OB Exam 2

Shoulder Dystocia Review: 1. A history of ______is a risk factor for shoulder dystocia 2. Shoulder dystocia is an emergency where the anterior shoulder can not pass under the ______ .3. Signs of shoulder dystocia may include _______the sign in which the fetal head retracts against the perineum immediately after it is delivered. 4. Maneuvers used to free the shoulder include the_____maneuver, the ____ maneuver, and the ______ pressure.

1. Gestational Diabetes 2. pelvis 3. Turtle Sign 4. McRoberts maneuver,Gaskin maneuver,and the Suprapubic pressure

Okay, let's start with some physiology. So, after delivery, the ________ tends to regress back to its normal size and resume its pre-pregnancy position by the ________week, a process known as _______. Immediately after the delivery of placenta, the __________of the uterus continue to ________ and ____________ down on the placental __________ where they are attached to the uterine wall, causing them to clamp them shut and __________ uterine bleeding.

1. Uterus 2. 6th 3. Involution 4.Smooth Muscles 5. Contract 6.Squeeze 7.Arteries 8.Reduce

Fetal bradycardia: Define Interventions?

-FHR less than 110/min for 10 min or more Nursing Interventions: -Discontinue oxytocin if being administered. -Assist the client to a side-lying position. -Administer oxygen by mask at 10 L/min via nonrebreather face mask. -Insert an IV catheter if one is not in place and administer maintenance IV fluids. -Administer a tocolytic medication. -Notify the provider.

Third Maneuver: Pawlik's Grip Purpose? How would you perform this procedure? Findings?

-To determine engagement of presenting part. -Using thumb and finger, grasp the lower portion of the abdomen above symphysis pubis, press in slightly and make gentle movements from side to side. Findings: The presenting part is not engaged if it is not movable is not yet engaged if it is still movable.

Dystocia (Dysfunctional Labor) Define? Risk Factors?

Dystocia of labor is defined as difficult labor or abnormally slow progress of labor related to the five P's .(passenger, passageway, powers, position, and psychologic response). Risk Factors: -Can be caused by a typical uterine contractions -Failure of the cervix to efface and dilate

Pharmacological Pain Management: To avoid slowing the progress of labor, prior to administering analgesic medications, the nurse should ? For clients who requests pain management interventions during labor and birth the nurse should?

Includes analgesia and local/regional analgesics. To avoid slowing the progress of labor, prior to administering analgesic medications, the nurse should verify that labor is well established by performing a vaginal exam and evaluating uterine contraction pattern. -Alleviates pain sensations or raises the threshold for pain perception. - Also, the nurse should conduct a fall safety risk assessment for clients who requests pain management interventions during labor and birth which increases the risk for falls.

Lochia Assessment: When assessing the Lochia what are you looking for? Describe a perineal pad that is scant, light, moderate, heavy, and excessive blood loss?

Lochia amount is assessed by the quantity of saturation on the perineal pad as being : Scant: less than 2.5 cm Light: 2.5 to 10 cm Moderate: more than 10 cm Heavy: one pad saturated within 2 hr Excessive blood loss: one pad saturated in 15 min or less, or pooling of blood under buttocks -Assess the lochia for normal color, amount, odor, and consistency.

Psychological response: What are you looking out for here? Why?

Maternal stress, tension, and anxiety can produce physiological changes that impair the progress of labor.

Precipitous labor: Define it Risk Factors?

Precipitous labor is defined as labor that lasts 3 hr or less from the onset of contractions to the time of birth. Risk Factors: -Hypertonic Uterine Dysfunction: Nonproductive, uncoordinated, painful, uterine contractions during labor that are too frequent and too long in duration and do not allow for relaxation of the uterine muscle between contractions (uterine tetany). -Oxytocin Stimulation: -Administered to augment or induce labor by increasing intensity and duration of contractions. -Oxytocin stimulation can lead to hypertonic uterine contractions. -Multiparous Client: Can move through the stages of labor more rapidly.

Perineal Tenderness, Laceration, and Episiotomy: Remember REEDDA What measures could you use to promote comfort? - How would you educate you client on proper peri care?

R- Redness E-Edema E-Ecchymosis D-Discharges D-Drainage A-Approximation Promote comfort measures: -Apply ice/cold packs to the perineum for the first 24 hr to reduce edema and provide anesthetic effect. Do not apply directly to the perineum -Heat therapies (hot packs), moist heat, and sitz baths can be used to increase circulation and promote healing and comfort. -Encourage sitz baths at a hot or cool temperature for 20 min at least twice a day -Administer analgesics, such as nonopioids (acetaminophen), nonsteroidal anti-inflammatories (ibuprofen), and opioids (codeine, hydrocodone) for pain and discomfort. -Apply topical anesthetics (benzocaine spray) to the client's perineal area as needed or witch hazel compresses or hemorrhoidal creams to the rectal area for hemorrhoids. -Educate the client about proper cleansing to prevent infection. Client Education -Wash both hands thoroughly before and after voiding. -Use a squeeze bottle filled with warm water or antiseptic solution after each voiding to cleanse the perineal area. -Blot the perineal area dry to clean it after toileting, starting from front to back (urethra to anus). -Use topical antiseptic cream or spray sparingly. -Change the perineal frequently pad by removing the front part first, peeling it toward the back after voiding or defecating.

Regional blocks: What are the regional blocks most commonly used?

Regional blocks are most commonly used and consist of pudendal, epidural, spinal, and paracervical nerve block.

Immune system: When would a client receive the Rubella vaccine? Why? What should the client not do after receiving this vaccine? All Rh-negative clients who have have newborns who are Rh-positive must be given? How would Rho(D) be administered? Why is it administered? When would Varicella be administered to the client? What should the client not do after administration? When is the second dose given?

Rubella: A client who is nonimmune to rubella or has a negative or low titer is administered a subcutaneous injection of rubella vaccine or a measles, mumps, and rubella (MMR) vaccine during the postpartum period to protect a subsequent fetus from malformations. The client should not get pregnant for 4 weeks (28 days) following the immunization Rh: All Rh-negative clients who have have newborns who are Rh-positive must be given Rho(D) immune globulin administered IM within 72 hr of the newborn being born to suppress antibody formation in the mother. The nurse should check to see if the client has not been sensitized prior to administering Rho(D) immune globulin. Observe the client for at least 20 minutes post administration for an allergic reaction. Varicella: If the client has no immunity, varicella vaccine is administered before discharge. The client should not get pregnant for 1 month following the immunization. A second dose of vaccine is given at 4 to 8 weeks.

External electronic monitoring (tocotransducer):

Separate transducer applied to the maternal abdomen over the fundus that measures uterine activity

Mechanism of labor in vertex presentation: Define it What are they? (7)

The adaptations the fetus makes as it progresses through the birth canal during the birthing process • Engagement • Descent • Flexion • Internal Rotation • Extension • External Rotation • Birth by Expulsion

Fourth Maneuver: Pelvic Grip Purpose? How would you perform this procedure? Findings?

To determine the degree of flexion of fetal head. To determine attitude or habitus. Facing foot part of the woman, palpate fetal head pressing downward about 2 inches above the inguinal ligament. Use both hands. Findings: -Good attitude - if brow correspond to the side (2nd maneuver) that contained the elbows and knees. Poor atitude - if examining fingers will meet an obstruction on the same side as fetal back (hyperextended head)Also palpates infant's anteroposterior position. If brow is very easily palpated, fetus is at posterior position (occiput pointing towards woman's back)

Second Maneuver: Umbilical Grip Purpose? How would you perform this procedure? Findings?

To identify location of fetal back. To determine position -One hand is used to steady the uterus on one side of the abdomen while the other hand moves slightly on a circular motion from top to the lower segment of the uterus to feel for the fetal back and small fetal parts. Use gentle but deep pressure. Findings: -Fetal back is smooth, hard, and resistant surface Knees and elbows of fetus feel with a number of angular nodulation

External fetal monitoring (EFM)

Transducer applied to the abdomen of the client to assess FHR patterns during labor and birth

Accelerations: Define ? What are the two types? Are these Okay? What do they mean?

- Abrupt increase in FHR above baseline from : -UC's -Vaginal exam - Breech position Accelerations= Okay Types: Non-periodic- Does NOT occur with contractions Periodic : Occurs with contractions What do they mean? - Reassuring -Fetal Well being -Well oxygenated

Epidural block: - What medications make up this? - Where is it injected? - Adverse Effects? -Nursing Actions?

- Consists of a local anesthetic, bupivacaine, along with an analgesic, morphine or fentanyl, injected into the epidural space at the level of the fourth or fifth vertebrae. -This eliminates pain from the level of the umbilicus to the thighs, relieving the discomfort of uterine contractions, fetal descent, and stretching of the perineum. Adverse effects: -Maternal hypotension -Fetal bradycardia -Fever -Itching -Inability to feel the urge to void -Urinary retention -Loss of the bearing down reflex Nursing Actions: -Administer a bolus of IV fluids to help offset maternal hypotension. -Encourage the client to remain in the side-lying position after insertion of the epidural catheter to avoid supine hypotension syndrome with compression of the vena cava. -Assess for orthostatic hypotension. Be prepared to administer an IV vasopressor (such as ephedrine), position the client laterally, increase the rate of IV fluid administration, and initiate oxygen. -Provide for client safety, such as by raising the side rails of the bed.

Variability: Define What are the types and there ranges? What is a normal Variability rate?

- Irregular amplitude fluctuations in FHR - Most important indicator of fetal oxygenation Types: Absent= amplitude undetected Minimal= < 5 bpm Moderate = 6 - 25 bpm = Normal Marked = > 25 bpm

Early Decelerations - Fetal Heart Rate: Define? **(Flip to take note of the explanation provided ) ** - The key to remembering if this an early deceleration is to? - Are Early Decelerations an emergency? - Why does the baby heart rate slightly decrease thus causing this type of strip? Interventions?

- Slowing of FHR at the start of contraction with return of FHR to baseline at end of contraction Explanation: The picture above is known as an "early decelerations". The top line is monitoring the baby's heart rate and the bottom line is monitoring mom's contractions. On the bottom line (mom's contraction), you can see that the line start to go up and then down.......this means mom is having a contraction. The top line (baby's heart rate) then responds to this contraction and notice that it slightly dips down while mom is having her contraction. The Key to Remembering: -The key to remembering if this an early deceleration is to see if the baby's heart rate mirrors moms contraction and it does here. Plus look to see if the baby's heart rate is staying within normal limits of 110-160 beats per minutes. The baby's heart rate dips slightly at the same time the contraction starts and recovers to a normal range after mom's contraction is over. Early decelerations: Are nothing to be alarmed about. The reason the baby's heart rate starts to slightly decrease is due to head compression (probably from the baby's head being in the birth canal) causing the vagus nerve to be compressed which in turn decreases the heart rate. - NO interventions required

uterine tachysystole: Define

- Uterine Contractions are too frequent! more than five contractions in 10 minutes, averaged over a 30-min window

Cervical Ripening: Define it What chemical agents are used to thin and soften the cervix? What pain med is used? What would you monitor for?

-"primes" and softens the cervix to get ready for labor. Chemical agents: - Prostaglandins: used to thin and soften the cervix, can be given orally or vaginally (misoprostol, dinoprostone) - Low dose oxytocin Monitor: -Monitor for urinary retention - Rupture of membranes - Uterine tenderness - contractions - Vaginal bleeding - Fetal distress -Monitor for tachysystole and notify provider as needed -Proceed with caution in clients who have glaucoma, cardiovascular or renal disorders, asthma, and glaucoma - IURP as needed

Patient-Centered Care Postpartum: - When and how should oxytocics be administered? Why do we administer oxytocics? - Oxytocics include what medications? What adverse effects should you monitor for with these medications? -For a client that is lactating, what should you encourage and why? -Why should you encourage emptying of the bladder postpartum?

-Administer oxytocics intramuscularly or IV after the placenta is delivered to promote uterine contractions and to prevent hemorrhage. -Oxytocics include oxytocin, methylergonovine, and carboprost. Misoprostol, a prostaglandin, also can be administered. Monitor for adverse effects of medications: -Oxytocin and misoprostol can cause hypotension. ---Methylergonovine, ergonovine, and carboprost can cause hypertension. -Encourage early breastfeeding for a client who is lactating. This will stimulate the production of natural oxytocin and prevent hemorrhage. -Encourage emptying of the bladder to prevent possible uterine displacement and atony.

F E T A L F I B R O N E C T I N What is it? How do you obtain it?

-Amniotic enzyme keeps the amniotic sac attached to the uterus -Obtain vaginal -Detect preterm labor by 1-2weeks

Assessment of amniotic fluid: What should it look like? What should it smell like? What is normal Volume? Indication of nitrazine paper? What does blue indicate? What does yellow indicate?

-Amniotic fluid should be watery, clear, and have a slightly yellow tinge. -Odor should not be foul. -Volume is between 700 and 1,000 mL. -Use nitrazine paper to confirm that amniotic fluid is present. Amniotic fluid is alkaline: Nitrazine paper is deep blue, indicating pH of 6.5 to 7.5. Urine is slightly acidic: Nitrazine paper remains yellow

Anaphylactoid syndrome of pregnancy (amniotic fluid embolism): Define? Expected Findings? Nursing Care?

-An amniotic fluid embolism occurs when there is a rupture in the amniotic sac or maternal uterine veins accompanied by high intrauterine pressure that causes infiltration of the amniotic fluid into the maternal circulation. The amniotic fluid then travels to and obstructs pulmonary vessels and causes respiratory distress and circulatory collapse. -It can occur during labor, birth, or within 30 min following birth. -Meconium-stained amniotic fluid or fluid containing particulate matter can cause devastating maternal damage because it readily clogs the pulmonary veins completely. -Serious coagulation problems, such as disseminated intravascular coagulopathy (DIC), can occur. Expected Findings: Report of sudden chest pain and/or sudden shortness of breath Physical Assessment Findings: -Indications of respiratory distress -Restlessness -Cyanosis -Dyspnea -Pulmonary edema -Respiratory arrest -Indications of coagulation failure -Bleeding from incisions and venipuncture sites -Petechiae and ecchymosis -Uterine atony Nursing Care: -Administer oxygen via a mask at 8 to 10 L/min. -Assist with intubation and mechanical ventilation as indicated. -Perform cardiopulmonary resuscitation(CPR) if necessary. -Administer IV fluids. -Position the client on one side with the pelvis tilted at a 30° angle to displace the uterus. -Administer blood products to correct coagulation failure. -Insert an indwelling urinary catheter, and measure hourly urine output. -Monitor maternal and fetal status. -Prepare the client for an emergency cesarean birth if the fetus is not yet delivered.

Fundal Assessment: -At the end of the third stage of labor, the uterus should be palpable at ? - After 1 hr of delivery, where should the fundus rise? - Every 24 hr, the fundus should descend approximately? -It should be halfway between the ______ and the _________ by 6 days postpartum. -The uterus should lie within the true pelvis and should not be palpable after how many weeks?

-At the end of the third stage of labor, the uterus should be palpable at midline and 2 cm below the umbilicus. -1 hr after delivery, the fundus (top portion of the uterus) should rise to the level of the umbilicus. -Every 24 hr, the fundus should descend approximately 1 to 2 cm. It should be halfway between the symphysis pubis and the umbilicus by 6 days postpartum. -After about 2 weeks, the uterus should lie within the true pelvis and should not be palpable.

Phase 1: Early labor (Latent): Cervical Dilation Range? Contraction duration and Frequency? Do all mothers notice contractions? If mom is at home what should you instruct her to do? What would mom look/act like during this phase? Nursing Interventions?

-Cervix dilates from 0 to 3 cm* -Contractions occur every 5 to 30 minutes and 30-45 seconds in length -Contractions are less intense compared to other phases and stages -If woman at home, should monitor contraction duration and intensity...try to stay comfortable at home until water breaks or enters active phase of labor -Woman will be talking, excited, and nervous. Nursing Interventions - SVE (dilation, effacement, station), Leopold's maneuvers - Prepare for bedside US to determine fetal presentation - Monitor fetal heart tones via intermittent auscultation or continuous fetal monitoring - Prepare for possible exam to rule out rupture of membranes (ferning, pooling, nitrazine)

Phase 2: Active Labor: Cervical Dilation Range? Contraction duration and Frequency? If mom is at home what should you instruct her to do? What should you do if once water breaks? What should you look out for and WHY ? What is meconium and how would you describe it? What test would you perform and why? How would you know that this test is positive? What Pharmacological and Non- pharmacological interventions would you apply? What would you encourage the mother to do and why? What would you monitor during this phase? What would mom look/act like during this phase?

-Cervix dilates to *4 to 7 cm -Contractions will be noticeably stronger and longer, Moderate to strong (45 to 60 seconds) every 3 to 5 minutes -If woman at home, time to go to the hospital! Water may break (if hasn't already) -Important to monitor for meconium -stained fluid which is greenish brown/yellowish ammonitic fluid...baby can aspirate this into lungs causing infection or blocking airway and this usually indicates fetal distress) -Perform Nitrazine paper test to confirm the water has broke (turns blue if positive) Interventions: -Provide comfort (non-pharmacological and pharmacology). Non-pharmacological: changing positions, warm shower or bath, massages between contractions, breathing techniques, ice or fluids for dry mouth. Pharmacological: epidural etc. Encourage frequent urination to keep bladder empty (full bladder prevents uterus from contracting properly and can slow down labor), -monitor vitals of mother and fetal heart rate. -Mother will be serious, anxious, and in pain.

Uterine rupture: Define the two ( incomplete vs Complete) Assessment Findings? Nursing Care?

-Complete rupture involves the uterine wall, peritoneal cavity, and/or broad ligament. Internal bleeding is present. -Incomplete rupture occurs with dehiscence at the site of a prior scar (cesarean birth, surgical intervention). Internal bleeding might not be present. -This is a rare but life-threatening obstetric injury. Expected Findings: • May feel a sensation of "ripping", "tearing", or sharp pain • May report abdominal pain or uterine tenderness Physical Assessment Findings: • Nonreasoning FHR with indications of distress • Change in uterine shape and fetal parts may be palpable • Cessation of contractions and loss of fetal station • Symptoms of hypovolemic shock: tachypnea; hypotension; pallor; and cool, clammy skin Nursing Care: • Administer IV fluids • Administer oxygen • Administer blood products • Prepare for immediate cesarian and possible laparotomy and/or hysterectomy

Pudendal block:(lidocaine, bupivacaine) How is it administered? When is it administered? Indications? Adverse effects? Nursing Actions?

-Consists of a local anesthetic (lidocaine, bupivacaine) administered transvaginally into the space in front of the pudendal nerve. -It is administered during the late second stage of labor 10 to 20 min before delivery, providing analgesia prior to spontaneous expulsion of the fetus or forceps-assisted or vacuum-assisted birth. -It is suitable during the second and third stages of labor and for repair of episiotomy and lacerations. Adverse effects: Compromise of maternal bearing down reflex Nursing Actions​​​​​​​ -Instruct the client about the method. -Coach the client about when to bear down.

Group B Streptococcus ( GBS) : Culture is obtained when? What is prescribed if positive?

-Culture is obtained if results are not available from screening at 36 0/7-37 6/7 weeks for screening patients.. If positive, an intravenous prophylactic antibiotic is prescribed.

Manifestations of Abnormal Lochia: What S/S would indicate excessive Cervical or Vaginal Tear? What Sign would indicate a hemorrhage? What signs would indicate an infection? What signs would indicate a retained placental fragments? What signs would indicate endometritis?

-Excessive spurting of bright red blood from the vagina, possibly indicating a cervical or vaginal tear -Numerous large clots and excessive blood loss (saturation of one pad in 15 min or less), which can indicate hemorrhage -Foul odor, which is suggestive of infection -Persistent heavy lochia rubra in the early postpartum period beyond day 3, which can indicate retained placental fragments -Continued flow of lochia serosa or alba beyond the normal length of time can indicate endometritis, especially if it is accompanied by fever, pain, or abdominal tenderness.

Management of thrombophlebitis:

-Facilitate bed rest and elevation of the client's extremity above the level of the heart. (Avoid using a knee gatch or pillow under knees.) Encourage the client to change positions frequently. -Administer intermittent or continuous warm moist compresses -Do NOT massage the affected limb to prevent thrombus from dislodging and becoming an embolus. -Measure the client's leg circumferences. -Provide thigh-high antiembolism stockings for the client at high risk for venous insufficiency. -Administer analgesics (nonsteroidal anti-inflammatory agents). -Administer anticoagulants for DVT

B E T A M E T H A S O N E: What does it do? How would you administer? When is it given? What would you monitor for ? What would you assess? Client Education?

-Glucocorticoid enhances fetal lung maturity -Administer IM x 2 doses, 24hours apart -Give between 24-34 weeks gestation -Monitor for maternal hyperglycemia. -Assess the preterm infant's lung sounds. Client Education: Report findings of pulmonary edema (chest pain, shortness of breath, and crackles).

Late Decelerations: Is this an emergency? What is happening to baby heart rate when mom has a contraction? What causes this type of strip? Interventions?

-Late decelerations are NOT good either just like variable decelerations. -Notice that when mom has a contraction the baby's heart rate goes down long after the beginning of mom's contraction and recovers way after the contraction is over. - placental insufficiency is what causes this type of strip Some nursing interventions include: - Intrauterine resuscitation -turn mom onto her side -stop Picotin if infusing -administer 10 L of O2 - IV bolus normal saline / lactated ringers - May need emergency Delivery if continues.

Uterine Assessment Postpartum: - How should the client be positioned? Bed should be where? -How should the fundus be palpated? -How would you determine the fundus height? - Where should the fundus be, midline or displaced? What causes a displaced fundus? If displaced, what should you instruct your client to do? - Determine whether the fundus is firm or boggy. If the fundus is boggy (not firm) what action should the nurse take? - How would you document the position and location of the uterus? If above the umbilicus, document as? If below the umbilicus, document as?

-Position the client supine with their knees slightly flexed so that the fundal height is not influenced by positioning. Bed should be flat. -Apply clean gloves and a lower perineal pad, and observe lochia flow as the fundus is palpated. -Cup one hand just above the symphysis pubis to support the lower segment of the uterus, and with the other hand, palpate the abdomen to locate the fundus. Never palpate the fundus without cupping the uterus. . -Determine the fundal height by placing fingers on the abdomen and measuring how many fingerbreadths (centimeters) fit between the fundus and the umbilicus above, below, or at the umbilical level. -Determine whether the fundus is midline in the pelvis or displaced laterally (caused by a full bladder, if distended have patient empty bladder). -Determine whether the fundus is firm or boggy. If the fundus is boggy (not firm), lightly massage the fundus in a circular motion. QEBP -​​​​​​​If the uterus does not firm after massaging, keep massaging and notify the provider -.Document the position and location of the uterus by the number of fingerbreadths and according to facility policy. -If above the umbilicus, document as U+1. -If below the umbilicus, document as U-1.

Shoulder Dystocia: Define it? What causes this? Risk Factors? Complications? Nursing Care?

-The fetal shoulders are unable to pass through the pelvis after the head is delivered. -This is caused by a size discrepancy between the fetus and the pelvis Risk Factors: - Gestational Diabetes and prolonged second stage of labor Complications: - Complications to fetus include asphyxia/hypoxic-ischemic encephalopathy (HIE), fracture of the clavicle or humorous, and unilateral brachial plexus injuries -Most common maternal complications include postpartum hemorrhage and rectal injuries. Nursing Care: -McRoberts maneuver and suprapubic pressure are the first-line interventions McRoberts maneuver- maternal legs are hyper flexed against her abdomen • Suprapubic pressure can be applied to help dislodge the shoulder • Gaskin maneuver may also be used this involves having the women move to a hands and knees position- difficult to accomplish if she has regional anesthesia

Postpartum Physiological Adaptations: *It is important to provide comfort measures for the client during the fourth stage of labor. This recovery period starts with delivery of the placenta and includes at least the first 2 hr after birth. Also during this stage, parent-newborn bonding should begin to occur.* What is the main goal? What are the greatest risk during the postpartum period? What does Oxytocin do ? What does Breastfeeding Stimulate?

-The main goal during the immediate postpartum period is to prevent postpartum hemorrhage. -The greatest risks during the postpartum period are hemorrhage, shock, and infection. -Oxytocin, a hormone released from the pituitary gland, coordinates and strengthens uterine contractions. -Breastfeeding stimulates the release of endogenous oxytocin from the pituitary gland.

Cutaneous stimulation strategies: What are some cutaneous strategies? How should you place mom in supine position and why?

-Therapeutic touch and massage: back rubs and massage -Walking -Rocking -Effleurage: Light, gentle circular stroking of the client's abdomen with the fingertips in rhythm with breathing during contractions -Sacral counterpressure: Consistent pressure is applied by the support person using the heel of the hand or fist against the client's sacral area to counteract pain in the lower back -Application of heat or cold -Transcutaneous electrical nerve stimulation (TENS) therapy -Hydrotherapy (whirlpool or shower) increases maternal endorphin levels -Acupressure -Frequent maternal position changes to promote relaxation and pain relief: -Semi-sitting -Squatting -Kneeling -Kneeling and rocking back and forth -Supine position only with the placement of a wedge under one of the client's hips to tilt the uterus and avoid supine hypotension syndrome

First Maneuver: Fundal Grip Purpose? How would you perform this procedure? Findings?

-To determine fetal part lying in the fundus. To determine presentation. -Using both hands, feel for the fetal part lying in the fundus. Findings: -Head is more firm, hard and round that moves independently of the body. Breech is less well defined that moves only in conjunction with the body.

Terbutaline: What does it do? Contraindications? What would you notify the provider of? How would you administer?

-beta adrenergic agonist- relaxes smooth muscles and inhibits uterine activity *Contraindications -cardiac disease, -pregestational or gestational diabetes, -preeclampsia with severe features of eclampsia, -severe gestational hypertension, -hyperthyroidism, or significant hemorrhage. -Notify the provider of heart rate greater than 130/min, chest pain, cardiac arrhythmias, myocardial infarction, blood pressure less than 90/60 mm Hg, or pulmonary edema. -Administer 0.25 mg subcutaneously every 4 hr, for up to 24 hr.

Variable decelerations: What does this deceleration look like? Are this an emergency? What is happening to baby heart rate when mom has a contraction? What causes this type of strip? Interventions?

-remember the dips in the fetal heart tones look like V's. -Variable decelerations are NOT good! -Notice that every time mom has a contraction the baby's heart rate majorly decreases. -Remember a normal fetal heart rate is 110-160 bpms. -The cause of the decrease fetal heart rate is due to umbilical cord compression. (Prolapsed Cord) Interventions: - #1 Reposition mom (moving her around could help relieve cord compression) - Administer Oxygen( 100% o2 w/non-rebreather face mask) (because cord is being compressed which in turn is causing the baby to not receive enough Oxygen) -May need amnioinfusion ( Rupture of Membranes= Low ammonitic fluid) -Stop Picotin infusion if running, and contact the doctor.

How many Stages of Labor and Delivery are there?

4 stages

Prolapsed umbilical cord: Risk Factors? Expected Findings? Physical Assessment Findings? Nursing Care?

A prolapsed umbilical cord occurs when the umbilical cord is displaced, preceding the presenting part of the fetus, or protruding through the cervix. This results in cord compression and compromised fetal circulation. Risk Factors -Rupture of amniotic membranes -Abnormal fetal presentation (any presentation other than vertex [occiput as presenting part]) -Transverse lie: Presenting part not engaged, which leaves room for the cord to descend -Unengaged presenting part Expected Findings Client reports that they feel something coming through the vagina. Physical Assessment Findings -Visualization or palpation of the umbilical cord protruding from the introitus -FHR monitoring shows variable or prolonged deceleration Nursing Care: -Call for assistance immediately. -Do not leave the client. -Notify the provider. -Using a sterile-gloved hand, insert two fingers into the vagina, and apply finger pressure on either side of the cord to the fetal presenting part to elevate it off of the cord. Stay in this position until the birth of the baby. -Reposition the client in a knee-chest, Trendelenburg, or modified lateral semi-prone recumbent position with a rolled towel under the client's right or left hip to relieve pressure on the cord. -Apply a warm, sterile, saline-soaked towel to the visible cord to prevent drying and to maintain blood flow. -Provide continuous electronic monitoring of FHR for variable decelerations, which indicate fetal asphyxia and hypoxia. -Administer oxygen at 8 to 10 L/min via a face mask to improve fetal oxygenation.

A nurse is providing education to a client who is 2 hr postpartum and has perineal laceration. Which of the following information should the nurse include? A. Use a perineal squeeze bottle to cleanse the perineum B. Sit on the perineum while resting in bed. C. Apply a topical anesthetic cream or spray to the perineum. D. Wipe the perineum thoroughly with a back-and-forth motion E. Apply cold or ice packs to the perineum.

A, C ,E

A nurse is caring for a client who is at 40 weeks of gestation and experiencing contractions every 3 to 5 min and becoming stronger. A vaginal exam reveals that the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the following actions should the nurse take? (Select all that apply.) A. Encourage the use of patterned breathing techniques. B. Insert an indwelling urinary catheter. C. Administer opioid analgesic medication.​​​​​​​ D. Suggest application of cold.​​​​​​​ E. Provide ice chips.

A, C, D A.) Based on the assessment findings the nurse should encourage the client to use of patterned breathing techniques which can assist with pain management at this time. C.) An opioid analgesic can be safely administered. D.) The use of a non-pharmacological approach, such as the application of cold, is an appropriate intervention.

A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad for lochia. The pad is saturated approximately 12 cm with lochia that is dark red and contains small clots. Which of the following findings should the nurse document? A. Moderate lochia rubra B. Excessive lochia serosa C. Light lochia rubra D. Scant lochia serosa

A. The client has moderate lochia rubra containing small clots, which is an expected finding for 2 days postpartum

A nurse is caring for a client who is in the second stage of labor. The client's labor has been progressing, and a vaginal birth is expected in 20 min. The provider is preparing to administer lidocaine for pain relief and perform an episiotomy. The nurse should know that which of the following types of regional anesthetic block is to be administered? A. Pudendal B. Epidural​​​​​​​ C. Spinal D. Paracervical

A. The nurse should identify that a pudendal block is a transvaginal injection of local anesthetic that anesthetizes the perineal area for the episiotomy and repair, and the expulsion of the fetus.

A nurse is caring for a client who is at 40 weeks of gestation and experiencing contractions every 3 to 5 min and becoming stronger. A vaginal exam reveals that the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the following actions should the nurse take? (Select all that apply.) A. Encourage use of patterned breathing techniques. B. Insert an indwelling urinary catheter. C. Administer opioid analgesic medication.​​​​​​​ D. Suggest application of cold.​​​​​​​ E. Provide ice chips.

A. Based on the assessment findings the nurse should encourage the client to use of patterned breathing techniques which can assist with pain management at this time. C. An opioid analgesic can be safely administered. D. The use of a non-pharmacological approach, such as the application of cold, is an appropriate intervention.

A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take? A. Assist the client into the left-lateral position. B. Apply a fetal scalp electrode. C. Insert an IV catheter. D. Perform a vaginal exam.

A. The greatest risk to the fetus during late decelerations is uteroplacental insufficiency. The initial nursing action should be to place the client into the left-lateral position to increase uteroplacental perfusion - All other options are not the priority

A nurse is caring for a client who is in active labor. The cervix is dilated to 5 cm, and the membranes are intact. Based on the use of external electronic fetal monitoring, the nurse notes a FHR of 115 to 125/min with occasional increases up to 150 to 155/min that last for 25 seconds and have moderate variability. There is no slowing of the FHR from the baseline. This client is exhibiting manifestations of which of the following? (Select all that apply.) A. ​​​​​​​​​Moderate variability B.FHR accelerations C.FHR decelerations D. Normal baseline FHR E. ​​​​​​​​​​​​​Fetal tachycardia

A. There is moderate variability of 20/min. (6 to 25/min is expected reference range.) B. FHR accelerations are present with increases up to 150 to 155/min lasting for 25 seconds. D. There is a normal baseline FHR of 115 to 125/min that falls within the expected reference range of 110 to 160/min.

A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie? ​​​​​​​​​​​​​A. Apply palms of both hands to the sides of uterus. B ​​​​​​​​​​​palpate the fundus of the uterus. C Grasp lower uterine segment between thumb and fingers. D ​​​​​​​​​​​​​Stand facing client's feet with fingertips outlining cephalic prominence.

B Palpating the fundus of the uterus identifies the fetal part that is present, indicating the fetal lie (longitudinal or transverse).

A nurse is completing postpartum discharge teaching to a client who had no immunity to varicella and was given the varicella vaccine. Which of the following statements by the client indicates understanding of the teaching? A. "I will need to use contraception for 3 months before considering pregnancy." B."I need a second vaccination at my postpartum visit." C."I was given the vaccine because my baby is O-positive." D. "I will be tested in 3 months to see if I have developed immunity."

B. A second varicella immunization is needed at 4 to 8 weeks following delivery by clients who had no history of immunity.

A nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. The nurse should identify that this contraction pattern increases the risk for which of the following complications? A. Prolonged labor B. Reduced fetal oxygen supply C. Delayed cervical dilation D. Increased maternal stress

B. Inadequate uterine relaxation results in reduced oxygen supply to the fetus.

A nurse is caring for a client who is in active labor. The client reports lower-back pain. The nurse suspects that this pain is related to a persistent occiput posterior fetal position. Which of the following nonpharmacological nursing interventions should the nurse recommend to the client? A. Abdominal effleurage​​​​​​​ B . Sacral counterpressure​​​​​​​ C. Showering if not contraindicated ​​​​​​​​​​​D. Back rub and massage

B. Sacral counterpressure to the lower back relieves the pressure exerted on the pelvis and spinal nerves by the fetus which is related to persistent occiput posterior fetal position. - All other answers are appropriate pain management technique but does not address the pressure on the pelvis due to the fetal position.

A nurse is caring for a client who is 40 weeks of gestation and reports having large gush of fluid from the vagina while walking from the bathroom. Which of the following actions should the nurse take first? A. Examine the amniotic fluid for meconium. B. Check the FHR. C. Dry the client and make them comfortable. D. Apply a tocotransducer.

B. The greatest risk to the client and fetus is umbilical cord prolapse, leading to fetal distress following rupture of membranes. The first action to take is to check the FHR for clinical findings of distress.

A nurse is completing an admission assessment for a client who is 39 weeks of gestation and reports fluid leaking from the vagina for 2 days. Which of the following conditions is the client at risk for developing? A. Cord prolapse B. Infection C. Postpartum hemorrhage D. Hydramnios

B. The nurse understands because the client reports leaking of fluid for 2 days places the client at risk for infection. Rupture of membranes for longer than 24 hr prior to delivery increases the risk that infectious organisms will enter the vagina and then eventually into the uterus.

A nurse is assessing a postpartum client for fundal height, location, and consistency. The fundus is noted to be displaced laterally to the right, and there is uterine atony. The nurse should identify which of the following conditions as the cause of the uterine atony? A. Poor involution B. Urinary retention C. Hemorrhage D .Infection

B. Urinary retention can result in a distention of the bladder. A distended bladder can cause uterine atony and lateral displacement from the midline.

A nurse is caring for a client who is in active labor. The client reports lower-back pain. The nurse suspects that this pain is related to a persistent occiput posterior fetal position. Which of the following nonpharmacological nursing interventions should the nurse recommend to the client? A. Abdominal effleurage​​​​​​​ B. Sacral counterpressure​​​​​​​ C. Showering if not contraindicated D. ​​​​​​​​​​​​Back rub and massage

B. Sacral counterpressure to the lower back relieves the pressure exerted on the pelvis and spinal nerves by the fetus which is related to persistent occiput posterior fetal position. It is not D , because though a back rub with massage is an appropriate pain management strategy it does not address the pressure on the pelvis due to the fetal position.

A nurse is caring for a client in active labor. When last examined 2 hr ago, the client's cervix was 3 cm dilated, 100% effaced, membranes intact, and the fetus was at a -2 station. The client suddenly states, "My water broke." The monitor reveals a FHR of 80 to 85/min, and the nurse performs a vaginal examination, noticing clear fluid and a pulsing loop of umbilical cord in the client's vagina. Which of the following actions should the nurse perform first? A. Place the client in the Trendelenburg position. B. Apply pressure to the presenting part with the fingers. C. Administer oxygen at 10 L/min via a face mask. D. Initiate IV fluids.

B. The nurse notes an umbilical cord prolapse when performing a vaginal examination. According to evidence-based practice, apply pressure to the presenting part with the fingers.

A focused postpartum physical assessment should include assessing the client's? The breast should be assessed for ? What could a boggy uterus indicate? What should you do if the uterus is boggy? What could a deviated uterus indicate? How many days would it take for woman to have bowel movement after baby? Why? What might be given? If the bladder becomes distended the woman is at higher risk for what? Why? What should the Lochia be assessed for? If the woman had an episiotomy, the nurse should assess? The lower extremities must be assessed for? How would you assess for a DVT? A DVT could lead to what? Which S/s would indicate a PE? How would you check for Homan's Sign? What would indicate a positive sign? Why is the mother at risk for developing DVT? Hormone fluctuations, as well as the birth experience, can cause the mother to experience many new and strong emotions. What should the nurse assess for?

B: Breasts ( Breast size,shape,and engourgment) The breasts should be assessed for signs of infection (mastitis) such as pain, redness, and warmth. U: Uterus (fundal height, uterine placement, and consistency, is it firm or boggy?) The uterus must remain firm and contracting in order to prevent postpartum hemorrhage. If the uterus feels boggy, it should be massaged. If the uterus becomes deviated to one side, it may indicate bladder distention. B: Bowel movement? It may take 2 or 3 days for the woman to have a bowel movement due to pain, lack of food, dehydration, and soreness from lacerations or hemorrhoids. A stool softener may be given to the woman in order to aid in easier passage of the bowel movement. B: Bladder: tender or distended? Postpartum, the woman may experience difficulty voiding resulting in a distended bladder. If the bladder becomes distended, the woman is at a higher risk for hemorrhage because the distended bladder applies pressure on the uterus. L: Lochia (color, odor, consistency, and amount [COCA]) The lochia should be assessed for color, amount, and odor. Too much lochia may indicate hemorrhage so it is important to know how the lochia is expected to look. In addition, foul smelling lochia may indicate infection. Lochia is usually bright red and contains small clots after birth. Normal shedding of blood and decidua is referred to as lochia rubra (red/red-brown) and lasts for the first few days following delivery. Between day 3-4 the lochia becomes more pink/brown color and contains serum, leukocytes, tissue debris and old blood and is called lochia serosa. Around 10 days post birth, the lochia becomes yellow/white and contains mainly leukocytes. This is referred to as Lochia Alba. Lochia will last 4-8 weeks postpartum. E: Episiotomy Location: (edema, Stiches, ecchymosis, ) If the woman had an episiotomy, the nurse should assess for redness, edema, ecchymosis, discharge, and approximation. L: Lower Extremities The lower extremities must be assessed for deep vein thrombosis. This can be done easily by looking for redness, warmth and edema. DVT could lead to pulmonary embolism which presents with tachycardia and shortness of breath. There is controversy on the useful

Physiologic changes preceding labor (premonitory signs): What are they ( 9) B W L C V E G CR R Prolonged rupture of membranes greater than 24 hr before birth of fetus can lead to what? Immediately following the rupture of membranes, a nurse should assess what? Why?

Backache: Constant low, dull backache caused by pelvic muscle relaxation Weight loss: 0.5 to 1.5 kg (1 to 3.5 lb) weight loss Lightening: Fetal head descends into true pelvis about 14 days before labor; feeling that the fetus has "dropped"; easier breathing, but more pressure on bladder, resulting in urinary frequency; more pronounced in clients who are primigravida Contractions: (Braxton Hicks) Begin with irregular uterine contractions (Braxton Hicks) that eventually progress in strength and regularity. Increased vaginal discharge or bloody show: Expulsion of the cervical mucus plug may occur. Brownish or blood-tinged mucus plug resulting from the onset of cervical dilation and effacement. Energy burst: Sometimes called "nesting" response Gastrointestinal changes: Less common; include nausea, vomiting, and indigestion Cervical ripening: Cervix becomes soft (opens) and partially effaced, and can begin to dilate Rupture of membranes: Spontaneous rupture of membranes can initiate labor or can occur anytime during labor. - Prolonged rupture of membranes greater than 24 hr before birth of fetus can lead to an infection. -Immediately following the rupture of membranes, a nurse should assess the FHR for abrupt decelerations, which are indicative of fetal distress to rule out umbilical cord prolapse

Stage 4 of Labor When does this begin? What is the overall goal during this stage? What Vitals would you monitor and why? Describe discharge "Lochia"? What would you assess for? Describe how the fundus of the uterus should be during this stage? What would be abnormal? if the fundus is soft/boggy or displaced what should you perform? What should you instruct the mother to do? How often should you assess the fetus? The fundus of the uterus will decrease how many cm a day? When can it no longer be felt? What should you apply to perineum and why? Mom has delivered baby, what should you encourage mom to do?

Begins with the delivery of the placenta and includes at least the first 2 hrs afterbirth (recovery period) Goal: monitor mother's health status after birth due to risk for hemorrhage, infection (retaining placenta), and uterine atony etc. Monitor discharge "Lochia": red, moderate, may have small clots, however large clots not normal... - assess how many peri-pads are being used for the 1st hour...if changing every 15 minutes...this is abnormal. Monitor the fundus of the uterus for firmness: it should be firm and midline, and at or slightly below the umbilicus.... if soft/boggy or displaced perform: fundus massage and want to make sure bladder is empty so have the patient void (will be checking fundus every 15 minutes for 1 hour then 30 minutes for 2 hours). -The fundus of the uterus will decrease 1 cm a day and after 10 days post-delivery cannot be felt. -Apply witch hazel to perineum and ice pack due to edema, tearing, or episiotomy. -Promote bonding with parents and baby and help with breastfeeding.

During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On assessment, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being? A. Evidence of a possible vaginal hematoma B. An indication of a cervical or perineal laceration C. A normal postural discharge of lochia D. Abnormally excessive lochia rubra flow

C. Lochia typically trickles from the vaginal opening but flows more steadily during uterine contractions. Massaging the uterus or ambulation can result in a gush of lochia with the expression of clots and dark blood that has been pooled in the vagina, but it should soon decrease back to a trickle of bright red lochia in the early puerperium.

A nurse is caring for a client who is at 42 weeks of gestation and in active labor. Which of the following findings is the fetus at risk for developing? A. Intrauterine growth restriction B. Hyperglycemia C. Meconium aspiration D. Polyhydramnios

C. The nurse is caring for a client who is at 42 weeks of gestation and in active labor. The nurse should identify the fetus is at risk for developing aspiration of meconium.

A nurse is caring for a client following the administration of an epidural block and is preparing to administer an IV fluid bolus. The client's partner asks about the purpose of the IV fluids. Which of the following statements should the nurse make? A. "It is needed to promote increased urine output." B ​​​​​​​​"It is needed to counteract respiratory depression." C ​​​​​​​​​"It is needed to counteract hypotension." D It is needed to prevent oligohydramnios."

C. The nurse should tell the client's partner that maternal hypotension can occur following an epidural block and can be offset by administering an IV fluid bolus.

Metoclopramide: Indication Adverse Side effects? Nursing Action?

Can control nausea and anxiety. Does not relieve pain and is used as an adjunct with opioids. Adverse effects: Dry mouth and sedation Nursing Actions -Provide ice chips or mouth swabs. -Provide safety measures for the client.

Passenger: What does it consist of? Presentation? What are the three main presentations? Attitude? What are the two flexions? Lie? What are the two? When would these cause for a C-section? Station? What are the ranges?

Consists of the fetus and the placenta. The size of the fetal head, fetal presentation, fetal lie, fetal attitude, and fetal position affect the ability of the fetus to navigate the birth canal. The placenta can be considered a passenger because it also must pass through the canal. Presentation: The part of the fetus that is entering the pelvic inlet first and leads through the birth canal during labor. Three Main presentations cephalic(head first), breech(bottom or feet first),and shoulder presentation Lie: - Relation of the fetal spine to the mother's spine --Transverse, horizontal, oblique: Fetal long axis(spine) is horizontal, forms a right angle to maternal long axis, and will not accommodate vaginal birth. -The shoulder is the presenting part and can require delivery by cesarean birth if the fetus does not rotate spontaneously. --Parallel or longitudinal/vertical: Fetal is parallel to maternal long axis, either a cephalic or breech presentation. -Breech presentation can require a cesarean birth. Attitude: Relationship of fetal body parts to one another --Fetal flexion: Chin flexed to chest, extremities flexed into torso --Fetal extension: Chin extended away from chest, extremities extended Station: Fetal station refers to how far a baby's head has descended into your pelvis. -Stations range from -5 to +5, with 0 station meaning the head is aligned with your ischial spines.

Characteristics of True Labor : Contractions: Are Contractions Regular or irregular? Frequency? Duration? Intensity? Where can contractions be felt? Does walking increase or decrease contraction intensity? Does it continue or discontinue when comfort measures are applied? Cervix (assessed by vaginal exam): Is there a change in dilation and effacement? Where would the cervix be located? Would bloody show be present? Fetus: Would the presenting part be engaged or not engaged?

Contractions -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 contraction intensity -Continue despite comfort measures Cervix (assessed by vaginal exam) -Progressive change in dilation and effacement -Moves to anterior position -Bloody show Fetus: Presenting part engages in pelvis

Characteristics of False Labor : Contractions: Are Contractions Regular or irregular? Frequency? Duration? Intensity? Where can contractions be felt? Does walking increase or decrease contraction intensity? Does it continue or discontinue when comfort measures are applied? Cervix (assessed by vaginal exam): Is there a change in dilation and effacement? Where would the cervix be located? Would bloody show be present? Fetus: Would the presenting part be engaged or not engaged?

Contractions -Painless, irregular frequency, and intermittent -Decrease in frequency, duration, and intensity with walking or position changes -Felt in lower back or abdomen above umbilicus -Often stop with sleep or comfort measures (oral hydration, emptying of the bladder) Cervix (assessed by vaginal exam) -No significant change in dilation or effacement -Often remains in posterior position -No significant bloody show Fetus: Presenting part is not engaged in pelvis

A client calls a provider's office and reports having contractions for 2 hr that increased with activity and did not decrease with rest and hydration. The client denies leaking of vaginal fluid but did notice blood when wiping after voiding. Which of the following manifestations is the client experiencing? A. Braxton Hicks contractions B. Rupture of membranes C. Fetal descent D. True contractions

D. True contractions do not go away with hydration or walking. They are regular in frequency, duration, and intensity and become stronger with walking.

A nurse is caring for a client who is in labor. With the use of Leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the following possible complications should the nurse observe? A. Precipitous labor B. Premature rupture of membranes C. Post maturity syndrome D. Prolapsed umbilical cord

D. When the nurse is performing Leopold maneuvers and notes that the fetus is in a breech presentation, the nurse should recognize a prolapsed umbilical cord is a potential complication for a fetus in a breech presentation. Breech presentation is not associated with postmaturity syndrome, it should not have an effect on the premature rupture of membranes, and it would mostly cause dystocia rather than a precipitous labor.

A nurse is caring for a client who is using patterned breathing during labor. The client reports numbness and tingling of the fingers. Which of the following actions should the nurse take? A. Administer oxygen via nasal cannula at 2 L/min.​​​​​​​ B. Apply a warm blanket.​​​​​​​ C. Assist the client to a side-lying position. D . Place an oxygen mask over the client's nose and mouth.

D. The client is experiencing hyperventilation caused by low blood levels of PCO2. The nurse should place an oxygen mask over the client's nose and mouth or have the client breathe into a paper bag; this will reduce the intake of oxygen, allowing the PCO2 to rise and alleviate the numbness and tingling.

A nurse is caring for a client who is using patterned breathing during labor. The client reports numbness and tingling of the fingers. Which of the following actions should the nurse take? A. Administer oxygen via nasal cannula at 2 L/min.​​​​​​​ B. Apply a warm blanket.​​​​​​​ C. Assist the client to a side-lying position. D. Place an oxygen mask over the client's nose and mouth

D. The client is experiencing hyperventilation caused by low blood levels of PCO2. The nurse should place an oxygen mask over the client's nose and mouth or have the client breathe into a paper bag; this will reduce the intake of oxygen, allowing the PCO2 to rise and alleviate the numbness and tingling.

Decrease or loss of FHR variability: Define? Causes/Complications How long does a fetal sleep cycle last? Nursing Interventions?

Decrease or loss of irregular fluctuations in the baseline of the FHR Causes/Complications: -Medications that depress the CNS (barbiturates, tranquilizers, general anesthetics) -Fetal hypoxemia and metabolic acidemia -Fetal sleep cycle (minimal variability sleep cycles usually do not last longer than 30 min) -Congenital abnormalities Nursing Interventions: - Stimulate the fetal scalp. - Assist provider with application of scalp electrode. -Place client in left-lateral position.

Induction: Define it Indications?

Deliberate initiation of uterine contractions to stimulate labor before spontaneous onset to being about the birth by chemical or mechanical means Indications: - Post dates (greater than 42 weeks) - Labor dystocia - Prolonged rupture of membranes - IUGR - Chorioamnionitis - Fetal demis - Maternal medical complications: • DM, Rh-isoimmunization, GHTN Interventions : Obtain consent - Monitor FHR and uterine activity, notify provider as needed - Prepare client for bedside U/S to confirm presentation before starting induction - Initiate oxytocin no sooner than 4 hr after administration of misoprostol, and 6-12 hours after dinoprostone gell instillation or removal of a dinoprostone insert - Use the infusion port closest to the client for administration. - VS every 30-60 minutes. - Assess fluid intake and urinary output - Bishop score should be assessed prior to initiation of induction - Increase oxytocin until desired contraction pattern is obtained and then maintain the dose - Discontinue if tachysystole occurs

Fetal tachycardia: Define Interventions?

FHR greater than 160/min for 10 min or more Nursing Interventions: -Administer prescribed antipyretics for maternal fever, if present. -Administer oxygen by mask at 10 L/min via nonrebreather face mask. -Administer IV fluid bolus

Nonpharmacological Pain Management: Define Gate-Control theory of pain What are some Cognitive strategies? What are signs of hyperventilation? What nursing action should you take if the patient is experiencing hyperventilation? What are some sensory stimulation strategies?

Gate-control theory of pain: - .The theory that the spinal cord contains a neurological "gate" that blocks pain signals or allows them to pass on to the brain Cognitive strategies: -Childbirth education -Childbirth preparation methods (Lamaze, patterned breathing exercises) promote relaxation and pain management. -Doulas can assist clients using methods for nonpharmacological pain management. -Nursing implications include assessing for findings of hyperventilation (caused by low blood levels of PCO2 from blowing off too much CO2), such as lightheadedness and tingling of the fingers. If this occurs, have the client breathe into a paper bag or their cupped hands. -Hypnosis -Biofeedback Sensory stimulation strategies: -Aromatherapy -Breathing techniques -Imagery -Music -Use of focal points -Subdued lighting

Stage 1 of Labor: What is the Goal? What are the phases? Remember the mnemonic?

Goal: Cervical dilation (opening) 0-10 cm & 100% effacement (thinning) due to contractions Phases: Early Labor (Latent), Active, and Transition Remember the mnemonic: " Labor is Actively Transitioning"

Leopold maneuvers: Define it Vertex presentation: Where Fetal Heart Tones be assessed? Breeched Presentation: Where Fetal Heart Tones be assessed? What would you do to prep for this procedure? (5) List them in order Interventions?

Leopold maneuvers consist of performing external palpations of the maternal uterus through the abdominal wall to determine the following: -Presenting part, fetal lie, and fetal attitude -Degree of descent of the presenting part into the pelvis -Location of the fetus's back to assess for fetal heart tones Vertex presentation: Fetal heart tones should be assessed below the client's umbilicus in either the right- or left-lower quadrant of the abdomen. Breech presentation: Fetal heart tones should be assessed above the client's umbilicus in either the right- or left-upper quadrant of the abdomen. Preparation 1. Instruct woman to empty her bladder first. 2. Place woman in dorsal recumbent position, supine with knees flexed to relax abdominal muscles. Place a small pillow under the head for comfort. 2.Drape properly to maintain privacy. 3.Explain procedure to the patient. 4. Warms hands by rubbing together. (Cold hands can stimulate uterine contractions). 5.Use the palm for palpation not the fingers. Listed in order First Maneuver: Fundal Grip Second Maneuver: Umbilical Grip Third Maneuver: Pawlik's Grip Fourth Maneuver: Pelvic Grip Interventions: -Auscultate the FHR post-maneuvers to assess the fetal tolerance to the procedure. -Document the findings from the maneuvers.

Lochia: Define? How many stages are there? Describe Lochia Rubra: Color, consistency, odor? Can clots be present? How long does it last? Describe Lochia Serosa: Color, consistency? Can clots be present? How long does it last? Describe Alba: Color, consistency? Can clots be present? How long does it last?

Lochia is post-birth uterine discharge that contains blood, mucus, and uterine tissue. -The amount of lochia is similar to a heavy menstrual period about 2 hr afterbirth, then decreases gradually at a consistent rate. Three Stages of Lochia: Lochia rubra: Dark red color, bloody consistency, fleshy odor. Can contain small clots, transient flow increases during breastfeeding and upon rising. Lasts 1 to 3 days after birth. Remind the client that they can experience a surge of discharge upon arising after lying in bed for an extended period of time. This should not be mistaken for hemorrhage. Lochia serosa: Pinkish brown color and serosanguineous consistency. Can contain small clots and leukocytes. Lasts from approximately day 4 to day 10 afterbirth. Lochia alba: Yellowish white creamy color, fleshy odor. Can consist of mucus and leukocytes. Lasts from approximately 10 days to 6 weeks postpartum.

Meconium-stained amniotic fluid: Define it Risk Factors? When is it most common? Physical Assessment Findings? What steps would you take in an emergency treatment? (3) When would you suction mouth and nose? When would you suction the trachea?

Meconium staining is when your baby passes meconium before birth.(Indicated that the fetus has passed its first stool before birth) Risk Factors: -More common after 38 weeks gestation due to fetal maturity of normal physiological functions • Result of hypoxia-induced peristalsis and sphincter relaxation • Sequel to umbilical cord compression-induced vagal stimulation in mature fetuses Physical Findings: -Amniotic fluid can vary in color: black to greenish, or yellow, though meconium-stained amniotic fluid is often green. Consistency can be thin or thick Emergency Treatment! -Assess amniotic fluid for presence of meconium -Gather equipment and supplies that might be necessary for neonatal resuscitation if there is presence of meconium -Have at least one person capable of performing intubation present at delivery -Suction mouth and nose if the baby has strong respiratory effort, good muscle tone, and HR >100 beats/minute -Suction trachea if newborn has depressed respiratory rate, decreased muscle tone, HR <100 beats/minute

Nonreassuring fetal status ( Fetal Distress) Expected Findings? Nursing Care?

Nonreassuring fetal status is present when: -The FHR is below 110/min or above 160/min. -The FHR shows decreased or no variability. -There is fetal hyperactivity or no fetal activity. -late decelerations associated with absent or minimal variability -recurrent variables -prolonged decelerations. Nursing Care: -Monitor vital signs and FHR. -Position the client in a left side-lying position. (Other possible positions include knee-chest and Trendelenburg.) -Administer 8 to 10 L/min of oxygen via a face mask. -Prepare the client for an emergency cesarean birth if indicated.

Opioid analgesics: What are some opioid analgesics? When should these be given? How should these be given? Adverse effects? Nursing Action?

Opioid analgesics (meperidine hydrochloride, fentanyl, butorphanol, nalbuphine) act in the CNS to decrease the perception of pain without the loss of consciousness. The client can receive opioid analgesics IM or IV, but the IV route is recommended during labor because the action is quicker. These are usually given during the early part of active labor. Butorphanol and nalbuphine provide pain relief without causing significant respiratory depression in the mother or fetus. Both IM and IV routes are used. Adverse effects: -Respiratory depression in the neonate if mother medicated too close to time of delivery -Reduction of gastric emptying; increased risk for nausea and emesis -Increased risk for aspiration of food or fluids in the stomach -Bladder and bowel elimination can be inhibited -Sedation -Altered mental status -Tachycardia -Hypotension -Decreased FHR variability -Allergic reaction Nursing Actions -Prior to administering analgesic medication, verify that labor is well established by performing a vaginal exam. -Administer antiemetics as prescribed. -Monitor maternal vital signs, uterine contraction pattern, and continuous FHR monitoring. Assess maternal vital signs and fetal heart rate and pattern and documented before and after administration of opioids for pain relief. -Assess for adverse reactions (difficulty breathing) and be prepared to administer antidotes whenever medications are administered. -Naloxone, an opioid antagonist, should be readily available for reversal of opioid-induced respiratory depression. QS

Medications: Oxytocin, Methylergonovine, Misoprostol, Carboprost Tromethamine What are the Classifications for these medications? What are these medications used for? What Adverse effect does Oxytocin cause? What are the signs? Methylergonovine is contraindicated in patients who have? Carboprost Tromethamine (Hemabate) is contraindicated in patients who have?

Oxytocin Classification: Uterine stimulant Therapeutic intent: Promotes uterine contractions Nursing Actions -Assess uterine tone and vaginal bleeding. -Monitor for adverse reactions of water intoxication (lightheadedness, nausea, vomiting, headache, malaise). These reactions can progress to cerebral edema with seizures, coma, and death. Methylergonovine Classification: Uterine stimulant Therapeutic intent: Controls postpartum hemorrhage Nursing Actions -Assess uterine tone and vaginal bleeding. -Do not administer to clients who have hypertension or cardiac disease Monitor for adverse reactions, including hypertension, nausea, vomiting, and headache. Misoprostol Classification: Uterine stimulant Therapeutic intent: Controls postpartum hemorrhage. Nursing Actions: -Assess uterine tone and vaginal bleeding. Carboprost tromethamine Classification: Uterine stimulant Therapeutic intent: Controls postpartum hemorrhage Nursing Actions -Assess uterine tone and vaginal bleeding. -Monitor for adverse reactions, including fever, hypertension, chills, headache, nausea, vomiting, and diarrhea. Contraindicated in patients who have asthma

Analgesia Sedatives (barbiturates): What are some barbiturates? When should these be given? Adverse effects? Nursing Action?

Sedatives (secobarbital, pentobarbital, phenobarbital) are not typically used during birth, but they can be used during the early or latent phase of labor to relieve anxiety and induce sleep. Adverse effects: -Neonate respiratory depression secondary to the medication crossing the placenta and affecting the fetus . -These medications should not be administered if birth is anticipated within 12 to 24 hr. QEBP -Unsteady ambulation of the client. -Inhibition of the mother's ability to cope with the pain of labor. Sedatives should not be given if the client is experiencing pain because apprehension can increase and cause the client to become hyperactive and disoriented. Nursing Actions -Dim the lights, and provide a quiet atmosphere. -Provide safety for the client by lowering the position of the bed and elevating the side rails. -Assist the mother to cope with labor. QS -Assess the neonate for respiratory depression.

Stage 2 of Labor: When does this phase start and end? Cervical Dilation Range? Contraction duration and Frequency? Where should the fetal station be? What would you monitor/assess for? What S/S would indicate changes in perineum that represents birth of baby is approaching? How would you teach mom how to push?

Starts when cervix has fully dilated and ends when baby is fully delivered. -Cervix is fully dilated so baby can start descending into the birth canal (woman will have intense pressure in rectum as baby descending)... -watch fetal station +1 to 5+ (5+ is head crowning). -Contractions will be strong and intense like in the transition period.... 60-90 seconds length every 2-3 minutes). Interventions: -Monitor mother's vital and baby heart during, after, and before contractions with continuous fetal monitoring (Every 5-30 mins). Watch for changes in perineum that represents birth of baby is approaching: -Bulging perineum and rectum -Parts of baby present -Increase in bloody show Teach mom how to push: exhale when pushing and positioning (High-fowler and lithotomy), squatting, side-lying , maintain comfort measures, encouragement and praise, record exact time birth of the baby.

Stage 3 of Labor: When does it start and end? How long does this stage last? The longer the stage last, this increase risk for? Which can cause? Signs that the placenta is about to be delivered? Delivery Mechanisms of the Placenta? What would you monitor and how often ? What medication would you administer and when? What does this medication do? How would you assess the placenta? Momma gave birth! What would you encourage mom to do?

Starts with full delivery of baby and ends with full delivery of the placenta. -Lasts 5 to 15 minutes...the longer the stage the increased risk for hemorrhage and retained placenta (which can cause infection/hemorrhage). Signs that the placenta is about to be delivered: -Umbilical cord starts to lengthen -Trickling/gush of blood and uterus changes from an oval shape to globular * With these signs mother will give a gently push Delivery Mechanisms of the Placenta: -Schultz Mechanism: REMEMBER "Shiny Schultz". This is the "shiny" side from the side of the baby...remember shiny and new which is the baby...this part comes out first. -Duncan Mechanism: REMEMBER "Dull/Dirty Duncan". This side is "dull", red, and rough and is the side from the mother. Also, try to remember the mother is dirty from labor and is in rough condition, so it is the maternal side. Interventions: -monitor BP ,Pulse, and RR every 15 mins -administer oxytocin "Pitocin" as ordered by the physician AFTER delivery of the placenta...helps uterus contract after delivery of placenta and prevents hemorrhage, assess placenta to make sure it is enact : (cord should have two arteries and one vein), -make mother comfortable and encourage bonding with baby ( Skin to Skin and breastfeeding), change linens, peri-care. - QBL vs EBL - Apgar scoring at 1 and 5 mins

Passageway: Define it The cervix must ______ and _____ in response to contractions and fetal descent.

The birth canal that is composed of the bony pelvis, cervix, pelvic floor, vagina, and introitus (vaginal opening). The size and shape of the bony pelvis must be adequate to allow the fetus to pass through it. The cervix must dilate and efface in response to contractions and fetal descent.

Position: What should mom do? Why? What positions can gravity aid in fetal descent?

The client should engage in frequent position changes during labor to increase comfort, relieve fatigue, and promote circulation. Position during the second stage is determined by maternal preference, provider preference, and the condition of the mother and the fetus. Gravity can aid in the fetal descent in upright, sitting, kneeling, and squatting positions.

Postpartum Hemorrhage or PPH : ( 4 T's) , Risk Factors, and Treatment. The most common causes of postpartum hemorrhage can be divided into two groups; What are they? What are the early causes of PPH? Define Tone? What are some things that could cause Uterine Atony? The next T is Trauma, and it refers to? Next is Tissue, which refers to ? Lastly, Thrombin, refers to? What are some risk factors that cause PPH? Remember that Blood loss can be overt or occult , so how would you assess for this? Severe blood loss can lead to shock with signs and symptoms such as? How would you treat and manage postpartum hemorrhage?

The most common causes of postpartum hemorrhage can be divided into two groups; the early causes and the late causes. The early causes can easily be remembered as the 4 Ts: Tone, Trauma, Tissue, and Thrombin. Tone refers to a lack of uterine tone, meaning the uterine contraction is weak or absent. This is also known as uterine atony, which is the most common cause of PPH. What causes Uterine Atony: Repeated distention of the uterus as a result of multiple previous pregnancies or overstretching from multigestational pregnancy can interfere with effective uterine contractions after birth and lead to uterine atony after birth. Uterine atony can also occur when uterine muscles become fatigued after prolonged labor, or if urine retention causes a distended bladder that interferes with uterine involution. Trauma: The next T is Trauma, and it refers to damage to any of the reproductive structures, like the uterus, cervix, vagina, or perineum during delivery. Tissue which refers to when a part of the placenta is retained in the uterus after birth, interfering with the involution process. Thrombin refers to the mother having some condition that prevents blood clots from forming normally, for example, a coagulation disorder like von Willebrand disease. These conditions can turn even a tiny bleed into a serious bleed due to the inability to form blood clots. Risk Factors: Finally, some risk factors for PPH which include a history of PPH in previous pregnancies; placental disorders like placenta previa, placenta accreta or placental abruption; an overdistended uterus due to polyhydramnios, multiple gestation, or macrosomic infant; infection, prolonged labor, and lastly delivery by cesarean section. S/S - Remember that blood loss may be overt, where you can see large amounts of blood loss, or occult, where blood pools up somewhere inside the body. Ensure that you roll patient over to look under the buttocks. -Severe blood loss can lead to shock with signs and symptoms such as tachycardia, shortness of breath, cool and clammy skin, and hypotension Treatment: -Treatment and management focus on increasing uterine contraction through medication and uterine massage to stem the bleeding and maintaining adequate

Five P's: What are they?

There are five factors that affect and define the labor and birth process: passenger (fetus and placenta), passageway (birth canal), powers (contractions), position (of the client ), and psychological response.

Epidural and spinal regional analgesia: Adverse Effects? Nursing Action?

These opioids produce regional analgesia, providing rapid pain relief while still allowing the client to sense contractions and maintain the ability to bear down. Adverse effects -Decreased gastric emptying resulting in nausea and vomiting -Inhibition of bowel and bladder elimination sensations -Bradycardia or tachycardia -Hypotension -Respiratory depression -Allergic reaction and pruritus -Elevated temperature Nursing Actions -Institute safety precautions, such as putting side rails up on the client's bed. The client can experience dizziness and sedation, which increases maternal risk for injury. QS -Assess for nausea and emesis, and administer antiemetics as prescribed. -Monitor maternal vital signs per facility protocol. -Monitor for allergic reaction. -Continue FHR pattern monitoring

Phase 3: Transition: Cervical Dilation Range? Contraction duration and Frequency? What would mom look/act like during this phase? What would mom possibly report during this phase and why ?What should she avoid and why? Nonpharmacological interventions? What 3 things would you monitor for? Where should baby and station be? Define The ischial spine? What should you encourage mom to do?

This phase will lead into Stage 2 where the baby will be delivered. -Cervix dilates to 8 to 10 cm and thins -Shortest phase but most intense/painful -Contractions will be very intense and long (back to back contractions) 60-90 seconds length every 2-3 minutes. -Mother will be concentrating, irritated, pain, nauseous, shivering. -May report intense pressure (bowel movement) due to baby pushing down...don't want the mother to start pushing until fully dilated because it can cause swelling of the cervix...hence it won't fully dilate. -Interventions: Nonpharmacological -provide support, breathing techniques, encouragement What to monitor: -monitoring mother's vitals and fetal heart rate (esp. during contractions, and before, and after...want heart rate 110 to 160), -mother's contractions (length, frequency) -monitoring status of cervix (dilation and effacement), -assessing fetal position and station (station 0 baby head is engaged and at ischial spine). -The ischial spine is the narrowest part of the pelvis. - Encourage mom to void every 2 hrs

External Cephalic Version (ECV): Define? When is it performed? Nursing Interventions? Contraindications? Risks?

Ultrasound guided procedure to manipulate a breech fetus into a cephalic lie -performed 37 to 38 weeks Interventions -Informed consent -NST, -Rhogam if patient is Rh- at 28 weeks -place IV and give tocolytics as ordered -monitor FHR, -monitor patient pain, monitor for bleeding, monitor uterine activity, monitor fetal movement. Contraindications: - Uterine anomalies, previous c/s, CPD, placenta previa, multiples, oligohydramnios, nuchal cord, uteroplacental insufficiency, third-trimester bleeding Risk: - Placental abruption - Umbilical cord compression resulting in fetal distress - Emergent c/s

Powers: What happens during this phase?

Uterine contractions cause effacement (shortening and thinning of the cervix) during the first stage of labor and dilation of the cervix (enlargement or widening of the cervical opening and canal) that occurs once labor has begun and the fetus is descending. Involuntary urge to push and voluntary bearing down in the second stage of labor helps in the expulsion of the fetus.

How much blood would be considered too much blood loss during child birth and cesarean birth.?

Vaginal= 300 - 500 ml Cesarean= 500Ml - 1000Ml

How would you assess uterine labor contraction characteristics? Resting tone of uterine contractions: Define it? A prolonged contraction duration __________ or too frequent contractions ___________ without sufficient time for uterine relaxation __________ in between can reduce blood flow to the placenta. This can result in ______ ______ and ______ _______.

by palpation (placing a hand over the fundus to assess contraction frequency, duration, and intensity) or by the use of external or internal monitoring. Resting tone of uterine contractions: Tone of the uterine muscle in between contractions. A prolonged contraction duration (greater than 90 seconds) or too frequent contractions (more than five in a 10-min period) without sufficient time for uterine relaxation (less than 30 seconds) in between can reduce blood flow to the placenta. This can result in fetal hypoxia and decreased FHR.