternal prenatal Hx you should run these tests: syphyillis screening hep B (HbsAg) screening group B streptococcus (GBS) HIV testing possible drug screening if Hx is positive
assessment during the second stage of labor it involves identifying the typical signs of the 2nd stage of labor including:
increase in apprehension or irritability spontaneous rupture of membranes sudden appearance of sweat on upper lip increase in blood tinged show low grunting sounds from woman complaints of rectal and perineal pressure beginning of involuntary bearing-down efforts other ongoing assessments: contraction freq/duration/intensity maternal vital signs q 15 min fetal responce to labor as indicated by FHR monitor strips amniotic fluid for color/odor/amount when membranes are rupture copying status of woman and partner determining progress of labor: bulging of perineum labial separation advancing + retreating of newborns head crowning vaginal exam is completed to determine if woman should push -pushing appropriate if woman is fully dilated to 10 cm and the woman feels the urge to do so
Baseline variability of FHR moderate variability
indicates that the autonomic and central nervous systems (CNSs) of the fetus are well developed and well oxygenated It is considered a good sign of fetal well-being and correlates with the absence of significant metabolic acidosis
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: Pharmacologic measures regional analgesia/anesthesia: (pain relief c/out loss of consciousness) c or c/out opioids: epidural analgesia
injection of local anesthetic agent (lidocaine or bupivacaine) into the lumbar epidural space -increases the duration of the second stage of labor, instrument assisted vaginal deliveries and administration of oxytocin -complications include: nausea/vomiting hypotension fever pruritus intravascular injection maternal fever allergic reaction respiratory depression effects on fetus: fetal distress
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: Pharmacologic measures SYSTEMIC ANALGESIA: benzodiazepines: Midazolam (Versed) 1-5 mg IV
is not used for analgesic, but amnesia effect -used as adjunct for anesthesia -is secreted in breast milk
summary of assessments during the first stage of labor: vaginal examination
latent phase (0-3 cm): initially on admission to determine phase and as needed on maternal cues to document labor progression active phase (4-7): as needed to document monitor labor progression transition phase (8-10 cm): as needed to document monitor labor progression
summary of assessments during the first stage of labor: vital signs
latent phase (0-3 cm): q 30-60 min active phase (4-7): q 30 min transition phase (8-10 cm): q 15-30 min
summary of assessments during the first stage of labor: contractions
latent phase (0-3 cm): q 30-60 min by palpation or cont if EFM active phase (4-7): q 15-30 min by palpation or cont if EFM transition phase (8-10 cm): q 15 min by palpation or cont if EFM
summary of assessments during the first stage of labor: temp
latent phase (0-3 cm): q 4 hr more freq if membranes are ruptured active phase (4-7): q 4 hr more freq if membranes are ruptured transition phase (8-10 cm): q 4 hr more freq if membranes are ruptured
summary of assessments during the first stage of labor: fetal heart rate
latent phase (0-3 cm): q hr by doppler or cont by EFM active phase (4-7): q 30 min by doppler or cont by EFM transition phase (8-10 cm): q 15-30 min by doppler or cont by EFM
summary of assessments during the first stage of labor: behavioral/psychosocial
latent phase (0-3 cm): with q client encounter: talkative, excited, anxious active phase (4-7): with q client encounter: self-absorbed in labor; intense and quiet now transition phase (8-10 cm): with q client encounter: discouraged, irritable, feels out of control, declining coping ability
To palpate the fundus for contraction intensity, place the pads of your fingers on the fundus and describe how it feels:
like the tip of the nose (mild), like the chin (moderate), or like the forehead (strong).
nurses interventions through second stage of labor
main: motivating woman assist c positioning encourage to push give feedback/progress -mouth care -changing bed linens/pads -bearing down positions and techniques -delaying pushing for 90 min after cervical dilation of 10 cm -use ab muscles when bearing down, short 6-7 sec pushes -pushing c slight glottis and exhalation -monitoring contractions + FHR patterns -reasuring/coaching -assessing vitals -pain management -nurse presence -notifying MD of estimated time frame for birth -preparing delivery bed and positioning -offering mirror -explaining all procedures -setting up delivery instruments -recording time of birth, time of placenta, type of birth -recieving newborn and transferring to mom w warm blanket
Signs of intrauterine infection to be alert for include
maternal fever fetal and maternal tachycardia foul odor of vaginal discharge an increase in white blood cell count.
an admission assessment includes
maternal health Hx physical assessment fetal assessment lab studies psychological status
The admission assessment: lab values -risk factors for GBS -maternal infections assc with GBS -neonatal infections assc with GBS -GBS carriers receive
maternal intrapartum fever prolonged ruptured membranes previous birth of infected newborn GBS bacteriuria in the present pregnancy -acute chorioamnionitis -endometritis -UTI pneumonia sepsis -IV antibiotic prophylaxis (penicillin G or ampicillin) at the onset of labor or ruptured membranes -universal screening at 35-37 wks gestation
PrepU The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control?
meperidine
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: asia, latino, orthodox jewish
want their own mothers, not husbands at birth
COMFORT PROMOTION AND PAIN RELIEF DURING BIRTH: cherokee, hmong, japanese women
will remain quiet, outwardly expression of pain not appropriate
To confirm that membranes have ruptured, a sample of fluid is taken from the vagina via a nitrazine yellow dye swab to determine the fluid's pH. The membranes are most likely intact if the nitrazine swab remains
yellow to olive green, with pH between 5 and 6.
