NSG 3600 Maternal Theory Exam 2

NSG 3600 Maternal Theory Exam 2 1. Asynclitism ● Face and brow presentations hyperextend the neck and increase the overall circumference of the presenting part ● Uncommon and associated w/ fetal anomalies like anencephaly, nacrisinuam of the maternal pelvis ● Examples: Face and brow presentations 2. Frank Breech ● Most common ● Fetal legs are completely extended up towards fetal shoulders Hips are flexed, knees are extended and the fetal buttocks present first in the maternal pelvis 3. Hypertonic Uterus ● The uterus is contracting too much → can be d/t: ○ Too much pitocin → Causes the body to have a harder time contracting down which increases the hemorrhage risk ○ Occurs right before an abruption (if the mother uses drugs) ○ Dehydration ● Contractions are strong and often painful but are ineffective in producing cervical effacement and dilation 4. Nuchal Cord ● Cord that is wrapped around the infant’s neck ● Which rarely causes hypoxia occurs in most often in fetuses w/ long umbilical cords ● A tight knot is present in the cord, variable heart rate decelerations associated w/ fetal asphyxia may be noted ● Would not give this mom pitocin b/c it would make contractions worse and have more issues for baby (bradycardia) 5. Umbilical Cord Prolapse ● Occurs when a loop of the umbilical cord slides down below the presenting part of the fetus ● Prolapse can be occult (hidden or not visible) at any time during labor whether or not the membranes have ruptured ● Or complete cord prolapse where the cord descends into the vagina and it is felt a pulsating mass of vaginal exam ● Frank prolapse most commonly occurs immediately after rupture of membranes as gravity washes the cord in front of the presenting part ● Risk factors: ○ Long (greater than 100 cm) cord ○ Malpresentation ○ Transverse lie ○ Hydramnios ○ Preterm ○ Low birth weight infant ○ Multiple gestation ○ Unengaged presenting part 6. Lamineria ● Dried seaweed that swells as it absorbs moisture and mechanically dilates the cervix ● Can be inserted 4 to 24 hours before the pregnancy termination ● Pon removal the cervix has usually dilated two to three times its original diameter ● Further instrumental dilation is unnecessary 7. NST ● Nonstress test ● Use of electronic fetal monitoring for approximately 20 minutes ● Based on the premise that a normal fetus moves at various intervals ● Response is demonstrated by acceleration of the FHR reacts 8. Uterine Inversion ● Uterus is turned inside out ● Rare but life threatening complication that most often results from excessive pulling on the umbilical cord in an attempt to hasten the third stage of delivery ● Contributing factors: ○ Fundal implantation of the placenta ○ Vigorous fundal pressure ○ Uterine atony ○ Macrosomic infants ○ Magnesium sulfate ○ Precipitous labor ○ Congenital uterine malformation ○ Abnormally adherent placenta tissue 9. Chorioamnionitis ● Group B streptococcus frequent cause ● Group B streptococcus is an opportunistic organism ● Infection in bag of water or in bloodstream 10. Hypotonic Uterus ● Uterus is not contracting ● Can be d/t sedatives or topolytics like magnesium sulfate ● Should give this patient pitocin ● Uterine contractions decrease in frequency and intensity ● Pattern usually occur using the active phase of labor ● Defines as fewer than two to three contractions during a 10 minute period ● Associated w/ excessive uterine stretching and overdistention 11. Caput- Swelling of the soft tissue 12. Oblique Lie - One that is at some angle between the longitudinal and transverse lie 13. Transverse Lie - If the head to tailbone axis of the fetus is at a 90 degree angle to the woman 14. Vacuum/Forceps Vacuum: (Only doctor can use) moldable cup that goes inside the introitus and w/ gentle suction to help pull the baby out while the mother pushes ● Shoulder dystocia is a risk ● Nurses job: Document how long the vacuum was used, how many contractions that the vacuum was on for, “pop offs” Forceps: Very rare to use now ● After removal of the instrument, it is important for nurses to check her external and internal b/c risk of hematoma, lacerations and damage to side walls can happen Appropriate use: Maternal exhaustion 15. Placenta Previa ● Painless bright red bleeding ● Occurs when there is an implantation of the placenta in the lower uterine segment, near or over the internal cervical os ● Can be associated w/ conditions that cause scarring of the uterus such as a prior C section or previous baoritons w/ curettage ● May also occur w/ a large placental mass as seen in multiple gestations, diabetes and eythroblasosis fetalis. 16. Complete Breech ● Also called full breech ● Same as the flexed positions / fetal buttocks presenting first ● Legs are typically flexed ● This position is a reversal of the common cephalic presentation 17. Non-Reassuring FHR ● Things to tell your patient if a non-reassuring FHR pattern is detected via electronic monitoring: ○ We are concerned about your baby’s heart rate pattern ○ I am going to change you reposition to your side to increase oxygen glow to you baby ○ I am also going to place this oxygen mask on your face to increase the oxygen flow to you and to your baby and increase you IV rate ○ Do you have any questions ○ I am to help in any way and I will stay here with you. Please let me know what concerns you have ● Non-reassuring FHR patterns constitute a risk indicator for cesarean birth, the nurse and all members of the healthcare team must be ready for this outcome at all times ● Important to provide ongoing support for the laboring woman and keep her informed of her labor progress and fetal status 18. Post-term / Post-dates ● Post term pregnancy is one at 42 weeks and beyond ● Postdate: identifies a pregnancy that has gone past the estimated date of birth. 19. Abruptio Placenta ● Premature separation of a normally implanted placenta from the uterine wall ● Aburtoption results in hemorrhage between the uterine wall and the placenta, causing abdominal pain and vaginal bleeding ● Rigid board like abdomen w/ dark red bleeding 20. True Labor - refer to her slide she said ● Contraction occur w/ regularity and increase in frequency, duration and intensity ● Pain of true labor usually begins in the woman’s lower back regions and radiates to the abdomen ● Pain intensifies w/ walking 21. Tocolytic ● Medications used in attempt to stop labor ● May be given to prevent uterine contraction ● Bedrest is also essential ● Medications: ○ Terbutaline ○ Nifedipine ○ Magnesium Sulfate - high risk med (CNS depressant) 22. Uterine Rupture ● Most often associated w/ the tearing if the uterine scar (usually from a previous classic cesarean birth), uterine trauma, and a congenital uterine anomaly ● More often occurs in mulgravidas than in primigravidas ● Intrapartum uterine rupture may result from over distention (multiple grastations), tachysystole (oxytocin and prostaglandin), external or internal version, malpresentation, or a difficult forceps assisted birth ● Can be complete or incomplete: ○ Complete: Rupture extended through the endometrium, myometrium and peritoneum ■ Woman will complain of severe sudden abdominal pain and strong contractions ■ Will have bleeding ○ Incomplete: extends into the peritoneum but not onto the peritoneal cavity or broad ligament. ■ Bleeding is usually internal and woman may be asymptomatic (silent rupture) or complain of localized tenderness and machine pain over the lower uterine segment 23. False Labor ● Contractions are irregular and do not change in intensity and duration ● Does not lead to dilation and effacement of the verxis ● Pain of false labor is usually felt in the abdominal region and often stops w/ activities such as walking, position changes and hot showers or other comfort measures 24. Peanut Ball/Sims ● A ball used to help a women bear down and prepare for labor ● Can be used for non-pharmacological pain relief 25. Amnioinfusion ● Transcervical instillation of warmed normal saline into uterus via sterile catheter (IUPC) ● Infusion of NORMAL saline provides additional intra amniotic fluid to cushion the umbilical cord and help lessen cord compression ● May be used in an attempt to reduce the severity of repetitive variable decelerations caused by cord compression ● Normal saline that’s warm 26. Footling Breech ● One or both of the fetal legs are extended w/ one foot (single footling) or both feet (double footling) are presenting first into the maternal pelvis 27. mmHG ● Resting tone of uterus is 20mmHg ● As uterus increases in contraction tone the mmHg increases as well ● Practice Question: ○ If a patient’s contractions are over 80-90 mmHg you should go see that patient (very hard contraction - need to assess how mom/baby are handling) 28. FSE ● Fetal spiral electrode ● Internal fetal monitor ● Must be inserted into the fetal scalp or presenting part during a vagical examination ● An RN can insert an FSE ● Cardiac signal is transmitted through the spiral electrode and a fetal cardiogram tracing in produced 29. Doppler ● Handheld device that uses ultrasound to locate fetal heart sounds ● Requires no special skills because placement of the instrument in the general vicinity of the fetal heart will most likely produce audible heart tones ● Although this approach may provide an easy quick assessment, nurses who use this method may no be performing a detailed patient examination and can miss vital information ● FHT can be asubculated by 10 to 12 weeks ● Usually use for spot checks or a cerclage 30. IUPC ● Intrauterine pressure catheter ● Introduced into the uterine cavity ● Measures contraction frequency, duration and intensity ● Only a doctor can insert an IUPC 31. Toco ● External contraction monitoring ● Pressure sensitive device that is applied against the uterine fundus ● Can be continuous or intermittent ● Provides information about the frequency and duration of contractions ● Does not give accurate data regarding the intensity of contraction b/c there are many variables (maternal position, obesity, and the placement of the monitor) that can affect the tracing ● Contraction intensity best assessed w/ palpation 32. Variability ● Manifested by fluctuations in the baseline fetal heart rate observed on the fetal monitor ● Pattern denotes an irregular changing FHR rather than a straight line that indicated few changes in the rate ● Result of the interplay (a push and pull effect) between fetal sympathetic nervous system, which assists to increase the heart rate and the parasympathetic nervous system which acts to decrease the heart rate ● Types of Variability: ○ Absent: ■ FHR change: Undetectable ■ Cause: May represent fetal cerebral asphyxia. ■ Warrants immediate evaluation ○ Minimal: ■ FHR Change: 2 -- 5 beats per minute ■ Cause: Can be related to narcotics, tranquilizers, magnesium sulfate, barbiturates, anesthetic agents, supine hypertension, cord compression, uterine tachysystole, prematurity or fetal sleep ○ Moderate: ■ FHR Change: 6 -- 25 bpm ■ Cause: Indicate fetal well being ○ Marked: ■ FHR Changes: 25 bom ■ Cause: Marked variability is believed to be a less common response to fetal hypoxia 33. Early Decels ● Head compression ● Delivery is coming soon ● They are mirror contractions ● The patient has probably changed in dilation or station 34. Late Decels - ominous ● Indicate utero-placental insufficiency ● Nursing Interventions: ○ Discontinue oxytocin ○ Change position ○ Give I/V fluids ○ Administer Oxygen ○ Consider internal fetal monitoring ○ Prepare for delivery 35. Variable Decels ● D/t cord compression ● Nursing Interventions: ○ Change position ○ Provide oxygen ○ d/c oxytocin ○ Vaginal exam to assess for cord prolapse 36. Fetal Accels ● This is good ● Baby has 15 seconds to go above baseline and should stay there for 15 seconds - CNS is intact! 37. Fetal Bradycardia ● Defined as a sustained (greater than 10 minutes) baseline FHR of less than 110 bpm ● Can be associated w/ ○ Late fetal hypoxia ○ Medications: Beta adrenergic blockers like propranolol ○ Maternal hypotension ○ Maternal fetal hypothermia and dehydration ○ Prolonged umbilical cord compression ○ Fetal bradyarrhythmias ○ Abruptio placentae ○ Uterine rupture or vasa previa ○ Vagal stimulation during the second stage ○ Chronic fetal head compression 38. Authoritative ● Parents find a common ground between enforcing rules and allowing some freedom for their children to participate in decisions ● Parents are firm ● Set realistic standards ● Punishment centers on assisting the child develop an inner consciousness about behavior ● Produces children who are assertive, self reliant, and highly interactive w/ high self esteem ● Tends to meet the child’s needs better than other styles 39. Laissez-faire ● Allows the child control over their environment and subsequent behavior / less input from the parents, few rules to follow, children are able to make their own decisions, punishment is inconsistent when use, children from this familte nd to be disrespectful, aggressive, and disobedient, possibly group up to be irresponsible members of the community 40. Informed Consent ● Providing the patient w/ the necessary knowledge to make a decision regarding healthcare ● Implies that person understands the benefits and risks of treatment or the refusal of a treatment 41. Uterine Tachysystole ● Can lead to uterine rupture ● Also referred to as hyperstimulation, a condition of excessively frequent contractions w/ the following characteristics ○ Greater than 5 uterine contractions in 10 minutes (averaged over a 30 minute window) w/ contraction occurring within 1 minute of each other, and a uterine resting tone of greater than 20 to 25 mmHg w/ a peak pressure greater than 8- mmHg ● May occur in spontaneous or stimulated labor and is most commonly caused by cervical ripening agents, induction and augmentation of labor. ● Medical management centers on addressing the cause of tachysystole (discontinuing oxytocin, or removing cervical ripening medication) ● Nursing interventions center on reducing uterine activity w/ intrauterine resuscitative actions such as maternal position change, increasing hydration, relieving maternal anxiety and pain, and administering a tocolytic medication as ordered 42. Turtle Sign ● When the fetal head emerges on the perineum (crowning), ir retracts instead of protruding w/ subsequent contractions, and external rotation does not occur 43. Acme of Contraction - Peak of the contraction 44. First Stage of Labor ● Latent ○ Begins w/ established contractions ○ Contractions are 5 minute apart, lasts 30-45 seconds w/ mild intensity ○ 0-3 cm dilated ○ Patient is ok with therapeutic touch for pain relief at this stage ○ Excited, able to verbalize ● Active: ○ More active contractions ○ Contractions are 3-5 minutes apart, lasts 60 seconds w/ moderate intensity ○ 4-7 cm dilated ○ Patient starts to become more irritable with therapeutic touch for pain relief ○ A little more serious, focused, hurting ○ Stage where there should be dilation progression ● Transition ○ Most intense phase of labor ○ Contractions are 2-3 minutes, lasts 60-90 seconds w/ strong intensity ○ 8-10 cm dilated ○ Patient do not want anything done to them at this point as far as therapeutic touch 45. Second Stage of Labor ● Baby Stage ● Normal Progress: ○ Enter into second stage of labor when fully dilated (10 cm) and fully effaced (100%) ○ Ends w/ birth of the baby ○ The woman feels “urge to bear down” ● Cardinal Movements: ○ Decent ○ Flexion ○ Internal Rotation ○ Extension ○ External Rotation/ Restitution ○ Expulsion ● “Laboring Down:” Allows the woman to rest w/ the use of an epidural as the fetus descends ● Open Glottis Pushing: ○ Involuntary pushing ○ The woman is supported to begin pushing when she feels the urge to push ○ Recommended pushing method ● Closed Glottis Pushing ○ Directed pushing ○ Not much sounds → no air exchange ○ The woman beings to push when fully dilated and effaced regardless of the urge to push 46. Third Stage of Labor ● Placenta Stage ● Normal Progress: ○ Begins w/ the birth of the infant ○ Ends w/ delivery of the placenta ○ Uterus becomes spherical in shape ○ Uterus rises upward in the abdomen ○ Umbilical cord descends further through the vagina ○ Gush of blood occurs once the placenta detaches from the uterus ● Placenta Expulsion ○ Schultze Mechanism: ■ Most common method ■ Separates from the inside to the outer margins w/ the shiny fetal side of the placenta presenting first ○ Duncan Mechanism ■ Separates from the outer margins inward, rolls up and presents sideways ● Nursing Interventions: ○ Oxytocin IV or IM: After birth to clamp down the youtube ○ Asses for vulvar injuries ○ Monitor for hemorrhage ○ Monitor VS ○ Emotional support ○ Initiate infant attachment: “Golden hour” promote skin to skin 47. Fourth Stage of Labor ● Recovery Stage ● Period of maternal physiological adjustment that occurs from the time of delivery of the placenta through the first 1-2 hours after birth ● Monitoring of the mother and infant takes place frequently during this time ● Nursing Care: ○ Perform fundal palpation: left hand is placed directly above the symphysis pubis and gentle downward pressure is exerted. Right hand is cupped around the uterine fundus. Palpation the uterus is expected to feel firm and at the midline or below the umbilicus. Should be around the size of a grapefruit ○ Promote attachment and breastfeeding ■ First hour after birth is the most ideal time for parent infant attachment ■ Infant is in a state of alertness and is responsive to voice and touch ■ Provide a quiet, private environment 48. Oxytocin Indications: ● IV: Induction of labor at term ● IV: Facilitation of threatened abortion ● IV, IM: Control of postpartum bleeding after expulsion of placenta Actions: ● Stimulated uterine smooth muscle producing uterine contractions similar to those in spontaneous labor ● Stimulates mammary gland smooth muscle facilitating lactation ● Has vasopressor and diuretic effects Therapeutic Effects: ● Induced labor ● Reduces postpartum bleeding ● Induces breast milk let down Nursing Implications: ● Feta maturity, presentation and maternal pelvic adeaucy should be assessed before administration to induce labor ● Monitor contractions and resting uterine tone frequently ● Monitor maternal BP and pulse frequently and FHR continuously throughout administration ● Monitor uterus for firmness and early detection of boddiness ● Monitor lochia for signs of excessive bleeding Monitor patient for signs and symptoms of water intoxication (drowsiness, listlessness, confusion, headache,and nuria) and monitor electrolytes (hypochloremia and hyponatremia) status 49. Premature Rupture of Membranes ● Also called PROM ● Notify MD, infection risk! ● Management: IM Betamethasone for lung development ● Diagnosis: Nitrazine Swab Test ○ Yellow - intact ○ Blue - rupture 50. Magnesium Sulfate ● Tocolytic ● CNS Depressant ● High risk med 51. Preeclampsia - most common complication Multisystem disease; basically mom’s body does not like the pregnancy → delivery is the solution ● Occurs in second trimester ● Clinically defined: increase in BP after 20 wks gestation accompanied by proteinuria Signs & Symptoms ● Blood pressure 140/90 ● Proteinuria ● Seizures (eclampsia only) ● HELLP Syndrome ○ Hemolysis ○ Elevated ○ Liver Enzymes ○ Low ○ Platelets ● Edematous ● Early Signs ○ Headache, vision changes, elevated BP, edema Assessment ● Identifying hypertension ● Significance of proteinuria ● Assessing edema ● CNS alterations Treatment ● Magnesium Sulfate ● Bedrest in SL position ● Antihypertensive meds: Alpha-Methyldopa, Labetalol, Nifedipine 52. Placenta Accreta - describes a slight penetration of the myometrium by the trophoblast Pathology: placenta is growing too deeply into the uterine wall and once childbirth has been complete, usually the placenta will detach and deliver, however with PA, part or all of the placenta remains attached ● Can cause severe blood loss following delivery ● Possible for placenta to invade the muscles of the uterus (placenta accreta) or grow through the uterine wall (placenta percreta) ● Considered a high risk pregnancy complication ○ If diagnosed during pregnancy → early C-section delivery followed by the surgical removal of your uterus (hysterectomy) ● Signs & Symptoms ○ None during pregnancy but vaginal bleeding during 3rd trim can happen ● Causes ○ Abnormalities in lining of uterus ○ Scarring after a C-section ○ Other uterine surgeries ○ Or simply unknown 53. Couvelaire Uterus - accumulation of blood between the separated placenta and the uterine wall ● Rare; its implications are severe ○ Results from abruptio placentae Signs & Symptoms ● Uterus takes on bluish tinge as blood extravasation from the clot into the myometrium ● Contractility is lost Treatment ● Hysterectomy to control bleeding 54. Eclampsia - presence of new-onset grand mal seizures (and/or unexplained coma) in a women with preeclampsia who has no other cause for seizure Before Onset of Seizure Activity Patient May… ● Complain of headaches ● Visual disturbances ● Blurred vision ● Scotomata - specks or spots in vision where the pt cannot see “blind spots” ● Cortical blindness (in rarer cases) Pathology ● Widespread of vasoconstriction that is occurring throughout the body Assessment ● Routine DTRs to assess for evidence of irritability and clonus (rapidly alternating muscle contraction relaxation 4+) 55. Lacerations 1st Degree Laceration - involve the perineal skin and vaginal mucous membrane 2nd Degree Laceration - involve the skin, mucous membrane, and fascia of the perineal body 3rd Degree Laceration - involve the skin, mucous membrane, and muscle of the perineal body and extend to the rectal sphincter 4th Degree Laceration - extend into the rectal mucosa and expose the lumen of the rectum 56. High Dose Oxytocin - hormone produced by pituitary gland, stimulates uterine contractions Can be used to induce labor or augment a labor that is progressing slowly b/c of ineffective uterine contractions. ● Begin at 4 milliunits per minute ● Increase by 4 milliunits per minute q 30 min until less than or equal to 5 contractions lasting 45 to 90 seconds in 10 minutes averaged over 30 minutes ● Max dose: 20 milliunits per minute The patient should be reevaluated if the dose reaches 20 milliunits per minute; oxytocin may exceed 20 milliunits per minute with provider discretion and documentation of rationale for exceeding protocol. 57. Low Dose Oxytocin Can be used to induce labor or augment a labor that is progressing slowly b/c of ineffective uterine contractions. ● Begin at 2 milliunits per minute ● Increase by 2 milliunits per minute q 30 minutes until less than or equal to 5 contractions lasting 45 to 90 seconds in 10 minutes averaged over 30 minutes ● Max dose: 20 milliunits per minute The patient should be reevaluated if the dose reaches 20 milliunits per minute; oxytocin may exceed 20 milliunits per minute with provider discretion and documentation of rationale for exceeding protocol. 58. Bulging Perineum - when a contraction finishes, the uterus relaxes and the baby’s head recede slightly ● After a while, the area b/w your vagina and anus will start to bulge and the baby’s scalp will become visible 59. Bishop Score - rating system that may be used to determine the level of cervical inducibility ○ A series of points is awarded to cervical dilation, effacement, station, consistency, and position ○ In general, labor induction is morse likely to be successful with a higher score (9 or more for nulliparous women; 5 or more for multiparous women) ○ You can add a point to the score if you’re pt has preeclampsia ○ You subtract points if they are post date ○ Successful score is around 8 (stated in class by April) 60. Freidman’s Curve - deviations from the norm ● A labor curve assessment tool ● Helps to identify whether a pt’s labor is progressing in a normal pattern! 61. Dilation 1.5 cm/hour for a multiparous woman 1cm/hr for a primigravida 62. Station - level of presenting part in relation to the maternal ischial spines (- 5 to + 5) 63. Effacement - Effacement (0-100%) means that the cervix stretches and gets thinner. Dilatation means that the cervix opens. As labor nears, the cervix may start to thin or stretch (efface) and open (dilate). This prepares the cervix for the baby to pass through the birth canal (vagina). 64. Bloody Show - cervix thins/dilates and capillaries will bleed ● During pregnancy the cervix is plugged with mucus which acts like a protective barrier for the uterus and its contents throughout pregnancy ● As cervix begins to soften/stretch/thin → rupture of small cervical capillaries ● The added pressure created by engagement of the presenting part may lead to the expulsion of a blood-tinged mucus plug → BLOODY SHOW ● Indicates labor will begin within 24 to 48 hours 65. Lightning - at about 38wk in the primigravid pregnancy, the presenting part (usually fetal head) settles downward into the pelvic cavity → causing the uterus to move downward as well ● Marks the beginning of engagement ● As uterus moves downward, the woman may state that her baby has “dropped” ● Patient may also report changes in the appearance of her abdomen such as a flattening of the upper area and an enhanced protrusion of the lower area ● The downward settling of the uterus may decrease the upward pressure on the diaphragm and result in easier breathing ● Downward settling may also lead to following maternal symptoms ○ Leg cramps or pains ○ Increased pelvic pressure ○ Increased urinary frequency ○ Increased venous stasis, causing edema in the lower extremities ○ Increased vaginal secretions b/c of congestion in the vaginal mucosa 66. Braxton Hicks - as pregnancy approaches term, most women become more aware of irregular contractions ● Usually dont hurt as bad as actual contractions ● Felt in abdomen or groin region, and patients may mistake them for true labor ● Sign of impending labor: prep of the cervix and uterus for the advent of true labor ● Do NOT lead to dilation or effacement of the cervix which is why we can also call this “FALSE LABOR” 67. Delayed Cord Clamping Team Infant ● Clamping should be delayed for at least 60 - 120 seconds ● Controversial - research does not provide sufficient benefits Preterm Infant ● Clamping should be delayed for at least 60 -120 seconds, if infant did not need resuscitation in the 1st minute of life ● Improves circulatory and respiratory function and reduces the need for blood transfusion 68. Episiotomies - incision made to enlarge the perineal opening to allow delivery of a fetus ○ Midline - from vaginal canal directly down ■ Easily repaired, heals quickly and is associated w/ less postop pain than mediolateral ■ Disadvantage: risk of 3rd/4th degree lacerations with extension through the rectal sphincter ○ Mediolateral - from vaginal canal diagonally outward ■ Less common ■ From vagina to the 5 oclock or 7 oclock position (the maternal left medial lateral or right mediolateral position) ■ Associated w/ smaller risk of 4th degree lacerations although 3rd degree lacerations may occur still ■ Amount of blood loss is greater, the surgical repair is more difficult and there is increased pain postpartum 69. Lochia - bloody vaginal discharge ● The first lochia that appears is bright red and is called LOCHIA RUBRA ● Amount of lochia is determined by examining the soaking of the perineal pads and the frequency of pad changes required 70. Fundal Assessment ● Nursing intervention that is implemented in 4th stage of labor ● Assessed for consistency (firm, soft, or boggy), location (should be midline), and height (measured in fingerbreadths) ● Nurse notes whether it is located midline or deviated to one side ○ On occasion fundus can be palpated slightly to the right b/c of displacement from the sigmoid colon during pregnancy ● Assessment of the fundus should be made shortly after the pt has emptied her bladder ○ Full bladder prevents the uterus from contracting and instead pushes the uterus upward and may deviate it from the midline because of laxness of the uterine ligaments ● A flabby, non contracted, boggy uterus is associated w/ increased bleeding ○ One of the reasons can be r/t remaining placental pieces that were left ● A well contracted fundus → firm, round and midline ● Nurse documents: location of fundus according to fingerbreadths above or below umbilicus 71. Cytotec - a prostaglandin analogue that promotes expulsion of the pregnancy ● Ripens the cervix (causes softening and initiates dilation and effacement) ● Stimulates uterine contractions ● Nursing Considerations ○ Stable at room temperature ○ Rectal absorption is likely slower than IV med ● In cases of postpartum hemorrhage, this medication can be given after hemorrhage is back under control to help uterus clamp back up 72. Cervidil/Dinoprostone Vaginal Gel/Prostin E1-2 Cervidil/Dinoprostone Vaginal Insert/Prostin E1-2: ripens the cervix (causes softening and initiatives dilation and effacement) ● Stimulates uterine contractions Prepidil Gel/Prostin E2: allow to reach room temp before admin; do NOT heat ● Continue admin until max dose is reaching or uterine contractions are established (3/10 min) or Bishop Score equals 8 or more Cervidil Insert: remove after 12 hours or at labor onset ● Keep insert frozen until ready to use 73. Narcotics - Can cause minimal variability 74. Narcan - completely blocks the effects of opioids including CNS effects and respiratory depression ● Opioid antagonist → reverse the CNS depressant effects ● Benefit When: ○ Labor progresses more rapidly than anticipated and birth is expected to occur when the opioid is at its peak effect ● Placental transfer of naloxone is variable → neonate may not require treatment w/ an opioid antagonist ● Should be administered if the maternal respiratory rate decreases to less than 10 breaths per minute or if the maternal oxygen saturation rate decreases to less than 89% ○ Oxygen may be admin by face mask and the anesthesiologist should be notified 75. FHR Baseline - 110 to 160 Usually always a range, never a set number 76. Terbutaline - tocolytic drug ● May be given to promote uterine relaxation 77. Nifedipine - calcium channel blocker used to inhibit preterm labor, works primarily by blocking the flow of calcium ions through the cell membrane → decreasing the activation of smooth muscle contractile proteins ● If nifedipine is given with mag sulf it can cause cardiac arrest ● PO 78. Methergine - causes uterine contractions by stimulating uterine and vascular smooth muscles ● Keep this med refrigerated ● Do not add to IV solutions or mix in a syringe with other meds ● Take precautions to prevent inadvertent admin to the newborn ● Can also control blood loss ● Postpartum hemorrhage med! 79. Hemabate - stimulates contractions of myometrium ● Do not administer if patient demonstrates shock b/c it will not be well absorbed ● Keep refrigerated ● This med is very expensive ● Can also control blood loss ● Postpartum hemorrhage med! 80. Augmentation - you already have some of something For Example: with a breast augmentation, you already have breasts and they are just working with what you already have ● Used to stimulate uterine contractions after labor has begun spontaneously but is not progressing satisfactorily ● Most commonly indicated for the management of hypotonic uterine dysfunction ● Can be accomplished with: ○ Amniotomy ○ Oxytocin infusion ○ Nipple stimulation ○ Non invasive - should be used first before invasive ■ Ambulation ■ Hydration ● Uterus d/t contraction creates a huge hydration demand → after starting IV bolus the uterus gets hydrated and will calm down or sometimes the body will allow the uterus to do what it needs to do ■ Relaxation ■ Hydrotherapy 81. Indications for Induction of Labor Induction - describes the use of chemical or mechanical modalities to initiate uterine contractions (before their spontaneous onset) to bring about childbirth ● Considered when: ○ Maternal or fetal condition exists that dictates the need for medical intervention in the labor process ● Leads to: ○ Increase in interventionist care including use of IV therapy, amniotomy, internal monitoring, epidural anesthesia, and a longer stay in the labor unit ● Following maternal/fetal conditions serve as some indications for induction: ○ Post Term pregnancy ○ Maternal medical conditions (DM, renal disease, chronic pulmonary disease, chronic hypertension, or antiphospholipid syndrome) ○ Gestational HTN ○ Chorioamniottis ○ Premature rupture of membranes ○ Fetal compromise (severe fetal growth restriction, isoimmunization, or oligohydramnios) ○ Preeclampsia, eclampsia ● Medication ○ Cervidil (cervical ripener) - usually left in for 12 hours but can be removed if the body responds faster! ■ Has a string attached to it and is able to be pulled out easily ■ It is not meant to send women into labor but it can ○ Cytotec (placed in anal cavity to help with hemorrhoids) ■ Pill placed into the cervix (harder to retrieve than the cervidil) ● Mechanical Methods ○ Balloon catheter: blow up the foley above your cervix and below cervix and then pulling on cervix to help thin and dilate ○ hygroscopic dilators ○ amniotomy 82. Oliguria - low urine output 83. Amniotomy - artificial rupture of membranes (AROM); non pharmacological intervention that may be down to augment or induce labor or to facilitate the placement of internal monitors during labor Involves: ● Insertion of amnihook or other sharp instrument into the lower segment of the fetal membranes; following rupture the fluid is allowed to drain slowly ● The rupture of the membranes causes a release of arachidonic acid, which converts to prostaglandins, known inducers of labor through the stimulation of oxytocin in the uterus ● Labor usually happens within 12 hours after AROM ○ If it does not → increased risk of infection, fetal injury or umbilical cord prolapse Nurse Monitors: ● Vital signs ● Cervical effacement, dilation, station ● FHR ● Contractions 84. Local Anesthesia Affected Areas: ● Perineum When Used During Labor and Birth: ● Immediately before birth for episiotomy; after birth for repair of lacerations Nursing Implications: ● Assess pt’s knowledge and understanding; provide info as needed ● Observe perineum for bruising, discoloration, hematoma, or signs of infection during the recovery period 85. Epidural Anesthesia - injection of a local anesthetic such as bupivacaine, an opioid analgesic such as fentanyl or sufentanil, or both into the epidural space (b/w L4 and L5) provides pain relief from uterine contractions and vaginal or cesarean birth ○ Safety Question on Test ■ d/t Epidural causing decrease in sensorium in legs so keeping her in bed is important ■ 500 cc bolus her before epidural (pre bolus or pre load) to prevent hypotension *need to know baselines* ■ Standing orders for Ephedrine (vasoconstrictor) to get BP back up if needed ○ Complications ■ Possible to get “hot spots” ● Intervention: offer the patient to redo the epidural 86. Spinal Anesthesia - involves the injection of a solution containing a single local anesthetic or an anesthetic combined with fentanyl through the 3rd, 4th, or 5th lumbar interspace where it mixes with CSF 87. Pudendal Block p.491 Affected Areas: ● Perineum and lower vagina When Used During Labor and Birth: ● Late in the 2nd stage for episiotomy, forceps, or vacuum extraction; during third stage for repair or episiotomy or lacerations ● Also used for patients who are feeling burning, pressureful and pain sensations at perineum Nursing Implications: ● Assess pt’s level of knowledge and understanding’ provide additional info as needed ● Monitor for signs of infection, urinary retention Med/Methods Used ● Lidocaine or Trompet 88. Effleurage - taken from french word “effleurer” which means to touch lightly ● Gentle stroking technique performed in rhythm with contractions ● The pt or her labor support person massages the abdomen using light circular motions ● Helpful b/c it distracts th pt from her contractions ● Massage of the hands, feet, and back may be effective in diminishing tension and in enhancing comfort 89. Types of C-Sections There are 2 main types of cesarean operations: the classic (vertical) incision and the lower-segment transverse (LST) incision ● Surgeon chooses the type based on the pt’s condition and the fetal status ● Types Include: ○ Vertical ○ Transverse ○ Low Transverse - associated with less blood loss, fewer post op infections and a decreased likelihood of uterine rupture during subsequent pregnancies ○ Low Vertical ○ Classic - associated w/ complications including considerable blood loss, infection and uterine rupture w/ subsequent pregnancies, women who undergo classic c section births may not attempt future vaginal births 90. Attitude - fetal position 91. Shoulder Dystocia - head is born but the anterior shoulder cannot pass under the maternal pubc arch ● Risk Factors ○ Maternal pelvic abnormalities ○ A history of shoulder dystocia in previous pregnancy ○ Obesity ○ Diabetes ○ Short stature ○ Prolonged labor ○ Postdate pregnancy ○ Fetal macrosomia ● Nursing Care ○ When the fetal head emerges on the perineum (crowning), it retracts instead of protruding w/ subsequent contractions (turtle sign) and external rotation does not occur ○ If the shoulder is stuck (turtle sign) for more than 1 min, then: ■ Place patient completely flat by lowering HOB ■ Place pt in McRobert’s position ■ Suprapubic dislodge 92. Oligohydramnios - less than 300 mL of amniotic fluid A decrease in amniotic fluid increases the viscosity of the meconium and the risk of neonatal aspiration during delivery ● May result from fetal renal abnormalities, poor placental perfusion, or premature rupture of the membranes ● During labor → absence of amniotic fluid buffer may lead to cord compression during contractions and decreased fetal blood flow as evidenced by variable decels ● Treatment ○ Amnioinfusion may be indicated to replace the cushion of fluid for the cord and relieve the frequency and intensity of variable decels 93. External Version - used to attempt to turn the fetus from a breech presentation to a vertex presentation to allow a vaginal birth ● May be attempted at 37wks of gestation ● Contraindications ○ Previous C section ○ Uterine anomalies ○ CPD ○ Placenta previa ○ Multifetal gestation ○ Oligohydramnios ● Before the version → ultrasonography is obtained to confirm the fetal position; locate the umbilical cord; rule out placenta previa; and assess the maternal pelvic dimensions and the amniotic fluid volume, fetal size and gestational age, and the presence of anomalies ● Before the version → NST is performed to confirm fetal well-being or the FHR and pattern may be electronically monitored for a brief period of 10-20 min ● Procedure: ○ Rotating the fetus requires uterine relaxation ○ Tocolytic agents such as maf sulf or terbutaline are used to facilitate this process ○ Acoustic stimulation of the fetus has also resulted in successful versions *performed through the maternal abdominal wall in an attempt to change the fetal position from a breech to a cephalic presentation* 94. Nitrazine ● Assessing for the presence of amniotic fluid helps determine whether the membranes have ruptured ● There are 3 tests that may be used to detect amniotic fluid: nitrazine tape test is one of them ● Tests pH → blue: amniotic fluid /yellow: just pee 95. CPD - Cephalopelvic Disproportion - indicates C section ● Used to describe unsuccessful attempts at vaginal birth ● Fetus cannot fit through the maternal pelvis to allow a vaginal birth ● r/t excessive fetal size (macrosomia) a condition that may be associated w/ maternal DM, obesity, and multiparity ● Nursing Care ○ Review of present and past pregnancies ○ Slow progression of effacement and dilation, lack of fetal descent, and excessive pain are all possible indicators of CPD ○ Maternal position changes → upright posture (sitting/squatting) to widen pelvic girdle, relaxation, and water therapy are strategies to facilitate labor progression ○ Analgesic agents to alleviate pain creating tension that is interfering with fetal descent 96. Meconium - the first stools of the infant Meconium-stained amniotic fluid during the intrapartum period is an indication for careful fetal surveillance by electronic fetal monitoring and possibly fetal scalp blood sampling ● Although not always a sign of fetal distress, its presence, which occurs during fetal loss of sphincter control, is highly correlated with its occurrence ● Reasons for the passage of meconium during labor include ○ Hypoxia - r/t peristalsis and sphincter relaxation ○ Breech presentation or normal physiological function that occurs w/ fetal maturity ○ Following umbilical cord compression-induced vagal stimulation in the mature fetus 97. DIC - acquired disorder of blood clotting ~ OOZE Affected individuals can experience widespread internal and external bleeding and clotting ● Clinical Symptoms ○ Easy bruising ○ The appearance of multiple petechiae ○ Bleeding from intravenous sites ● Triggered by ○ Release of large amounts of tissue thromboplastin which occurs in abruptio placentae and in retained dead fetus (the fetus has died and is retained in the uterus for 6 or more wks) and amniotic fluid syndromes ● Prompt Identification of DIC ○ Bleeding from multiple sites (IV access site, venipuncture site and site of urinary catheter insertion) ○ Spontaneous bleeding from the gums and nose ○ Widespread petechiae and bruising ○ GI bleeding ○ Tachycardia ○ Diaphoresis ● Treatment ○ Correct the underlying cause and replace fluids and essential clotting factors ○ When premature placental separation has triggered the coagulopathy → delivery of the fetus and placenta must be accomplished so that the production of thromboplastin, which is driving the process, is halted ○ Accomplished with IV admin of heparin to stop the clotting cascade ● Nursing Care ○ Continuous maternal-fetal assessment ○ Position woman in SL tilt to max placental perfusion, and oxygen may be admin via rebreathing mask at 8-10 L/min or according to PCP or protocol ○ Urinary output is closely monitored b/c renal failure can occur 98. Vasa Previa - occurs when the unprotected fetal vessels cover the cervical os and precede the fetus ● Usually seen with a velamentous insertion of the umbilical cord ● Since vessels are not covered w/ Wharton’s jelly, the examiner may be able to feel pulsations of the umbilical cord ● Lacerations of the vessels, which can occur at any time, cause sudden fetal blood loss ● Onset of sudden, painless bleeding at the beginning of cervical dilation or during rupture of membranes (ROM) may signal the presence of vasa previa; Dx may be confirmed by sonogram Maternal Lab 8/5: ● Client is getting an epidural what is a primary nursing intervention: ○ Giving a bolus LR ~ At least 500- 1000 cc ● Anesthesiologists care about platelets ● An RN can turn off epidural and if been cleared/ certified can remove an epidural catheter ○ Can NOT change an epidural bag ● Should lower HOB for a uterus check In Class Review ● Stages of Labor: ○ First Stage: ■ Latent: Usually get sent home. Psychologically these moms are like smiling and giggling, not so much pain ■ In active labor: If she feels like pushing do not let her and tell her to breathe! ■ Transition: Psychologically losing it!!! ● What conditions do we expect a physician to order an amnioinfusion: ○ Cord compression (variable decels) ○ They prefer warmed NS ● Main nursing intervention for cord prolapse: ○ Take the pressure off the cord ● Early decels: ○ Head compression ○ Not necessarily worried ○ Get the labor ready ● Late Decels: ○ Utero- placental insufficiency ○ Worried about these ○ Nursing interventions: ■ Reposition pt ■ Turn off pitocin ● Pg 414: Review palpate contractions (Look in book b/c it gives you more definitive things about indentation of the uterus): ○ Forehead = strong contraction ■ Can’t really indent this uterus ○ Nose = Mild contraction ○ Chin = Moderate or firm contraction ● 4th stage the goal is for the uterus to be clamped down and firm!! If the uterus is firm we want it located at the midline, ○ IMMEDIATELY after delivery the uterus goes in halfway between the umbilicus and the superpubic and then over the next few hours (post delivery) it goes back up (when it tightens/ firms) ● C-section: ○ Failure to progress: ■ No change in dilation or station ○ Cephalopelvic disproportion ■ Problem w/ passenger and passageway ○ Malpresentation: ■ Breech ■ Transverse ■ Previous shoulder dystocia ● Know the different breeches and what they look like: ○ Frank ○ Complete ○ Single footling ○ Double footling ● If your uterus is experiencing an episode where it is not getting resting tone (hyperstimulated) and hard: ○ Baby could be getting late decels ○ Or episodes of bradycardia ○ Relaxing the uterus is the intervention: ■ Give bolus ■ Turn off pitocin ■ Intrauterine resuscitation give the mom O2 ● 8-10 or 10-12 via rebreather mask ■ Reposition ■ Can give tocolytics if you have a tachysystole uterus ● Possible C Section indications: Recognize the risk factors: ○ These are your 4 patients ● Bladder empty!! (always the answer choice if it is there) ○ Uterus will clamp down if it is empty ○ Avoid PPH ○ Look at perineum ■ If they have any lacerations if they have approximation ● Know the degrees of lacerations ○ 1st Degree Laceration - involve the perineal skin and vaginal mucous membrane ○ 2nd Degree Laceration - involve the skin, mucous membrane, and fascia of the perineal body ○ 3rd Degree Laceration - involve the skin, mucous membrane, and muscle of the perineal body and extend to the rectal sphincter ○ 4th Degree Laceration - extend into the rectal mucosa and expose the lumen of the rectum ● If I have a hematoma that forms what is the intervention from happening: ○ Ice their perineum! ● With a hematoma: what size do we then need to a surgical intervention: ○ 4 cm and over ○ ● If a doctor choses to a episiotomy (2 types): ○ Midline ■ Heals better b/c it goes through a lot of muscle ○ Medial Lateral and it goes to the side ● Tachysystole ○ Give bolus ○ Decrease pitocin ○ Cervical ripener (Cytodele): remove it! ● True v. False labor ○ Check her slides ● Time contraction ○ Beginning of first contraction to the beginning of the next ○ Contraction at 1305 then 1310 then 1315 ■ Contractions are q 5 minutes ● Good Acceleration: ○ 15/15 ■ Increase by 15 bpm above baseline and stay there for at least 15 seconds ■ Means that the CNS is intact and baby can accelerate their heart rate ● Variability: ○ If flat lining → Absent (staying at 120 bpm the entire time) ■ Same as no variability or without variability ■ Tell the Dr b/c there is a problem ○ Minimal → might be okay ONLY if know the reasons why (change in 2-5 bpm) ○ Moderate → what we want!! ○ Marked → Okay ONLY if know why ● Normal fetal baseline: 110-160 ● Prioritization: ○ Know abnormal from fetal heart tone standpoint ● If a patient is not sure she broke her water: ○ Test w/ nitrazine paper ■ Positive: Blue- green/ purple ■ Negative: Yellow green ● Know the pH of urine and amniotic fluid ○ Acidic = Urine (4.5) ○ Alkaline (ish) = Amniotic fluid (6.5) ● Reasons why during a labor exam does the patient need to stay in bed: ○ Epidural ○ NOT WORRIED: Bag of water is broke and 4cm and +1 station (not worried about cord falling out) ○ Bag is ruptured and baby is not engaged w/ high station** (Cord prolapse!) ● EMTs are trained to see if the head is crowning ○ Same in the hospital ○ Precipitous delivery (if you see the head it's coming out) ● Maternal Temps: ○ We don’t get bent out of shape for maternal temp unless getting OVER 100.4 twice w/ 4 hours apart ○ If they get 100.6 ■ Give fluid bolus ■ If you get another temp like this call the dr ● Know rigid board like abdomen: abruption ● Painless bright red bleeding: previa ● Review Bishop’s score: ○ Know what we use it for (how well a women can be induced ○ Don’t need to memorize the whole score ○ Mainly looking at dilation and effacement ○ Higher the score = higher the likely for induction/augmentation ● Versions: ○ External version: turn the baby ■ Need informed consent ■ Treat her like a full admission: draw blood, hep lock ■ Empty bladder before ■ Give a shot of terbutaline ● Who is at risk for hemorrhage: ○ Fast labors ○ VBAC ○ Big baby b/c the uterus has been more stressed out and it is harder to stress out ■ Happens more w/ gestational diabetics ○ Shoulder dystocia ○ If they are on pitocin for too long ● Steps for shoulder dystocia: ○ Once you see the turtle sign need the baby out within ONE minute ○ Place them in, lower the HOB to flat, McRoberts, and do suprapubic dislodge ● C Section Aspiration Risk: ○ She is laying down, her arms are on the board ○ = HIGH aspiration risk!! ○ ASK WHEN THEY ATE LAST!!! (NPO status is vital) ○ Already has decreased peristalsis ● Forceps and vacuums ○ Bag of water has to be broken first ○ Ensure she is comfortable w/ a good epidural or give her something! ○ Bladder empty!! ○ Afterwards = increase risk of hemorrhage ○ Need to be completely dilated ● Birthing balls and Peanut balls: ○ Accomplishing: Helping w/ rotation to come anterior ○ Need to get the baby through the pelvis! (they need to rotate them) ● What to do if hyperventilating: ○ Put hand on chest and talk them out of it ○ Can give them a paper bag, breathe into their own cupped hands ● Cord Prolapse what to do: ○ Tell anesthesiologist to meet in OR ○ Knee Chest!!!!! (if has epidural put them in modified Sims) ● Appropriate reasons for Induction: ○ Past their due date or medical conditions ○ Post date! (Past 39 weeks) ○ Fetal demise is NOT a reason ○ Living far away from hospital NOT a reason ○ Beech NOT a reason ● No vaginal delivery for active herpes ● No induction for uterine scar ● If a patient has DIC the med that they give is heparin!!! ○ b/c clotting cascade is trying to over clot at some point ○ Anticipate that order ● Patient gets an epidural: ○ Keep their blood pressure from dropping so give them a bolus dose!!! (Preload dose) ○ Make sure you are taking baseline BP (before the bolus) and continue to monitor ○ May need to give Effederine if she drops ● Patient might bleed = Large bore IV (16 or 18) ● Reasons why to vacuum: ○ MATERNAL EXHAUSTION!! ○ OR: Patient w/ an epidural that is too strong and the baby is already coming out and the baby is having bradycardia ● Empty the bladder if labor is not continuing to progress ● ALWAYS ASSESS THE BLADDER b/c the uterus can not contract if the bladder is pushing on the uterus ● Bulging perineum = delivery sign ● Types of C Sections: ○ Stat: OB emergency ○ Repeat ○ Elective: Maybe mom can’t push b/c neuro condition or raped, or cultural like from south america ● Know the PPH meds: ○ Suppository Cytotec (Misoprostol): For anyone ○ IM Hemabate (Carboprost): Not for asthmatics ○ IM Methergine (Methylergometrine): NOT for hypertensive or CVD disease, PAD ● Review parenting styles