210 Final Review

Intrapartum

• Stages of labor are divided into latent phase (0-5cm), active phase (6-10cm), second stage, third stage, and fourth stage.
• Latent phase (0-5cm): Irregular contractions (frequency 5-30 minutes, duration 30-45 seconds). Mucus plug expels (scant brown, pale pink). Mother is talkative and calm.
• Active phase (6-10cm): Moderate-strong contractions (frequency 3-5 minutes, duration 40-90 seconds). Mother feels more anxious and in pain.
• Second stage: 100% dilated and 10 cm effaced; fetal decent occurs. Avoid pushing until fully dilated. Nursing care includes monitoring VS and FHR, coaching with pushing and position changes (High Fowlers, Lithotomy, side-lying), warm compresses (perineum) and cold compresses (neck/head), and promoting skin-to-skin after birth.
• Third stage: Delivery of placenta within 30 minutes of birth. Nursing care includes monitoring BP, HR, and RR every 15 minutes, instructing the patient to push once dilated, and gently cleansing perineum with warm water, blotting, and applying ice packs after birth.
• Fourth stage: Occurs 1-4 hours after birth for maternal VS stabilization. Normal blood loss is 500 mL for vaginal and 1000 mL for c/sections. Nursing care includes assessing the fundus regularly, and monitoring maternal VS every 15 minutes for the first 1-2 hours, and massaging the fundus if it is boggy.

True vs. False Labor

• True labor is characterized by stronger and longer contractions, pain in the lower back, and changes in cervix during dilation, with bloody show.
• False labor is characterized by irregular contractions, pain that stops with walking, and no changes to the cervix.

Factors Affecting Labor

• Passenger (fetus/placenta): presentation (e.g., cephalic, breech, shoulder), lie (relationship of maternal spine to fetal spine), attitude (relationship of fetal body parts to one another), and position (position of the fetal head to the maternal pelvis).
• Station refers to degree of fetal decent into pelvis (-1 to +5).
• Leopold's Maneuvers are used to assess fetal lie and presentation externally.

Fetal Assessment During Labor

• Leopold's Maneuvers: external palpation of the mother to determine presenting part, lie, and altitude of the fetus. Should be done with a supine position and empty bladder.

FHR Auscultation and Contraction Monitoring

• Indications include oxytocin infusion, abnormal NST, maternal complications, fetal growth restriction, meconium-stained amniotic fluid, and suspected or actual abruption placentae/placenta previa.
• Latent phase: at least hourly auscultation
• Active phase: every 15-30 min auscultation
• Second phase: every 5-15 min auscultation

Other Labor Complications

• Placental previa: abnormally implanted placenta near the cervical os; characterized by painless, bright red vaginal bleeding.
• Placental abruption: premature separation of placenta; characterized by dark red bleeding, severe abdominal pain, and uterine tenderness/tachysystole.
• Prolapsed umbilical cord: cord precedes fetal presenting part during labor.
• Meconium-stained amniotic fluid: presence of meconium in amniotic fluid, risk factor for hypoxia.
• Shoulder dystocia: fetal shoulder becoming stuck on maternal pelvic bone.
• Uterine rupture: tearing of uterus; characterized by nonreassuring FHR and sudden, severe abdominal pain and change in uterine shape.

Induction of Labor

• Indications: post-term pregnancy, dystocia (prolonged labor), fetal demise, chorioamnionitis (insufficient amniotic fluid).
• Cervical ripening: promotes cervical softening, dilation, and effacement when cervix is unfavorable.
• Methods: misoprostol, prostaglandin E2 (dinoprostone), amniotomy.
• Oxytocin: induces labor and used post-delivery to control bleeding.
• Artificial rupture of membranes: used to stimulate labor by rupturing the amniotic sac.

Episiotomy

• Incision made into perineum to facilitate birth and minimize tissue damage.
• Ice packs provided for the first 24 hours; then, sitz baths can be used.

Cesarean Section

• Consent, admission, education, skin-to-skin contact, cath insertion, SCD's, and positioning.
• Head-to-toe assessment to assess VS q5 minutes until stable; VS q15 minutes for 1 hour, then q30 minutes.
• Assessment of fundus, lochia, and assisting with coughing/deep breathing q2 hours.

Postpartum

• Physical changes: uterus shrinking and returning to pre-pregnancy state; fundus midline/umbilical; 24 hrs after birth, it should be 1-2 cm below the umbilicus.
• Lochia: assessment of color, amount, odor, and consistency.
• Lochia Rubra: bright red; days 1-3.
• Lochia Serosa: brownish-pink; days 4-7.
• Lochia Alba: white, yellow; days 11-14.
• Cervix, vagina, and perineum: assessment for healing.
• Breast: Assess for engorgement; if engorged, encourage feedings or pump/express regularly
• Activity, Nutrition, and Contraception
• GI System: assessment of bowel sounds, comfort measures for perineal pain, and diet.

Coagulopathies

• Idiopathic thrombocytopenic purpura (ITP): autoimmune disorder characterized by decreased platelet count. May cause severe hemorrhage following c/s or lacerations.
• Disseminated intravascular coagulation (DIC): life-threatening disorder characterized by widespread blood clotting throughout the body.

Postpartum Hemorrhage

• Bleeding > 1000 mL for vaginal, >500 mL for c/s
• Possible causes include uterine atony, multiparity, retained uterine segments, uterine rupture, and trauma.
• Manifestations: excessive bright red bleeding, blood clots, boggy fundus, and higher fundal height than expected.
• Nursing care includes monitoring VS, assessing fundal height, lochia, and trauma sites, as well as firmly massaging the fundus every 15 minutes.

Postpartum Infections

• Complications occurring up to 28 days after birth/abortion, including uterine/endometritis infections (foul-smelling lochia, fever, abdominal pain), wound infections (incision, episiotomy, lacerations), and mastitis.

Postpartum Mental Health

• Postpartum blues: occurs during first few days postpartum; resolves naturally within 10-14 days.

Other Related Studies

• Anaphylactoid syndrome (amniotic fluid embolism). This is characterized by a small amount of amniotic fluid that leaks into the maternal circulation. Sx: resp/circ distress, chest pain, and shortness of breath.
• Intrapartum pharmacology: includes medications such as uterotonics and tocolytics.
• Alcohol use. This is characterized by CNS depression and may cause inappropriate sexual/aggressive behavior, mood changes, slurred speech, disorientation.
• Opioid use. Manifestations of misuse include long-term opioid use- hyperalgesia, hypogonadism, and sexual dysfunction.
• Cardiovascular diseases include conditions such as heart failure, coronary artery disease , and deep vein thrombosis (DVT). DVT is characterized by a blood clot in a deep vein

Multiple Sclerosis

• Autoimmune disorder that affects the myelin sheath around nerves, causing inflammation and impaired nerve transmission.
• Risk factors for MS include being a female, family history, tobacco use, EBV, infections, and ethnicity.

Addison's Disease

• Characterized by insufficient secretion of mineralocorticoids (aldosterone), glucocorticoids (cortisol), and androgens (testosterone).
• Addisonian crisis is a life-threatening disorder when steroids are suddenly stopped.

Cushing's Syndrome

• Characterized by the overproduction of cortisol by adrenal cortex. Causes may include prolonged steroid use or pituitary/adrenal tumors.
• Manifestations include buffalo hump, moon face, truncal obesity, weight gain, fluid retention, bone loss, hirsutism, muscle wasting, osteoporosis, hyperglycemia.

Thyroid Disorders

• Hyperthyroidism: overproduction of T3 & T4, symptoms include tachycardia, hypertension, weight loss, diarrhea, intolerance to heat, moist skin, and bulging eyes (exophthalmos).
• Hypothyroidism: underproduction of T3 & T4, symptoms include weight gain, constipation, intolerance to cold, dry skin.

Eating Disorders

• Anorexia nervosa: severe restriction of calories, extremely thin, and malnourished.
• Bulimia nervosa: repeated episodes of binge eating followed by purging.
• Avoidant/restrictive food intake disorder (ARFID): significant restriction of food or eating behaviors leading to weight loss or malnutrition.

Alcoholism

• CNS depressant; causes inappropriate behavior, mood lability, judgment impairment, vomiting, nausea.
• Symptoms vary but are characterized by withdrawal delirium. Interventions include benzodiazepines (first line), antiseizures, and disulfiram to prevent alcohol (EtOH) ingestion.

Opioid Abuse

• Opiate withdrawal is characterized by symptoms such as abdominal pain, cramps, mydriasis (pupil dilation), goosebumps, muscle cramps, tachycardia, and excessive sweating.
• Interventions involve the use of medications like methadone.

Heart Failure

• Condition in which the heart is unable to effectively pump blood throughout the body.
• Causes include high blood pressure, coronary artery disease, and conditions such as left-sided or right-sided HF; left-sided is caused by obstructed flow back into left atrium,
• manifested as lung-fluid, dizziness, shortness of breath, dry/hacking cough, edema, orthopnea, and weight gain. Interventions consist of monitoring, medications, lifestyle changes, and surgeries like cardiac transplantation or valve replacement to help improve condition.

Fractures

• Types of fractures include closed (doesn't break skin surface), open (breaks skin surface), impacted, compression, oblique, greenstick, and spiral.
• Symptoms associated with fractures can vary, such as bone pain, severe bruising, swelling, deformity, instability, tenderness, and loss of function.
• Complications include osteomyelitis, deep vein thrombosis (DVT), and compartment syndrome. Treatment typically involves splinting, casting, or surgery.

Multiple Sclerosis

• Autoimmune disorder causing the myelin sheath of nerves to be damaged.
• Manifestations include symptoms such as exacerbations and remissions; flare-ups include muscle spasticity, ataxia, muscle hyperreflexia, urinary retention, cognitive impairment (short-term memory loss, impaired judgment, depression), and sensory issues (blurred vision, hearing loss, vertigo, sense of temperature).
• Interventions include monitoring height, encouraging weight-bearing exercise, safety checks, patient education on avoiding triggers, and pharmacological interventions.

Coronary Artery Disease (CAD)

• Conditions caused by atherosclerosis, plaque buildup, and narrowing or clogging of vessels.
• Manifestations include chest pain (classic or atypical), indigestion, nausea, or upper back pain.
• Interventions include monitoring VS, cardiac rhythm, electrolytes, and glucose levels, initiating cardiac monitoring, implementing bed rest and a quiet environment, lifestyle modifications, and medications.

Osteoporosis

• Condition characterized by the breakdown of bone tissue faster than new bone is created, leading to reduced bone density and increased risk of fractures.
• Common manifestations include back pain, stooped posture, decreased height, and balance issues.
• Interventions include increasing calcium and vitamin D intake, regular weight-bearing exercises, and taking certain medications to slow bone loss.

Severe TB

• Infection caused by Mycobacterium tuberculosis, an airborne bacterium that usually infects the lungs. Risk factors for infection include close contact with infected people, homelessness, tobacco use, drug abuse, immunocompromised individuals.
• Manifestations include progressive fatigue, weight loss, chronic cough, night sweats, and hemoptysis.
• Interventions to manage include monitoring respiratory status, encouraging high-calorie nutrition, and providing education on infection control.