NURS 307 ~ Exam 2.pdf

,Pelvic shapes - gynecoid= female pelvis Platypelloid Anthropoid Android= male pelvis Functions of contractions - - Voluntary (actively pushing) & involuntary(contractions) use of intra abdominal pressure when a women pushes Rhythmic, intermittent Can be altered with deflation, pain medication,...

,Pelvic shapes - gynecoid= female pelvis Platypelloid Anthropoid Android= male pelvis Functions of contractions - - Voluntary (actively pushing) & involuntary(contractions) use of intra abdominal pressure when a women pushes Rhythmic, intermittent Can be altered with deflation, pain medication, illness, anxiety Effacement (softness of the cervix) - 2cm thick cervix= 0% effaced - 1cm= 50% effaced - Paper thin= 100% effaced Rest period is to allow blood to return to fetus and relaxation for mother Intra-abdominal pressure- PUSHING, needs to be coordinated Premonitory signs of labor Cervical changes: - softening of the cervix and possible dilation can occur as fetal part descends in the pelvis, effacement (thickness of cervix) and dilation are only possible once the cervix is soft Lightening: - When the fetal presenting part descends into the pelvis, shape of abdomen changes, baby “dropped” *using the fundal assessment wont be accurate at this point Nesting: - *extra energy*, typically 24-48 hours before labor, can be energy focused on getting ready for baby Bloody show: - Mucous plug that was filling the cervical canal is expelled due to increased pressure and softening of the cervix, prevents bacteria from coming in and will when body is preparing for labor Braxton hicks: Becomes stronger and more frequent, helps move the cervix from a posterior position to an anterior position, improves with walking, change in position, water, rest, voiding, and eating. *felt more in the upper abdomen* *does not get stronger with time* SROM: - Prelabor rupture of membranes, water breaks prior to onset labor, once ruptured we have no barrier from infection, must go to the hospital, note *color, odor, amount, time* Passenger Fetal attitude: - Amount of flexion the baby has, flexed is the typical and most favorable - When labor begins, we want all the joints flexed with rounded back,chin on chest, thighs on abdomen, legs flexed at the knees - Non-flexed positions or atypical attitudes can lead to increased diameters that the baby will have to pass through the pelvis - WE WANT AN OA position!! Fetal lie: - Relationship of the fetal spine to the maternal spine - longitudinal - only possible lie for vaginal delivery Fetal position: - The presenting part of the fetus to a designated point of the maternal pelvis - Identify the presenting part - The presenting part we want is: occipital anterior Fetal station: - Relationship of the presenting part with the maternal ischial spines - Considered engaged when fetus is at 0 station - Floating- means the presenting part above the pelvic inlet and is freely movable: ABOVE ISCHIAL SPINE True v. False labor True labor: - Regular, become closer together, usually 4-6 minutes apart, lasting 30-60 seconds - Become stronger with time, vaginal pressure felt - Starts in the back and radiates around toward the front of the abdomen - Contractions continues no matter what positional changes is made False labor: - Irregular, not occurring close together - Frequently weak not getting stronger with time or alternating - Usually felt in the front of the of the abdomen - Contractions may stop or slow down with walking or making a position change Understand vaginal exams, and the meaning behind the different measurements - Way to assess labor progress Tells you dilation, effacement (thickness of cervix), station (relation to ischial spine), presentation, position (LOA, OT,) attitude, membrane status (intact, bulging or ruptured) Dilation, effacement, station Labor Management Category 1,2 or 3 tracings Including reading fetal monitor tracings, and interventions based on the tracings Stage 1 - Normal - Predictive of normal acid-base balance, - Baseline FHR 110-160 - Moderate baseline variability - Present or absent accelerations - Present or absent decelerations - No late or variable decelerations - Safe to monitor fetus intermittently - REQUIRES NO INTERVENTIONS Stage 2 Interventions: - Intermediate watch closer - Not predictive of abnormal fetus acid-base status - DOES REQUIRE EVALUATION AND CONTINUED SURVEILLANCE - Can include: - Fetal tachycardia - Fetal bradycardia (not accompanied with absent baseline variability) - Absent baseline variability (not accompanied by decelerations) - Minimal or marked variability - Recurrent late deceleration with moderate variability - Recurrent variable deceleration accompanied by minimal or moderate baseline variability - Prolonged decelerations greater than 2 mins but less than 10 minutes Category 3- abnormal Predictive of abnormal fetus acid-base status & requires intervention Interventions: - notify MD - Dc Pitocin - Change position (L or right lateral, knee chest, hands & knees - Oxygen - Increase IV fluids Emergency C-section If pattern not better in 30 minutes need an emergent surgical delivery Includes: - Fetal bradycardia - Recurrent late decelerations - Recurrent variable decelerations w/ declining or absent variability - Sinusoidal pattern VEAL CHOP: V- variable E- early A- Acceleration L- Late C- cord compression H- Head compression O- Okay P- Placental insufficiency Maternal and Fetal physiologic responses to labor *knowing the difference between what is normal for a laboring mother is important* Maternal: - Increased heart rate, cardiac output, blood pressure - Blood pressure should drop when baby is delivered - Increased WBC - Increased respiratory rate and oxygen consumption - Decreased gastric emptying and gastric pH - Slight temperature elevation - Muscle aches/ cramps - Increased basal metabolic rate - Decreased blood glucose levels Fetal: - Periodic FHR accelerations and slight decelerations - Decrease in circulation and perfusion - Increase in arterial carbon dioxide pressure - Decrease in fetal breathing movements - Decrease in fetal oxygen pressure; decrease in partial pressure of oxygen Understand the differences between the stages of labor! First stage: - LONGEST STAGE - From 0-10cm - Latent: - 0-4/6 cm dilated - Contractions Q5-10 minutes lasting 30-35 seconds, mild - Active: - 6-10 cm - Contractions Q2-5 minutes, lasting 45-60 seconds, moderate - Transitional: - May not be present with pain medication - 8-10cm - Faster progression - Feels EVERYTHING Second stage: - From complete dilation until birth of baby*** - Laten & active - Baby is moving through birth canal - Contractions are Q2-3 minutes lasting 60-90 seconds - Maternal urge to push when fetal head has contract with pelvic floor - There's an active pushing and a latent phase where we are waiting for the baby to come down the Third stage: - Begins at the birth of the newborn and ends at the separation and birth of the placenta*** - Placental separation- uterus continues to contact after birth of newborn, causing placenta to pull away from uterine wall Fourth stage: - Begins after the delivery of the placenta*** - Beginning of postpartum period - VS, lochia are monitored at least Q15 minutes for the first 1-2 hours after birth - Primary focus is to monitor for hemorrhage, bladder, distension, and venous thrombosis Obstetric emergencies (what are they, what places a mother or fetus at high risk for them) - Uterine rupture: - Tearing of the uterus at the site of a previous scar into the abdominal cavity, - S/S- sudden fetal bradycardia, acute and continuous abdominal pain, vaginal bleeding, hematuria, loss of fetal station (MOST COMMON, BABY GOES UP), hypovolemic shock for both mother and fetus - Placental Abruption: - Placenta detaches - Partial separation (concealed hemorrhage), partial separation (apparent hemorrhage), Complete separation (concealed hemorrhage) - Placenta previa: - Placenta is partially or fully covering the internal os of the cervix - Results in spontaneous placental separation and hemorrhage with cervical dilation - Most common: sudden painless bleeding - Umbilical cord prolapse: - What is it: go through cervix and goes around baby's neck - Increased risk factors: breech, premature (can’t block cervix), hydramnios (to much fluid) Pain management in labor- types, contraindications - Pharmacologic measures - - Regional analgesia/ anesthesia - Pain relief w/o loss of consciousness - Obstetrical referring to loss of pain sensation - Epidural: may increased second stage labor, doesn’t slow down labor but pushing won't be felt, complications; hypotension→ fetal distress, N/V, fever, pruritus (itching), respiratory depression - Combined spinal/ epidural: rapid onset but limited duration, injection of an anesthetic, agent (with or without opioids), in the subarachnoid space *spinal will be a longer needle* - Local infiltration - Pudendal block: provides long lasting perineal analgesia, pain refelif to lower bagina, must be given 15 minutes before painful procedure - Intrathecal (spinal) Systemic analgesia - Given PO, IM, IV - Need to avoid giving this before delivery d/t CNS depression in the newborn - Opioids: can cross the placenta, does not impact labor progression once active labor is reached, reversal agent is Narcan - Antiemetics: used in combo with an opioid to decrease nausea, vomiting, and lessen anxiety, no impact on labor progression, may decrease FHR variability and may cause newborn respiration depression - Benzodiazepines: velium/ versed (causes amnesia)/ ativan, all causes CNS depression in mother and newborn - Nonpharmacologic measures - Continuous labor support - Hydrotherapy - Ambulation - Maternal position changes - Attention focusing and imagery - Therapeutic touch and massage - Gate control theory - Application of heat and cold - Breathing techniques Signs of shock - Hypotension - Increase HR/pulse - Rapid respiration - Hnh increase - Peripheral cyanosis - Hypovolemia - Altered mental state - Decreased urine output - Weakness Types of dystocia, causes of dystocia - Definition: abnormal progression of labor - Can be issue with the powers, passenger, passageway - Failure to progress- includes arrest in dilation, failure to descend - Baby will be OP, eyes looking up and head facing mothers butt 10 P’s Factors affecting labor process 1.Passageway (birth canal) - Bony pelvis is important and won't change - Relaxin and estrogen work on the soft tissue and ligaments to allow more flexibility for the fetal descent - Most favorable is gynecoid (female pelvis) 2. Passenger (fetus and placenta) 3. Powers (contractions) 4. Position (Maternal) 5. Psychological response 6. Philosophy (low-tech/ high touch) 7. Partners (support) 8. Patience (natural timing) 9. Patient (client- childbirth knowledge base) 10. Pain Management (comfort measures) Dystocia- problems with power - - - - Precipitated labor - Labor that is complete in less than 3 hours - Can result in maternal injury- bc its working hard and can rupture, causing head trauma, hypoxica, hemorrhoid Arrest disorder: - No progression in cervical dilation in 2 hours - Things were going well, but then the cervix doesn’t change Hypertonic uterine dysfunction: - Uterus never fully relaxes between contractions - Contractions are not as effective or as coordinated - Too much tone Hypotonic uterine dysfunction - Contractions quality decreases, and fails to dilate & efface cervix - Contraction strength, and duration decreases - Risk for postpartum hemorrhage What is McRobert Maneuver - Lay flat on back push knee all the way back and push on abdomen to make the shoulder fit and baby can come out - Changing the angle of the pelvis Performing Leopld maneuvers - Trying to figure out the way the baby is positioned Feeling for the head, back flexed areas (arms, legs) Maneuver 1: what fetal part is at the fundus Maneuver 2: On which side of the mother is the fetal back Maneuver 3: What is the presenting part Maneuver 4: Is the fetal head flexed and engaged in the pelvis Which way is the fetus facing Analysis of the Amniotic fluid - Meconium stained d/t - Transient hypoxia: fetus has no oxygen - Prolonged pregnancy - Cord compression: decreased oxygen to baby - IUGR (Intrauterine growth restriction) - Diabetes melitus - HTN - Chorioamnionitis: infection of the placenta - Breech presenting Meconium aspiration syndrome: baby takes in their first breath and breathes in meconium