Maternal Child: Intrapartum (Exam 2)

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1.

1st Degree Vaginal Lacerations: - involves the perineal skin

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and vaginal mucosa

2.

1st Stage: Active Phase: (Labor Song)

membrane, perineal muscle and anal sphincter

14.

*4-7cm dilated (1cm per hr)

-incr. anxiety
-incr. discomfort
-unwillingness to be left alone
-Ctxs mod-severe, freq 3-5 min, 30-60 sec duration
3.

4.

1st Stage of Labor: onset of reg contractions to complete

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3rd Stage of Labor: birth of the fetus to expulsion of the

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4th Degree Vaginal Lacerations: extends through rectal

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4th Stage Focused Assessments: -VS

placenta (max 30 minutes)

mucosa
-Orthostatic Hypotension
-Fundus
-Lochia
-Bladder / Elimination
-Perineum
-Breasts
-Lower extremities
-Homan's sign if needed
-Pain
-Bonding

dilation of the cervix

-latent phase
-active phase
-transition phase
5.

1st Stage: Transition Phase: (No Epid)

8cm to complete dilation
-Changed behavior
-Extreme irritability, don't touch although desirous of help
-Ctxs severe, freq 2 min, 60-90 sec duration

6.

2nd Degree Vaginal Lacerations: involves the perineal skin,

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vaginal mucosa and perineal muscles

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2nd Stage: Descent Phase: desire to push "Ferfusons Reflex"

8.

2nd Stage: Latent Phase: laboring down "rest"

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2nd Stage: Nursing Care: -Vitals q 15 min

-FHR q 5 - 15 min
-Palpate bladder for distension
-Monitor amniotic fluid for color, consistency
-Continue comfort measures
-Never leave patient unattended
-Instruct on bearing down efforts
-Call for DR table: gown, gloves, bulb syringe, cord clamp and
scissors
-Perform perineal cleansing
-Gentle counterpressure as needed
-Record birth time / Note nuchal cord

10.

2nd Stage of Labor: complete dilation of the cervix to the birth

of the fetus (max 2-3 hours)
-latent phase
-descent phase
-transition phase

11.

12.

2nd Stage: Transition Phase: head is on perineum

4th Stage Focused Assessments Frequency: -q15min x4

-then q30min until stable

19.

4th Stage of Labor: expulsion of the placenta to 1 - 4 hours

postpartum

20.

4th Stage of Labor: Physical Recovery: begins following

expulsion of placenta to 1-4hr after birth

21.

4th Stage Vitals: -BP < 140/90

-Pulse (50 - 100)
-Respirations < 24
-Temperature < 100.4 F

22.

The 5 P's Affecting the Process of Labor: 1) Passenger

(fetus)
2) Passageway (pelvis)
3) Power (contractions/pushing)
4) Position of the mother
5) Psyche (level of fear, anxiety)

23.

Additional Assessments: -Immediately after ROM

-Before and after medication
-Before and after any procedure

24.

Amniotic Fluid: Assessment Tests: -Nitrazine

-Ferning

2nd Stage of Labor "Pushing Phase": Begins with complete

dilation and ends with the birth of the newborn
-Latent - "laboring down"
-Active - "Ferguson's Reflex"
-Transition- process of crowning

3rd Stage Nursing Care: -Check BP, pulse pre & post
separation
-Following complete expulsion - Increase Pitocin flow rate
-Assess blood loss
-Fundal assessment
-Inspect placenta &membranes
-Check 3 vessel cord/obtain cord blood
-Note repair of episiotomy & vaginal tears

1st Stage: Latent Phase: Onset of true labor or ROM (Labor

Dance)
*0-3cm dilated
-Mildly anxious, conversant
-Able to continue ADLs
-Mild ctxs, freq 10-30 min, 15-20 sec duration, later freq 5-7
min, 30-40 sec

3rd Degree Vaginal Lacerations: involves the skin, mucus

25.

Amniotic Fluid: Color Assessment: -normal

-meconium
-bloody

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Amniotic Membranes: Assessment: 1) SROM spontaneous

2) AROM - artificially induced with amniohook

27.

APGAR: A SCORING SYSTEM FOR ASSESSING THE STATUS

OF A NEWBORN THAT ASSIGNS A NUMBER VALUE TO
EACH OF THE 5 AREAS OF ASSESSMENT (1) APPEARANCE
(2) PULSE (3) GRIMACE (4) ACTIVITY (5) RESPIRATIONS

28.

AROM increases risk for: -Frequent vaginal exams

39.

Effacement: shortening of the cervix, measured from 0 - 100%

40.

Engagement: when the lowermost portion of the head is passed

the ischial spines, the BPD is in the pelvic inlet

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dilated
- Inadequate secondary powers
- Anesthesia/analgesia
- Position of fetus
- Primipara
- LGA fetus

-Prolonged labor > 16 hours

29.

Arrest of Progress: *Prolonged latent: G1 > 20 hrs, G3 > 14

hrs
*Arrest of labor: no cervical change in > 2 hrs or no descent in >
1 hour

30.

Bearing Down Efforts: -involuntary response to Ferguson

Reflex; maternal exertion of downward pressure by contracting
abd muscles & relaxing pelvic floor muscles
-deep cleansing breath before and after contractions
-open glottis pushing helps to maintain oxygen levels and
prevent Valsalva maneuver
-should never hold breath >5 sec

31.

Birth: -Extension in OA position

-Check for nuchal cord
-Restitution and Ext.
-Rotation Bulb suction of mouth and nose
-Hands over ears
-Exert downward pressure

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43.

44.

Breastfeeding: -Encourage immediate breastfeeding while

mother and baby are excited and alert as both will soon want to
sleep
-Thermoregulation- skin-to-skin contact
-Release of oxytocin: stimulates milk ejection reflex; contracts
uterus and reduces lochia

36.

45.

37.

Comfort Measures/Coaching: -Ambulation

-Position changes q 30 - 60 minutes
-Diversional activities: music, talking, imagery, breathing
techniques (do what works for pt)
-Massage, counterpressure, efflurage
-Hydrotherapy: shower, hot/cold packs
-Perineal & Mouth care- keep pads dry, ice chips
-Void q 2 hours, catheterize if necessary
-Enema in early labor if constipated
-Malposition: squat or hands/knees

38.

Dilation: opening of the os, measured from closed to 10cm

FHR Assessment Performance: -Obtain 10 minute strip

-Must determine baseline FHR first
-Assess for variability
-Assess for periodic patterns (accels, decels)

46.

Following membrane rupture, assess: -maternal temp

47.

High Uterine Fundus with displacement to one side: -full

-monitor for fetal tachycardia

bladder
-bedpan or catheter
48.

Hyperstimulation of Contractions: -intensity > 80mmHg

per IUPC
OR
-resting tone > 20mmHg, Duration > 90 sec or < 2 min apart

49.

Hyperventilation: Results in respiratory alkalosis due to

blowing off too much CO2

Cardinal Movements: -Engagement

-Descent
-Flexion
-Internal Rotation to OA
-Extension
-Restitution
-External Rotation to align w/ shoulders

Fetal Distress: -bradycardia

-tachycardia
-absent or minimal short term variability
-late decels
-severe variables

-Fundal massage, empty bladder

35.

Ferning: examination of vaginal fluid under the microscope

after air-drying

Bloody Amniotic Fluid: abruption

Boggy Uterus: -Uterine atony

False Labor: -Reg contractions <1hr, cannot time them,

discontinue c walking
-No lower back pain, discomfort in abdomen
-No cervical change

Birthing Positions: -lithotomy

-semirecumbent
-lateral recumbent
-squatting

Factors Prolonging Second Stage: -Pushing prior to 10cm

50.

Hyperventilation Nursing Interventions: Instruct patient

to deep breathe into cupped hands in order to rebreathe CO2

51.

Intense Perineal Pain: -Hematoma, vaginal wall or perineum

-Ice pack, notify MD, monitor for hypovolemia

52.

Labor Progress: Active Phase: 3-6hr

Primip avg 1.2cm/hr; Multip avg 1.5cm/hr

53.

Labor Progress: Latent Phase: 6-8hr

Primip <20hr, Multip <14hr

54.

Labor Progress: Transition Phase: 20-40 minutes

55.

Length of Placental/Third Phase: 10-30minutes

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Length of Pushing Phase: varies (normal is 1-2hours)

Primipara - 1 hour
Multipara - 15 minutes

57.

Leopold's Maneuvers: 1) What is in the fundus- determine

69.

presenting part
2) Where is the back v. small parts- lie, locate PMI for FHR
3) What is in the pelvis- presenting part, position, engaged or
floating
4) Where is the cephalic prominence- attitude
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60.

-Loss of mucus plug, increased vaginal D/C

-Bloody show
-Low backache
-Braxton Hicks to progressive contractions
-Cervical softening, slight effacement
-GI changes: N/V, diarrhea
-Burst of energy, "nesting instinct"
-may have ruptured membranes
-wt loss

Maternal Positions: -walking

-sitting/leaning
-trailor sitting
-semirecumbent
-hands and knees
-standing
-squatting
-kneeling and leaning forward with support

70.

Meconium in Amniotic Fluid: green-brown, thick indicates

71.

Passenger Attitude: parts in relation to each other

fetal BM r/t fetal stress, increased risk of RDS and infection

72.

Passenger Lie: long axis of mother to long axis of fetus

Nitrazine: pH paper turns deep blue with vaginal pH of 7.5

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Passenger Position: relation of presenting part of the pelvis

Normal Amniotic Fluid: straw-colored, distinct smell w/o

odor, vernix

62.

Normal Fetal HR: 110-160

63.

Normal Maternal BP during Labor: <140/90

64.

Normal Maternal Pulse during Labor: <100bpm

65.

Normal Maternal Temp during Labor: <100.4F

*slight elevation often due to dehydration and incr. metabolism
of labor

66.

67.

Nursing Assessment during 1st Stage: Latent: VS: q3060min

Temp: q4hr
FHS/CTXs: q30min
Vaginal D/C: q30-60min
Bladder: q2hr
Vaginal Exam: None
Care: Home Care

68.

*Station: presenting part in relation to ischial spines

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Passenger Presentation:: presenting part

75.

Perineal Trauma: Episiotomy: -Perineal incision made to

enlarge vaginal outlet
-Performed to prevent uncontrolled, uneven tear or laceration

76.

Nursing Assessment during 1st Stage: Transition: VS:

q30min
Temp: q4hr
ROM: q1hr
FHR/CTXs: q15min
Vaginal D/C: q15min
Bladder: q2hr
Vaginal Exam: PRN for progress
Care: Prepare for birth

Placental Separation: Upward displacement of the uterus as

the placenta is released into the lower uterine segment

77.

Primary Powers: 1) Effacement

2) Dilation
3) Station

Nursing Assessment during 1st Stage: Active: VS: q30min

Temp: q4hr
ROM: q1h
FHR/CTXs: q15-30min
Vaginal D/C: q30min
Bladder: q2h
Vaginal Exam: PRN for progress
Care: Labor Coaching

Passenger: -presentation
-lie
-attitude
-position

(Vagina is acidic pH of 4.5 and amniotic fluid is alkaline.

61.

Onset of Labor: -Lightening

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Primary Risk of Placental/Third Phase of Labor:

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Problems in 4th Stage: -tachycardia

Hemorrhage
-boggy uterus
-high uterine fundus with displacement to once side
-hemorrhage (saturated pad in <1hr)
-intense perineal pain
80.

Psyche Factors: -Parity

-Phase of labor
-Fear / anxiety / catecholamines
-Pain level
-Pain medicine

81.

Secondary Powers: bearing down effort

82.

___________ shoulder is always birthed first.: Anterior

83.

Signs of Labor Complications: -arrest of progress

-hyperstimulation of contractions
-fetal distress
-meconium/foul smelling amniotic fluid
-persistent bright red bleeding
-maternal fever- prolonged ROM, too many VEs

84.

Signs of Progress:: -incr. bloody show

-bulding of perineum and anus
-presenting part visible (if primip, call provider to DR)

85.

Sinciput Presentation: fetal head is partially flexed,

occipitomental diameter presented in maternal pelvis

86.

S/S of Placental Separation: Sudden trickle of blood

-Lengthening of umbilical cord
-Contraction of the uterus (globular shape)
-Mother "full" feeling, desire to push

87.

Station: -Relation of the presenting part to the maternal ischial spines

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SX of Hyperventilation: -dizziness

-A measure of the degree of descent

-tingling of extr
-stiff mouth
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Tachycardia: -Hypovolemia, excessive blood loss

-Attempt to find cause
-Most common uterine atony, hematoma, high lac, retained POCs

90.

Third Stage of Labor: Placental Phase: -Begins after the birth of the baby and ends with the expulsion of the placenta

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True Labor: -Stronger, longer lasting, closer contractions that increase with walking
-Pain in lower back radiates to abdomen
-Progressive cervical change

92.

Uterine Activity: Assessment: Palpates with fingertips at the fundus

-Mild: easy to indent
-Moderate: difficult to indent
-Strong: rigid, board-like

93.

Uterine Activity Assessment: Determine: -frequency

-intensity
-duration of resting tone

94.

Vertex Presentation: The fetal head is fully flexed. This is the most favorable cephalic variation because the smallest possible diameter of
the head enters the pelvis. It occurs in about 96% of births