Maternity and Newborn Nursing

• Module 3: Intrapartum

Assessment of Fetal Heart Rate (FHR)

• Vertex Presentation: Fetal heart tones are best heard below the umbilicus in either the right or left lower quadrant of the abdomen.
• Breech Presentation: Fetal heart tones are best heard above the umbilicus in either the right or left upper quadrant.
• The Leopold maneuver is used to determine the baby's position.
• Normal FHR ranges from 110 to 160 bpm.

Electronic Fetal Monitoring

• Variability in FHR indicates oxygenation issues, such as contractions causing cord compression or placental issues.
• Variability can also be due to the mother sleeping or medications affecting her and the baby.
  • Absent Variability: 0-3 bpm, indicates significant oxygenation problems.
    • Maternal temperature should be checked.
  • Minimal Variability: 3-5 bpm, may be due to medications like magnesium sulfate which decreases respirations and can be seen on the strip.
  • Moderate Variability: 6-25 bpm - the desired range.
  • Marked Variability: >25 bpm - not good.
  • If variability is anything but moderate, reposition the mother.

Fetal Bradycardia and Tachycardia

• Fetal Bradycardia: <110 bpm for 10+ minutes can be caused by cardiac abnormality in the mother, sitting on vena cava, dehydration, hypotension, placental issues, anesthesia, or hypoxia/cord issues
  • Discontinue oxytocin, have the mother lay on her side, administer O2 via a non-rebreather mask at 10L/min, administer maintenance fluids intravenously and tocolytics, and notify the provider.
• Fetal Tachycardia: >160 bpm for 10+ minutes can be caused by fever, dehydration, anxiety, cocaine use, psychological issues, or cardiac abnormalities.
  • Administer antipyretics (Tylenol) suppositories for a fever, O2, and intravenous fluid bolus.
  • Check for fever in the mother, which could indicate chorioamnionitis, and begin antibiotics if ruptured.
  • Ensure to check mom's BP for fetal tachy
  • Chorioamnionitis (bacteria in the vagina moved into the uterus) can be caused by the BOW being broken for a while

Accelerations and Decelerations

• Accelerations: Good and indicate a variable transitory increase in FHR of 15 beats above baseline for 15 seconds.
• Decelerations: Bad and indicate a FHR that goes <15 beats below baseline usually due to contraction.
  • Use the mnemonic VEAL CHOP MINE (specifics down below)

VEAL CHOP MINE

This is about EFM pattern, cause and intervention.

• V (Variable Decelerations) = C (Cord Compression) - M (Move Mom)
• Abrupt onset with a U, W, or V shape on the strip, lasts 15 seconds then comes back up.
• Cause is cord compression, low amniotic fluid, or meconium.
• Treatment: First move the mom, and if that doesn't help, consider amnioinfusion with IUPC placement for low fluid or meconium. consider Terbutaline to stop contractions.
• E (Early Decelerations) = H (Head Compression) - I (Identify Labor Progress)
• U shape that lowers before or at the same time as a contraction then comes back up in 30-45 secs
• Only requires monitoring because the head is being well compressed and moving down.
• A (Acceleration) = O (Okay!) - N (No Intervention Needed)
• Means the baby is well oxygenated.
• L (Late Decelerations) = P (Placental Insufficiency) - E (Evaluate the problem)
• U shape that has gradual onset and takes comes back up after 45 seconds after the contraction
• Indicates placental insufficiency, meaning inadequate fetal O2.
• Treatment: Discontinue oxytocin (Pitocin) if being infused, administer O2, and consider Terbutaline. Must turn off Pitocin completely if you give O2.

Three-Tier System

• Category 1:
  • Good (green)
  • Baseline of 110-160 bpm
  • Moderate variability
  • Late or variable decelerations absent
  • Early decelerations may be absent or present.
  • Accelerations may be absent or present
• Category 2:
  • Cautious (yellow)
  • Bradycardia with variability that is minimal, moderate, or marked, tachycardia may be present.
  • Minimal or marked baseline variability.
  • Variability which is absent and/or not accompanies
  • Absence of accelerations with stimulation.
  • Prolonged deceleration (wide U shape because it's long lasting)
    • Is more than 2 mins but less than 10 mins.
  • It is important to do something because the baby is going through something.
• Category 3:
  • Bad (red)
  • Absent variability is telling you the baby is hypoxic.
  • Stop what you are doing and get baby out, fast!
  • • Recurrent late decelerations
  • • Recurrent variable decelerations
  • • Bradycardia

Intrauterine Resuscitation

• Sinusoidal pattern indicates to prep for C-section.
• For Category II or III patterns intrauterine resuscitation strategies include
  • Promote fetal O2: Move mother to her side, administer IV fluid, oxytocin, and O2
  • Reduce uterine activity: Discontinue oxytocin, administer an IV fluid bolus and Terbutaline, and move the mother to a lateral position.
  • Alleviate UC compression: Reposition baby, amnioinfusion.
  • Correct maternal hypotension: Lateral positioning, IV fluid bolus, and possibly ephedrine.

Communication

• Tell me more.. when they are scared of procedures/wtf is going on"
• Patients should be able to walk during labor if able if ROM happens.
• If the patient says that they;re about to push or feel pressure- Stay with them!

Uterine Contractions

• Frequency:
  • Expressed in minutes
  • Determined by counting the number of contractions within a 10-minute period, counting from the start of one contraction to the start of the next.
  • Normal = 5 contractions in 10 minutes
  • More than 5 in 10 minutes is tachysystole.
• Duration: Measured in seconds from the beginning to the end of one contraction
• Intensity
• Strength of contraction measured by palpitation or IUPC:
  • Palpitation:
    • Strong (3+) = feels like a forehead (cant indent the uterus)
    • Mod (2+) = feels like chin (can kinda indent)
    • Mild (1+) = tip of nose (easily indents)
  • IUPC
    • Solid/fluid filled transducer placed inside uterine cavity to monitor frequency, duration, and intensity of UC
    • can only be used if membranes are ruptured as it can cause placenta abruption if membrane isn't ruptured

The Five P's

• Passenger Includes the fetus and placenta
• Presentation = how it's trying to come out:
  • Transverse aka it's sideways and in the position that the shoulder is going to try and come out first of
  • Parallel/longitudinal = cephalic or breech position
• Fetopelvic/Fetal position: Includes the description of the fetus position
  • Right or Left (R vs L) = the side of the maternal pelvis
    • Occiput (O), Sacrum (S), Mentum (M), or Scapular (Sc)
    • Anterior (A), Posterior (P), or Transverse (T) = the part of maternal pelvis:
      • Anterior (A)= baby facing mom's butt
      • Posterior (P)= baby facing mom's face (longer labor)
      • Transverse (T) =we don't want this! (turn mom side to side and reposition baby)
      • Stations =
    • (-1,-2,-3) means that the baby is "still inside and floating around" or has NOT began to engage)
    • "0" - Ischial Spine(LFGGGGG!!)
    • (+1,+2,+3) means that the baby is engaging
• Passageway Passageway (birth canal/pelvis)
  • Size & shape of pelvis= "Gotta allow fetus" to be able to pass through it!
  • Gynecoid shape of pelvis= "It can fit!"
• PowerIncludes the contraction strength / pushing power: Power (Power of uterine muscles / Contractions + "Pushing Effort")
  • UCs (uterine contractions) causes effacement & dilation during 1st stage of labor!
  • Involuntary urge to push & bearing down in 2nd stage= helps in expulsion / birth of the fetus!
• PositionIncludes the position of the mom
  • Position (of mom):
    • Position changes are a good thing because this provide "better comfort / Less fatigue / circulation
    • gravity can also help "when they do that silly squat" & the baby will start sliding down
• Physiological Response
  • Psychological Response:
    • Stress, tension, & anxiety can impact the birth progress
    • Cultural beliefs/ issues, mental health issues, transgender, adoption, teenager

True Vs. False Labor

• True Labor

  • Contractions bring change to cervical effacement and/or dilation

• Becoming regular in frequency, stronger, and lasting longer.

• Walking increases the intensity of contractions

• Presents in the anterior position

• May experience blood

• False Labor

  • Irregular contractions with little/no change.

• Painless, irregular ones

• Decreases in intensity or duration

• Are able to stop if she falls asleep or drinks water or pees

• Fetus will remain in the posterior and/or isn't engaging - The amniotic rupture would then indicate that fluids will require assessment: C: color should be watery, clear, and have a yellow tinge

• Can use a Nitrazine paper test to see if their amniotic rupture occurred. - Paper will turn blue if there is amniotic fluid, and paper will stay yellow is pee is present - Oder is never an indication, and note down the amount on the paper!

Cardinal Movements

• These are the movements that happen during labor:
• Engagement:Baby is moving down at point "0"
• DescentBaby is actively coming down the vaginal canal
• Flexion: The baby's "head of fetus flexes so the chin goes to chest" so the baby can come out and get through!! -Internal rotation: This mean the "fetus rotates to lateral anterior position(corkscrew motion) to go through pelvis" -Extensiton: Baby extends chin away from chest & the head busts through! -External Rotations/ Restitution:The head is out & baby rotates to face the transverse, so the shoulders can come out also! -Delivery/Birth by expulsion:The baby will come out, after the head & shoulders by flexing toward the symphysis pubis!

Stages of Labor & Intervention

• Stage 1: (Has the following!) Latent stage 0-5cm and 0-40% -This would slow and should be the time in which the mom is home, can happen in 9.3 hours in multi babies and 11.8 hours for one baby! During this you would expect:
• Blood tinged mucus
• Intact or ruptured membrane
• Cramps, backache, talkative, good time to educate them Latent stage greater than 6cm
• Can get an epidural in the active phase!
• Stage 2 - Cervical dilation will be complete - Contractions = intense / every "2 mins; 60-90 secs long" -Baby is born
• Stage 3 - Starts after the baby is born & placenta is out - Mom will get oxytocin drug after the baby is birth & palcenta is out
• Stage 4 - Starts after delivery of both baby and placenta - Mom and baby will starts to bond

Care of the Labor Patient

• Non-Pharmacological
  • Encourage her to walk.
  • Warm bath, distraction, breathing control for pain. -Aromatherapy, imagery, music, focal points, and lighting
• Pharmacological Management:
  • Estrogen & oxytocin (Pitocin)=initiates labor / contractions and will assist with PP bleeding! Pitocin= give IV pump and will be titrated with fluids - This will STOP at active labor once baby is 6cm Do not given with O2
  • *Terb= "Stops contractions"(give for tachysystole)

Amnioinfusion

• See thick meconium but patient NOT fully dialation
• This will dilate the meconium
• • Membrance does NOT need too be ruptured
• Immediate risk: prolapsed cord!

Anesthesia

• Local or regional L: Time of delivery for"episiotomy- surgical cut of vagina! R: During labor delivery & most use for C- sections!

Care of the Epidural:

-  " Lasts 2 hours" so if you give it now you're baby will be out sleepy and ASAP!
- Note that FHR will decrease after the epidural, so always check the Mom!
-  "Bolus Fluids" are needed before countering hypotension!
- Should be Lateral with the head flex forward!

• Module 4: High-Risk Intrapartum

Operative Vaginal Delivery

• Vacuum-Assisted Delivery Hematoma can occur with this Use 'Three Pull-Rule" after the baby is not coming out after "3 tries=C-section TIME!
• Forceps -Assisted Delivery This can be used on patients at station RF - Lacerations, Hematoma, Fracture

Labs and Diagnostic

      -  (C Section)
       - CBC, TYPES,& SCREEN: platlet <100,000 =need a transfusion!

Indication of Labor:

• 39 weeks plus delivery
• Bishop Score determines weather or not weather she is ready by "evaluating cervix is able to come out"
  • MUST want a score of "8" (minimum)! - Dilation how many cms - Cervical Ripening
    • Mechanical / Physical -Vaginal exam and try stretching the cervix open in a sweeping motion - Increasing the number of bloody shows

Medical

:Cervical = insert releases for pregnancy that creates: PITOCIN

• You can't give this it's your patient has an scar from a procedure because there will be some bleeding

Amniotomy

• This will indicate chord of compression
• When you do make sure baby;s head is up!

Cervidil

• Inserted vaginally to soften and prepare cervix for birth.
• Take out when contractions are 1 minute apart

Cefazolin:

• Give if patient is allergic to penicillin.

Pitocin

• IV PUMP.
• Give if the issue is the the "5 P's" - Power

Cytotec

Stimulates contractions to dilate the cervix.

Vaginal Delivery

• (C Section) VBAC= vaginal birth after cesarean & fine unless incision was vertical! & Toloca a"trial after labor after cesarean, but If the baby's lies transverse can be there a problem

Operative Birth

• Needs if breech, shitty, and cord prolapse Give antiemetics (Zofran): figurer out which anesthesia is needed and NPO 8-12 hours also give to avoid blood clot!

Post: Monitor for Infection and Bleeding"

• "Educate patient to bed rest"
• Prolasped Umbilical Chord"

Sterile glove hand Biggest= station 2 ME conium

Amnotic Fluid

"Peasoup" & everything should be prepared: Have suction mouth

Cord is wrap, hypoxia Fetal Distress (O2):

FHR

• Anaphulatoid Syndorme (S&S)
• Low count, or bleeding!

Uterine

Complete the world or be "Incompleted"

• Hypovolemic, change in shape, palpate

Primiganda/Epideral

Contractions or delivering

Test your knowledge of maternity and newborn nursing concepts with this quiz. Topics covered include fetal heart monitoring, stages of labor, and immediate postpartum care. Perfect for nursing students and practicing nurses.