Intrapartum Test Map Exam 2 Fall 2024 PDF

Intrapartum Test Map Fall 2024  Acute mental status change or unresponsive (cannot follow verbal Labor- Chapter 16 commands)...

Intrapartum Test Map Fall 2024  Acute mental status change or unresponsive (cannot follow verbal Labor- Chapter 16 commands)  Signs of placental abruption =What is the Emergency Medical Treatment & Labor Act (EMTALA)- Chapter 19  Signs of uterine rupture The Emergency Medical Treatment and Labor Act (EMTALA) is a U.S. federal law that Fetal requires hospitals with emergency departments to provide a medical screening  Prolapsed cord examination to any individual seeking treatment. It ensures that patients are stabilized Imminent Birth- the baby will be born minutes or very soon and treated for emergency medical conditions before they can be transferred or  Fetal parts visible on the perineum discharged, regardless of their insurance status or ability to pay. EMTALA aims to  Active maternal bearing-down efforts prevent "patient dumping," ensuring that everyone has access to emergency medical care. Triage for Urgent 2 -everyone is an emergency must be treated or stabilize regardless if they cannot affor or have insurance -created the precedence they have evaluated and treated -if higher level then patient transfer. -need evaluated when in labor =You must know the triage information from rapid review, who must you see immediately/emergency, who is next, who is third, who is fourth and who is last to see? Hint...hint... Initial Nursing Assessment of client presenting in labor -urgent need to assess the patient and start interventions Triage for Emergency 1 URGENT/ Priority 2: urgent/ priority vital signs, severe pain without complaint of contractions, high-risk situations, woman and newborn need higher level of care than the institution provides Abnormal Vital Signs:  Maternal HR >120 or 26 or can get her out of bed and can have her walking, lunges or upright pelvic tils  If medicated and cannot get out pf bed because of safety -> turn her  Nullipara- zero pregnancies that have reached viability side to side, put in all fours position and pelvic tilt – use peanut pillow to  Primipara- one pregnancy that has reached viability / first time mother open the pelvis (this opens up the diameter  Multipara- two or more pregnancies that have reached viability *Multiparas deliver faster than primiparas =Rupture of membranes- COAT Color Odor Amount Time (color *high risk if Average duration of labor for primipara vs multipara: meconium staining and fetal distress- NICU must be at the delivery because Early phase (0-5 cm) - Nulliparous and multiparous women progress at similar rates there could be aspiration of the meconium plug and the neonate may not be Duration: 30-40s able to breathe, time (do not want to exceed 24 hrs- begin IV antibiotics at 18 Active (6-10 cm) - Multiparous women progress more rapidly than nulliparous hrs) What is the first assessment?- You always check the fetal heart tones women FIRST when the water breaks! Duration:80-90s Rupture of Membranes- COAT Color Normal: clear/straw colored with white flecks Abnormal- Meconium stained(must have NICU at delivery)-denotes fetal distress, Blood tinged  NICU must be at the delivery because there could be aspiration of the meconium plug and the neonate may not be able to breathe, time (do not want to exceed 24 hrs- Inteventions: begin IV antibiotics at 18 hrs Odor- Normal: no odor Amount- may vary- ask the pt how much Time- need to start antibiotics at 18-24 hours  Hourly temps after water ROM/infection – need 1hr check temps after water is broken to monitor for any infection  Monitor FHTs for Tachycardia/infection – assess Fetal heart tone during maternal tachycardia may have infections. Maternal Fever/Infection: If the mother has an infection, it can raise her body temperature, leading to fetal tachycardia. Chorioamnionitis, an infection of the amniotic fluid and Primiparas: Average total labor duration can be 12-20 hours. membranes, is a common cause during labor.  First stage (onset of labor to full cervical dilation): 12-18 hrs Verification- paper 6.5- 7.5. fern under the microscope, Amnisure test  Second stage (full dilation to delivery of the baby): 1-2 hrs  were going to get a sample of the fluid and send it to the lab for verification Multiparas: Average total labor duration is usually 6-12 hours that it is amniotic fluid.  First stage of labor: 6-8 hrs  If don’t have that capability, do a ferning test -> when put amniotic fluid on  Second stage: 20 min. – 1 hr the slide  or do nitrozene paper -> can be inaccurate =The labor curve addresses the trees/rocks or the highway. If you are a first- SAFETY- The first assessment is to listen to the fetal heart Rate for Variable time mom- it will be slower, if you are a multipara, it is faster. decelerations. The cord could be compressed when the membranes ruptured. - If you are not laboring in the expected timeline as referenced above, the baby What is the first assessment? may be too big or malpositioned. This may indicate a need for surgical - You always check the fetal heart tones FIRST when the water breaks! -> cord intervention. compression can happen resulting less oxygen to the baby Maternal labor nursing intervention including voiding, breathing techniques and hyperventilation (cup hands and rebreathe), ice chips, linen changes, and =Understand the labor partogram. Multiparas deliver faster than options for analgesia and anesthesia- Labor interventions: primiparas. What is the average duration of labor for a primipara versus a  Important to follow what the mom wants. If the mom doesn’t want pain multipara- Page 387 chart in the book medication we could do hydrotherapy, walking, ambulation, sway or dance with significant other , breathing relaxation and massage Labor partogram  Want to void frequently- so bladder does not get filled with fluid and cause - a graphical tool used to monitor the progress of labor and guide clinical decisions. It contractions to hurt more plots cervical dilation and fetal descent against time to help identify deviations from  Breathing techniques- slow deep breathing as long as she can. Let them the normal progress of labor. breathe at normal rate 12-20. -important to consider the effect of uterine activity on the fetus. Often the progress of -Don’t want her hyperventilation / or breathe too quickly -> fingers start to labor is evaluated using graphic charts (also called partograms or labor graphs) on tingly, feel lightheaded which cervical dilation is plotted as labor progresses  Interventions: tell her to take her hands and cupped around her face and Take temperature every 4 hours until membranes rupture, then every 2 rebreathe to increase amount of CO2 to improve hyperventilation status or hours (Lowd, 385). paper bag Ongoing FHR assessment  Give Ice chips, soups and popsicles – some moms are NPO for the risk External fetal monitoring for emergency surgery / c-section Low Risk: Assess FHR every 30 minutes in active phase and at least every  Want Clean linens/ don’t want to soiled – change linens all the time and 15 minutes during second stage. don’t want to be soiled Higher Risk: Assess FHR at least every 15 minutes in active phase and at  Options for analgesia with anesthesia- make sure discuss what they least every 5 minutes during second stage. would like and what would you do for them. Ask them what are their plans Assess contractions when assessing FHR. or what do they like today? Not do you want to get an epidural?. -if they don’t want nothing and support natural labor, want to be -Vaginal exams as needed to identify labor progress screen them for use of narcotics. May be using IV narcotics, if -Palpate for bladder distention and encourage regular voiding at least every 2 you give IV narcotics less than an hour prior to deliver. Then hours during labor (a full bladder can impede labor progress). may give Narcan to the baby resulting baby to respiratory Oral intake: depression. - It is becoming more common practice for clients to have clear liquids during labor; -if they want and epidural need to know information about epidural however, nurses should follow obstetric provider orders. and contraindication and medication -Provide mouth care as needed for dry mouth. -Intravenous intake may be needed if client is not permitted oral intake during labor. TESTING hint: The cervix should be completely dilated (10 cm) before the client begins pushing. If pushing starts too early, the cervix can become Ongoing Assessments edematous and never fully dilate. Assist woman with use of psychoprophylactic coping techniques, such as breathing exercises and effleurage (abdominal massage). Breathing techniques, such as deep chest, accelerated, and cued, are not prescribed by the stage and phase of labor but by the discomfort level of the =The first stage of labor dilation includes two phases: Early 0-5 cm- Active 6- laboring woman. If coping is decreasing, switch to a new technique. 10- Hyperventilation results in respiratory alkalosis that is caused by blowing off too First stage of labor -> dilation much carbon dioxide (CO2). Symptoms include Dizziness First Stage of labor-Needed Information Tingling of fingers Stiff mouth Identify the presence of a support person. Have the woman breathe into her cupped hands or a paper bag in order to Explain all activities and procedures to the mother and support person. rebreathe CO2. Discuss the Birth Plan. Encourage ambulation if membranes are intact, after ROM only if the fetal Analgesia and anesthesia are often offered and or needed presenting part is engaged, and if the client has not received pain medication. during the active phase of labor. If pharmacologic methods are - If unable to ambulate, encourage frequent position changes while lying in bed used too early, they may slow the progress of labor; if used (every 30 to 60 minutes). too close to delivery, narcotics increase the risk of neonatal respiratory depression. Non- pharmacologic Pain Relief Common causes of first-stage pain: dilation, effacement,  Cutaneous stimulation (effleurage, counterpressure, walking, rocking, stretching of cervix, contractions, distention of lower uterine water therapy) segment  Sensory stimulation (aromatherapy, breathing techniques, music) Discuss Postpartum preferences, i.e., cutting umbilical cord, rooming  Cognitive strategies (childbirth education and hypnosis). in, feeding choice Cultural considerations for birth and postpartum care Safety with IV/IM Pain Medications Check her cervix first to make sure she will not deliver within one hour. Document baseline- maternal pain, vitals, cervical exam, and FHTs. Give medication- Common drugs include meperidine, fentanyl, and Ongoing Assessments: nalbuphine. Naloxone (opioid antagonist) can promptly reverse CNS Assess maternal vital signs (BP, P, Respirations) depressant effects and provoke a seizure in a opioid depended mother. Take BP between contractions, every 30 to 60 minutes in early labor Document afterward- maternal pain, vitals and FHTs and every 15 to 30 in active labor unless abnormal or maternal appearance changes. Safety- Have her void before giving the medications, bed in the lowest position, call Difficulty breathing/cannot push- RN may turn the epidural pump off, but bell in reach, SR up x 2, instruct her not to get out of the bed, and continuous FHTs- Never turn it on- Anesthesia must restart the epidural pump document all of the above. After delivery- When discontinuing the epidural, make sure the blue tip of the catheter is visible Epidural – Before Post-dural puncture headache – may also happen with spinal anesthesia Consents If the pt has a headache after delivery- take the blood pressure and Contraindications: Platelets do a pad evaluation: do not want saturated pad in oLow Risk: assess FHR and pattern at least every 15 minutes during hour (indicate heavy bleeding) or 15 minutes (indicate hemorrhage) second stage. o Higher Risk: assess FHR and pattern at least every 5 minutes Dry and suction infant (if needed) perform Apgar assessment, and place during second stage. blanket on mother’s abdomen or allow skin-to-skin contact with mother after o Observe perineal area for increase in bloody show, signs of fetal delivery. descent (bulging perineum and anus, visibility of the  When baby is out, dry the baby to prevent cold stress presenting part).  Suction – if needed o Palpate bladder for distention- keep it empty  Perform APGAR score o Assess amniotic fluid for color and consistency.  Get rid of the wet linens o Comfort measures: continue mouth care, assist with position  Put the baby skin to skin - if allowed to mom during the golden hour (1 hour changes, help with pain relief, provide breathing instruction after delivery) where the baby has lots of epi, norepi and cortisol (fight or and support and positive reinforcement of pushing efforts. flight hormones wake and aware) o Teach mother positions for pushing such as squatting, side-lying, or Place a stockinette cap on the newborn’s head or cover head to prevent heat loss. high-Fowler/lithotomy and encourage open-glottis pushing Allow partner or other support person to hold infant during repair of (bearing down while exhaling) followed by a cleansing breath after episiotomy/laceration. Allow any siblings present to hold new family member. Gently each contraction. cleanse vulva and apply clean perineal pad. Place two on perineum. Do not touch o Set up delivery table, including bulb syringe, cord clamp, and sterile inside of pad. Do apply from front to back, being careful not to drag pad across the supplies. anus. Remove both legs simultaneously if legs are in stirrups for repair. Provide o Perform perineal cleansing if directed. clean gown and warm blanket. Lock bed before moving mother and raise the side o Make sure client and support person can visualize delivery if they rails during transfer. desire. A mirror can be offered. If siblings are present, make sure  Cover the baby’s head with a hat to prevent heat loss, they are closely attended to by support person explaining that their  Allow partner or other support person to hold infant during repair of mom is all right. episiotomy/laceration. Allow any siblings present to hold new family member.  Record exact delivery time (complete delivery of baby).  Gently cleanse vulva and apply clean perineal pad Place two on perineum. Do not touch inside of pad. Do apply from front to back, being careful not to =The Third Stage of Labor is the delivery of the placenta. drag pad across the anus. -> do not touch inside of the pad you can Delivery of the placenta: happen within 20-30 minutes. if does not, it is placenta contaminate it and introduce bacteria accrete or retained placenta that will cause mom to hemorrhage  Remove both legs simultaneously if legs are in stirrups for repair -> remove stirups gently How do you know when the placenta has separated?  Provide clean gown and warm blanket.  the uterus will rise, cord will lengthens (because the placenta is coming from  Safety: Side rails up x2, bed lowest position and call bell in reach the fundus and moving to the entrota) and a gush of blood  If have epidural, pull the epidural and look and make sure visualize the blood  after the placenta delivers, want to look at it and make sure all the pieces are tip in the end. To make sure all the epidural came out, have everything nice there ->if pieces not together, we retain placenta fragments (danger to mom and clean as she still have hormones of pregnancy and continue to bleed)  Lock bed before moving mother- move the mom in a bed and scoot over to another bed lock during transfer Make sure the uterus is firm after the delivery- Give oxytocin ASAP to prevent bleeding =Know the extent of a first -and fourth-degree laceration with nursing  after placenta comes out, the body is give natural oxytocin causing uterus to interventions. firm up. The fallen estrogen triggers the release in oxytocin  First degree: skin- Nursing interventions: ice pack  Need to evaluate the uterus and umbilicus or lower is to make sure the  Second degree: skin through the tissues or muscle ->interventions: want bladder is empty ice pack  Give bolus of oxytocin at the stage where the placenta is delivered – to  Third degree: skin – tissues -> through the rectum -> Nursing decrease the amount of bleeding -> hemorrhage problems in 3rd and 4th intervention: chux pad, lidocaine (foam or spray), ice pack, pain medication stage (motrin etc.)  4th degree laceration: skin- tissues -> through the rectum -> Nursing What is the sequela if oxytocin is given before the delivery of the placenta? intervention: chux pad, lidocaine (foam or spray), ice pack, pain medication -it make it difficult to get the placenta out (motrin etc.) Know normal estimated blood loss for a vaginal and a C-section delivery: *Never want to put anything in the rectum in 3rd or 4th degree oof laceration – < 500 for vaginal loss or need to watch them longer -rubra (red), moderate, and clots less than 2 to 3 cm. -Amount similar to a heavy menstrual period. Closely monitor: Vaginal bleeding: saturating a pad in 1 hour is heavy bleeding, -Suspect undetected laceration if fundus is firm and bright-red blood continues to and saturating a pad in 15 minutes is a clinical hemorrhage. trickle.  Close monitoring is just an estimate but the better thing is a quantitative Nursing interventions: blood loss. Quantitative blood loss is actually weigh and measure the  Always check perineal pad and under buttocks. amount of blood loss. This gives an exact amount of how much blood is loss. Perineum: Vital signs: Watch for widened pulse pressure followed by tachycardia followed by  Observe in good lighting. low blood pressure- as with all bleeding in pregnancy  Should be intact or assess lacerations/episiotomy for redness, edema, Nursing interventions: ecchymosis, drainage, and approximation (REEDA).  2 18g IVs, fluid to replacement,  Suspect hematomas if very tender or discolored or if pain is  blood replacement as necessary, and disproportionate to vaginal delivery.  possible surgical intervention. *start LR and lactated ringer to get the bleeding to slow down =High-risk labor complication- Chapter 32 PPT stage 4: Hypotonic Uterine Dysfunction, know physiology, signs, and symptoms, know nursing Risks for Hemorrhage maternal and fetal nursing interventions.- not enough or not strong enough Preeclampsia- high pressure to the uterus contractions to change the cervix-need augmentation such as Pitocin or Amniotomy. Uterine hyperstimulation- tired from so many contractions Hypertonic Uterine Dysfunction, know physiology, signs, and symptoms, know nursing Uterine overdistention- stretched out, does not want to go back maternal and fetal nursing interventions.- need to STOP. Will cause mom pain and Dystocia- difficult; uterus could be injured fatigue and will deoxygenate the fetus: terbutaline- (Remember s/e and Antepartum hemorrhage- placental problems, at risk for pp hemorrhage contraindications of this med), fluid, pain medications, rest. Hypotonic/Hypertonic Magnesium sulfate therapy- smooth muscle relaxer- will not tighten uterine dysfunction- Bladder distention- blocks the uterus from contracting down Long labor- uterus tired, worked too long Hypotonic uterine dysfunction Short labor- precipitous- uterus tired, worked too fast -low tone uterine dysnfunction Old or damaged placenta- parts may remain and the uterus is still getting -either don’t have uterine contractions or dont have enough contractions (not getting hormones and thinks it is still pregnant enough oxytocin from the brain) -Contractions are not strong enough, long enough, or close enough together to dilate Make sure they do not bleed to death!!!! the cervix Give oxytocin bolus as ordered to contract the uterus. Signs and symptoms : Check vitals  Not strong contractions – look at tracing make sure the contraction is 5  increased hr, followed by decreased blood pressure, denotes blood loss minutes apart (blood loss) Maternal and fetal nursing interventions:  Assessment- perineal pad soaked in 15 minutes,  Continue fetal monitoring – if every do anything to the mom (medications  signs of hypovolemic shock: pale, clammy, tachycardic, lightheaded, and treatment etc.) hypotensive- OPEN LR and Call for Help.  May change to IUPC to measure the strength of the contractions- very Check the uterine fundus to make sure it is firm (not bleeding) effective with use of oxytocin to strengthen the contractions  - UPC (Intrauterine Pressure Catheter) is a medical device used during labor =Obesity in labor challenges, intraoperative, and postoperative nursing to measure the strength and frequency of uterine contractions more maternal and fetal nursing interventions- What are the side effects? Soft Tissue accurately. and Obesity/  Augment with oxytocin (cause contractions to be stronger and frequent ) or amniotomy (break the water causing the contractions a lot more strong If the BMI is over 40 for the reason that there is not fluid around the baby)  want to do a c-section and -have to lift pannus (layer of excess skin and fat that hangs down, usually Hypertonic Uterine Dysfunction in the lower abdominal area) up to be able to do a low transverse -strong contractions, too many contraction incision to be able to get to uterus – need more than one hands -Frequent contractions that are uncoordinated and not change the cervix -Clean the perineum/vagina prior to doing the c-section -Very painful for mom and can deoxygenate fetus (hypoxia, acidosis) -keep the incision clean and dry – risk for infection Signs and symptoms : -a lot of surgery and estrogen, immobility – DVT risk  Contractions less than every 3 minutes  Painful -for mom  Cervix not changing or too many contractions – need to stop them because *If mom has high blood sugars, the fetus could have hypoglycemia. When the baby mom is going to get fatigue and terrible pain comes out, the baby could have respiratory issues if there is a long standing Nursing interventions: hyperglycemia causing decrease surfactant production Rest the pt- give fluid, = External Cephalic Version- understand the procedure and who is a good candidate, morphine- pain med at what gestational age and the risks associated with the procedure. maybe terbutaline- used as a tocolytic to temporarily stop or slow down = Good candidates- term, small baby, very stretchy uterus (P3 and above)- uterine contractions, Relaxes uterine muscles, inhibiting uterine activity and aggressive fetal monitoring to make sure placenta and fetus have not been injured- causing bronchodilation. may have to stay in the hospital at least 4 hrs post procedure if not followed by - Contraindication: suspected heart disease, preeclampsia with severe induction or c-section. Risk- risk for abruption- must have IV and the staff prepared features or eclampsia, pregestational or gestational diabetes mellitus, or that there could be an abruption or problems with the cord- eg. Have the OR ready to hyperthyroidism go if the baby goes into distress Narration ECV- 4 minutes 1 second -side effects: tachycardia, irregular pulse, myocardial ischemia, and pulmonary edema. Goal: send the patient home and contractions are no longer disjointed and External cephalic version coordinated, and began to change the cervix -the provider manually turn the baby form a breech or transverse position to head down =What is the interventions for a laboring woman with pelvic or soft-tissue -touching the placenta and the cord -> use ultrasound to try to avoid that dystocia for delivery?- C-section Who is a good candidate: -if the cervix starts to swell -> the baby is not going to come out and c-section -> term, small baby (at least 37 weeks) ->the provider will do an evaluation and prep her for c-section -> very stretchy uterus or have one or 2 babies (P3 and above)- aggressive fetal monitoring to make sure placenta and fetus have not been injured- may have to stay in the hospital at least 4 hrs post procedure if not followed by induction or c-section   Elective induction- after 39 weeks with a high bishop score. – schedule to What gestational age?-37 weeks or early termed deliver the baby for convenience time but need high bishop score Risk associated with the procedure: What are the risks?  Preterm labor -Starting the labor and breaking the water – risk for infection  Abruption placentae  Cord accident Medications/treatments: Know intended effects/ side effects/ and contraindications  Uterine rupture (if previous scar)- can tear open with nursing interventions maternal and fetal  * hint, you must use continuous fetal monitoring, watch for uterine Techniques: tachysystole.  Talc in the abdomen- help with movement Methods for induction:  Tocolytics- make the uterus more soft and not contract -cervix is favorable and high bishop score and cervix dilated  Administer anti-d (rhogam) - for rhesus negative emoms ->start Pitocin/ oytocin to start contractions or break the water -> watch to uterine tachysystole make sure we don’t have many contractions or too long Contraindication: contractions Absolute  Multiple pregnancies - If the Bishop's score is low, it means cervical effacement must be accomplished  Previous postpartum hemorrhage before giving her oxytocin. If her cervix is not effaced, she will not dilate.  Ruptured membranes- hard to turn the baby as not enough fluid harder to  Need to increase BISHOP score, before starting Pitocin. If not effaced support or dilated, Pitocin will not do any changes.  Oligohydramnios (refers to a condition in pregnancy where there is an Intervention: insufficient amount of amniotic fluid surrounding the fetus)- hard to  The Least risky intervention is a foley bulb – puts manual pressure on turned the actual cervix  Prostaglandin gel/ cervaidil-to improve cervical readiness or BISHOP Relative score for cervix. Put in the cervix and not very risky but need to continue  Previous caesarean section fetal monitoring  Intrauterine growrh restriction - Cervidil or prostaglandin gel uses medication to efface the cervix and fetal  Pre-eclampsia monitoring must be used  Rh-isoimmunization  Cytotec/misprostol - High risk use it in the cervix  Grand multiparity - contraindication to sue if scar in the uterus because can’t control the  Anterior placenta – cannot get our hand because touching the placenta and uptake of the medication/ not turn off like Pitocin can at risk for placenta abruption -High Risk is Cytotec/Misoprostol- it can be inserted in the cervix (risk of  Obesity uterine tachysystole) or taken by mouth. This medication cannot be turned off. It is completely contraindicated in a woman with a scar on her uterus Fetal monitoring during the procedure due to the chance of massive contraction, which could rupture the uterus *Need to have fetal monitoring the whole time and have not hurt the O2 supply to the *not causing too many contractions and not causing utero placental baby. insufficiency 1) move the baby- version 2)Make sure the heart rate is okay and document the heart rate To increase contractions or strength of contractions:  make sure not hurt the baby, the placenta and the cord  AROM- artificial rupture of membranes- risk for prolapsed cord if the 3)if it successful, they would like to do an induction. If it is not successful, need c- fetus is in a high station such as -2, -3- or in transverse or breech position section to follow  Oxytocin/Pitocin  may have to stay in the hospital at least 4 hrs post procedure if not -must be on a pump- very dangerous medication. It is titrated up by the followed by induction or c-section -> so no decrease in fetal heart tones or nurse to have contractions occurring every 3-5 minutes lasting 45-90 uteroplacental insufficiency or issue with the uterus ( seconds. -uteroplacental insufficiency refers to a condition in pregnancy where the -Uteroplacental insufficiency can occur it too much is given. This can placenta is not functioning properly, leading to inadequate delivery of fatigue the uterus and create a risk for pp hemorrhage. oxygen and nutrients from the mother to the fetus through the placenta) -if have utero placental insufficiency or uterine tachy systole or long contraction-> turn of pitocin/ oxytocin =Inductions- Narration 4 min 38 sec When is the appropriate time for a medical versus an elective induction? =Operative Vaginal Birth  Medical induction- schedules anytime the mother’s or fetus life is in jeopardy -Use of forceps and vacuum: risk to mom, risk to fetus, and when to activate the  Assess postpartum -> need ice pack chain of command. Assessment of mom with use of forceps- vaginal lacerations/ *  Need through assessment of the baby bleeding/hematoma- fetal- facial bruising or facial nerve damage *after two pulls of the vacuum, the chain of command must be initiated for patient safety. =Know Cesarean- elective versus repeat- who can have a trial of labor after Cesarean (TOLAC) with a vaginal birth after Cesarean (VBAC)- narration 1 min Use of forceps and vacuum 18 sec Risk to mom with forceps:  Risk for laceration – blindly put it in and lacerate and puncture the vagina C-section Risk to fetus with forceps: – indicated or could be scheduled  Risk for bruising/ hematoma: fetal- facial bruising or facial nerve damage -repeat or emergent (issue like herpetic outbreak or prolong rupture membranes) or Vacuum emergency (maternal seizures, uteroplacental insufficiency/no O2, thermal Risk to mom –laceration bradycardia) Risk to fetus- get a laceration around where the round portion used in the head and get a hickey or bruising or broken vessels where vacuum is applied Repeat C-section: Indicates that the mother has already had a cesarean in a -broken vessels lead to elevated bilirubin issues previous pregnancy and is having another one. It could be medically necessary or chosen based on the mother's and doctor’s preference. *after two pulls of the vacuum, the chain of command must be initiated for patient Elective C-section: Refers to a cesarean delivery that is chosen in advance without safety. urgent medical indications (could be a first-time C-section or not necessarily linked  call the charge nurse and tell 2 pulls to prior C-sections).  move forward that baby is not coming out Who can have a trial of labor after Cesarean (TOLAC) with a vaginal birth after Assessment of mom and baby Cesarean (VBAC)?  assess labia – as laceration/ hematoma * Trial of Labor After Cesarean (TOLAC) refers to the process of attempting a -may need to put ice vaginal birth after a previous cesarean section (C-section). If successful, this results  Assess the baby – FM in a Vaginal Birth After Cesarean (VBAC). Goal: The aim of TOLAC is to achieve a vaginal delivery while closely monitoring =Precipitous Delivery-Narration 1 min 41 sec the mother and baby for signs of complications that may necessitate an emergency Maternal risks- risk for injury to the vaginal canal and perineum, Fetal risks- head C-section. trauma/bruising, High risk for Postpartum Hemorrhage due to the hard work of the  as long as they have horizontal low transverse incision in their uterus uterus too fast. they are eligible.  Not eligible are vertical uterine incision. When woman goes into labor and has the baby within 3 hrs/ a labor less than 3 hrs -> dangerous because the uterus work really hard and fast in which the tissues do not have time to stretch out and the baby push out quickly and cause some =Meconium-stained fluid damage to the baby -by product of Gi formation by the fetus ileum and colon -dark, black sticky and sterile Maternal risks: -if the baby becomes hypoxic and become flaccid -> release the meconium stained  risk of laceration in vagina canal and perineum (1st, 2nd 3rd, 4th degree fluid into meconium plug-> amniotic fluid laceration) -the baby can drink and urinates, and huge problem when they inhales the amniotic  High risk for postpartum hemorrhage- due to the hard work of the uterus fluid -physiology: don’t want meconium-stained fluid, the baby could have hypoxic too fast. Uterus and tired and fatigue and does like to contract episode in utero Signs and symptoms: Fetal risks:  Meconium stain- green, brown and thick or dark yellow in color  Head trauma/ bruising Maternal assessment: Interventions:  COAT – Color, odor, amount, and time  Call the NICU- have the mom ready for deliver and need to have  Do assessments interventions when meconium plug is on the bronchus  Fetal monitoring and entire time of the delivery  Postdates pregnancy – many times have this, because the placenta is not functioning because the period of hypoxia.  -In postdates preg, could have a baby that is loss weight (not getting enough nutrition as like), the skin sloughing and peeling, trouble with glucose at deliver (small baby). =Preterm labor- Before 37 weeks Risk factors: Predisposing factors include medical conditions (diabetes, cardiac disease, preeclampsia, and placenta previa), infections (UTI, STIs), overdistention of uterus (multifetal gestation, hydramnios), substance abuse, high levels of personal stress. Diagnosis: Need labs: Fetal fibronectin, CBC, UA, and cervical cultures, need BPP Frequent contractions with cervical changes occurring Menstrual-like cramps; low, dull backache; and pelvic pressure Urinary frequency Increase or change in vaginal discharge ROM-rupture of membranes Preterm Labor Treatment Teach symptoms of preterm labor early in prenatal care. Educate on self-management of symptoms and when to notify obstetric provider. =Postterm Pregnancy Select women may be managed at home with activity restriction, pelvic rest (avoidance of sexual activity), oral medications, adequate hydration. Ppt slide: Teach about side effects and warning signs of medications. Post Dates>40 weeks Many women will be admitted for observation, bed rest, and management Bishop score- The higher the number, the more favorable the induction will result in with tocolytics (i.e., indomethacin, nifedipine, magnesium sulfate, a vaginal delivery. Brethine/terbutaline) to arrest labor after uterine contractions and cervical Low bishop score- bulb to dilate cervix, misoprostil, change has occurred. High bishop score- oxytocin to cause contractions and break water Follow protocols for continuous uterine and FHR monitoring, assessment of May have a big baby if the placenta is working well- be ready for a shoulder maternal vital signs. dystocia Glucocorticoids (betamethasone) may be administered to women between May have a small baby if the placenta is not working well- hypoxic, floppy, and 24 and 34 weeks’ gestation to accelerate fetal lung maturity (stimulates fetal can have cold stress surfactant production). Typically two IM injections are given to the mother, 24 hours a part. Magnesium Sulfate is given as a cerebral neuro protectant for Bishop score is a clinical assessment tool used to evaluate the readiness of the the fetus and to relax the uterus. cervix for labor. It helps healthcare providers determine the likelihood of successful If labor continues to progress despite interventions, the obstetric provider vaginal delivery and can guide decisions regarding induction of labor. should be notified immediately, and the nurse should prepare for emergent delivery of a preterm infant. Personnel who are skilled at neonatal resuscitation should be present at the birth. =Placental Abruption, know physiology, signs, and symptoms, know nursing maternal and fetal nursing interventions Placental abruption -when the placenta detaches from the wall of the uterus -the baby is bleeding out of the placenta and mom is bleeding out of the uterus where placenta was attach Signs and symptoms:  Extreme abdominal pain- extreme abdominal pain even with the presence of an epidural  Board like rigid abdomen- Uterus tight because is filled with blood  Fetal heart decrease- as soon as she starts abruption. -May have tiny abruption and may not affect fetal heart tones. -If complete abruptions, emergent c-section Interventions: STAT C-section to get the baby out (serious emergency -as mom and  Abnormal uterine measurement- greater measurement in gestational age baby bleed out) especially at term  2 18 gauge IV’s for fluid  Ultrasound that shows greater than 4000 grams/ 8lb-  NICU-  Glucose urea- glucose in the urine for gestational diabetic  Need Blood product Symptoms: pressure unable to get the baby out  Check Vitals Maternal history risk factors:  Gestational diabetes = Placenta Previa, know physiology, signs, and symptoms; know Maternal and  Maternal overnutrition – gain too much weight fetal nursing interventions. Narration 1 min 41 sec  Or normal size baby and marginal pelvis- shoulder may be too big Medical SIGN the event is occurring:  Turtle sign- - Shoulders get stuck and the fetus pulls his/her head back in What not to do:  Do not use traction (pulling the baby out during the delivery process). Traction can cause spinal problems, damage and severe spinal nerves which results to paralysis. NEVER PULL THE HEAD! Interventions: Provider: Episiotomy – so more room to go down Nurse(RN): McRoberts position – pull the legs back and elevate the pubic bone -> decreases difficult angle Nurse(RN): Suprapubic pressure – pushing the shoulder doen so it can clear the pubic bone. NEVER EVER GIVE FUNDAL PRESSURE!  Fundal pressure may sometimes be used in cases where labor isn't progressing, or the baby needs additional help descending through the birth canal. However, it is not widely recommended because there are concerns about safety, including risks of uterine rupture, fetal injury, or maternal Placenta Previa trauma. Partial placenta previa- half covering the cervix Total placenta previa- Provider: Wood’s maneuver- cork screw the baby out Signs:  Provider put the finger inside and turn the baby 90 degrees so the babys  painless vaginal bleeding shoulder is not trap and glide the baby Maternal assessment:  No vaginal intercourse or nothing in the vagina Implications for the mom: 3rd or 4th degree lacerations/ hematoma  Start contractions with bleeding- needs to go to the hospital Fetus risk: clavicle injury and difficuluty moving the arm – don’t want permanent Fetal nursing interventions: paralysis hematoma) and fetus  Need fetal monitoring- dilation of the cervix could cause an abruption results c-section. Goal: stop cervical dilation and if cannot do c-section Interventions:  2- 18 gauge IVs  Resuscitation – if an abruption happens because dilation of the cervix. Baby could lose blood from the placenta which is dangerous =Shoulder Dystocia- Narration 4 min 57 sec Shoulder Dystocia-Emergency The head is out but the shoulders are stuck under the pubic bone The fetal brain is deoxygenating because the carotids are compressed Ppt slide: Shoulder Dystocia-Emergency What physical signs and symptoms and risk factors? The head is out but the shoulders are stuck under the pubic bone Risk factor: big baby The fetal brain is deoxygenating because the carotids are compressed Physical signs: Dx: Turtle sign- Shoulders get stuck and the fetus pulls his/her head back in Interventions: 3) Apply firm pressure to the presenting part(usually head)- to take the Provider: Episiotomy pressure off the cord Nurse: McRoberts position Place the woman into the extreme Trendelenburg or lateral recumbent position (see Nurse: Suprapubic pressure Fig. 32.18C) or a knee-chest position. Provider: Wood’s maneuver- cork screw the baby out 4) Patient head down or Trendelenburg -> – to let reverse gravity to push the baby back to fundus 5) Call for someone for help. Talk to patient and explain the situation =Prolapsed cord- signs and symptoms, know nursing maternal and fetal 6) Ride the bed to the OR. Continuously hold the presenting part until the nursing interventions- Narration 5 minutes surgeon makes the incision and takes the baby out 7) Once the baby is out, then the nurse can remove her hand away Prolapsed cord If the cord is protruding from the vagina, wrap loosely in a sterile towel saturated -problem when the baby malpositioned or the baby is very high in the pelvis and the with warm sterile normal saline solution. Do not attempt to replace the cord into the water breaks and allows the cord to present before the baby presents cervix. - is an obstetric emergency where the umbilical cord slips into the birth canal ahead Administer oxygen to the woman by nonrebreather mask at 8–10 L/min until of the baby or alongside the presenting part (such as the baby's head or buttocks). birth is accomplished. Start IV fluids or increase existing flow rate. First thing to do when water breaks: listen to fetal heart tones -> don’t want any Continue to monitor fetal heart rate continuously by internal fetal scalp electrode changes, no variable decelerations. if possible. - If variable deceleration, the cord is being compressed and causing the heart rate to Explain to woman and support person what is happening and the way it is being go down. managed. Ride the bed to the OR - If variable decelerations appear, suspicion that there is a prolapse cord. Prepare for immediate vaginal birth if cervix is fully dilated or cesarean birth if it is Prolapsed cord- Emergency- ppt not. Water breaks and the cord comes out before the baby- it gets compressed and deoxygenates the neonate- VARIABLES WITH ROM Nursing interventions: Risks Factors: 1) listen to fetal heart tones  Baby in a high station (-3 or-4 station), 2)verify the cord. Once the found the cord. Press and elevate the presenting part  breech, head not engaged/ 3)place in the patient in Trendelenburg  abnormal position(high in the pelvis) and cord compression 4) call for help 5) STAT c-section Call for assistance. Do not leave the woman alone. Have someone notify the interprofessional health care team immediately. Team members include the obstetric care provider, anesthesia care provider, extra nurses, surgical technician, and neonatal care professionals. Glove the examining hand quickly and insert two fingers into the vagina to the cervix. With one finger on either side of the cord or both fingers to one side, exert upward pressure against the presenting part to relieve compression of the cord. Do not move your hand. Another person may place a rolled towel under the woman’s right or left hip. 1) Put gloves 2) Verify the presenting cord  if she is still pregnant- do all the uteroplacental insufficiency interventions 1)reposition 2)give O2 3)fluid bolus 4) Arrows indicate direction of pressure against presenting part to relieve compression of prolapsed umbilical cord. Pressure exerted by the examiner's fingers in A, vertex presentation, and B, breech presentation. C, Gravity relieves pressure when woman is in modified Sims' position with hips elevated as high as possible with pillows. D, Knee-chest position. = Uterine Rupture- What happens to the contractions, what are the patient symptoms? What are the nursing interventions? =How do you prevent a uterine inversion? What are the medical interventions once it occurs. =Amniotic Fluid Embolism- Narration 2 min 25 sec physiology, signs and symptoms, and nursing interventions- if she is still Uterine inversion- is a rare but serious childbirth complication where the uterus turns pregnant- do all the uteroplacental insufficiency interventions as well inside out, usually following the delivery of the baby and placenta. It occurs when the uterus collapses and the top part (the fundus) moves downward through the cervix Physiology: amniotic fluid (with vernix)gets into the maternal system and into or beyond the vaginal canal. This condition can lead to severe bleeding -Amniotic fluid (with vernix ) get pushed into the maternal veins of the uterus usually (hemorrhage) and shock, requiring immediate medical attention. during delivery of the placenta. It can go to the maternal inferior vena cava and can go to the right atrium. Once get through the lungs, it cause anaphylaxis of the lungs To prevent: and cannot breathe/ can stop breathing. -When evaluating the uterus, you have to support the bottom portion so that the top -> if go past the lungs, it could go to the left heart and left ventricle and go to the brain hand doesn’t push through the uterus -> the ligaments are all loose because uterus is and cause stroke stretch out *Need to have one hand on the bottom of the abdomen and one hand on the top -Causes immediate respiratory collapse due to allergic reaction -Pt may have respiratory failure, stoke, or Cardiac failure. Medical interventions: Interventions:  Tocolytics- to softens the uterus to push it back in  Raise the HOB  Pitocin/ oxytocin- do after tocolytics to clamp down the uterus  Call a code, If it doesn’t go back in -> surgical interventions needed  ambu bag,  give O2, It occurs:  Start CPR if necessary  when inappropriate assessment or lack of support of the uterus  excessive traction on the placenta – 3rd stage the provider is pulling the cord, *emergency c-section if the baby is still inside and fetal monitoring needed and the placenta is well adhered it can cause the uterus to invert