Intrapartum Period Unit Outcomes

 

1. Describe methods of determining gestational age

EDB and EDC stands for estimated date of birth and estimated date of confinement. This is used to figure out due date.

 

Nagele’s Rule is used to figure out baby’s due date.

First step is to figure out first day of last period. Add 7 days, subtract 3 months, and add 1 year.

Ex. Aug 20^th last menstrual cycle-add 7 to make Aug 27^th and subtract 3 months-May 27^th and then add 1 year-due date is May 27^th, 2008. This is accurate within +/- 2 weeks of date.

LMP-stands for first day of last period

 

What are different reasons that a due date may not be accurate?

the pill

endometriosis-irregular cycle

 

To have an US is becoming the norm-to have an US in the 1^st or 2^nd trimester. If US detects due date within 7 days then will keep calculated due date. But if US is not within 7 days, will go with US due date. The US will detect a more accurate gestational age of the fetus.

 

An US measures crown to rump length and measures head and femur length.

 

All fetus’s growth is the same up until 20 weeks, after 20 weeks, growth differs and depends on genetics.

 

 

1. Differentiate between gravida and para.

Gravity equals the total number of pregnancies a female has had. This includes abortions and miscarriages. Ex-Primigravida and multigravida.

 

Parity-This is the number of past viable births (20 weeks)

Way to remember what numbers stand for-

Florida Light and power

1. Florida=all full term births
2. Power=before 37 weeks-number of pre-term deliveries
3. And=Abortions/Miscarriages-losses-Before 20 weeks
4. Light=living children-outcome of pregnancies

 

Ex. Mother lost all 3 pregnancies and is pregnant now

G4

P0030

This info tells you the mother will have a lot of anxiety!

 

1. Describe how to perform Leopold’s maneuver.

This procedure is performed with the woman briefly lying on her back. These maneuvers help ID the number of fetuses, the presenting part, fetal lie, and fetal attitude;the degree of the presenting part’s descent into the pelvis, and the expected location of the PMI of the FHR on the woman’s ab.

 

Ask woman to empty bladder and position woman supine with towel rolled under hip-this offsets pressure off inf. vena cava.

1. ID fetal part that occupies the fundus-this maneuver ID’s fetal lie (longitudinal or transverse) and presentation (cephalic or breech)
2. Locate and palpate the smooth contour of fetal back and small parts-ID’s fetal presentation
3. determine which fetal part is presenting over inlet to pelvis. If head is presenting and not engaged-determine the attitude of the head-flexed or extended
4. If the cephalic prominence is found on the same side as the small parts, this means that the head must be flexed and the vertex is presenting. If cephalic prominence is on the same side as the back, this indicates that the presenting head is extended and the face is presenting.

 

1. Identify nursing responsibilities in caring for a woman who is Group B strep positive.

It is normal vaginal flora, but in the NB it can cause pneumonia. 10% of NB will get SIDS and die. Treat with antibiotics while in labor. The woman gets 2 doses-IV penicillin-4 hours apart. They will observe NB for longer if don’t get penicillin and mom is positive. Once you test positive for group B strep will always be positive.

 

1. ID nursing responsibilities in caring for a woman who is rubella negative.

All pregnant women should have a  rubella titre. If woman gets rubella in the first 3 weeks of pregnancy-she will miscarry. If she gets rubella within 3-8 weeks of pregnancy-baby will have cardiac/neurologic defects. If gets rubella within 8 weeks of pregnancy-structure of baby is formed but may cause IUGR.

 

This is a live vaccine that’s given-GIVE ONLY WHEN NOT PREGNANT!!

 

It is a minor disease for the mom but for fetus it is devastating.

 

If  mom is infected with Rubella then she is at more risk for choria amnionites-infection on the chorion and endometritis. Immune sytem is more vulnerable. Inflammation reaction in the amniotic membranes caused by bacteria

 

1. Define supine hypotension and nursing measures to prevent it’s occurance

In the supine pregnant woman at or near term, maternal hypotension; maternal hypotension is due to obstruction by the gravid uterus of the inferior vena cava with resulting decrease in venous return to the heart; foetal hypoxia is due to maternal hypotension and obstruction of the maternal aorta by the gravid uterus with resulting decrease in placental perfusion.

Signs and symptoms

Pallor

Dizziness, faintness, breathlessness

Tachycardia

Nausea

Clammy (damp, cool) skin;sweating

 

Nursing Interventions

Position woman on her side until her s+s subside and v.s. stabilize within normal limits.

 

1. Describe the four stages of labor and related maternal behavioral changes.

 

1. Review factors involved in the initial assessment of the woman in labor.

 

Assesment begins at the first contact with the woman, whether by telephone or in person. The nurse should ask the woman for a description of what she is experiencing that signals to her that she is in labor. These s+s can include recurrent or nonrecurrent pain, watery or blood stained fluid from the vagina, GI symptoms (vomiting, stomachache, diarrhea) emotional upheaval (anxiety) and sleep disturbances.

 

Asses btw true and false labor-regular/irregular contractions

This is the physiological process by which REGULARLY OCCURING  uterine contractions result in PROGRESSIVE effacement and dilation of the cervix.

If a woman is 2/100/0 and came back after walking and is still 2/100/0-she isnot in labor-maybe early labor. But since she is not progressing, it would not be considered active labor.

 

Contractions begin irregular and short and then become more regular and stringer-every 20 min.

Mother will get Braxton-Hicks contractions during last tri mester

Active labor is contractions every 2-3 minutes lasting 1 minute long.

Encourage mother in early labor to eat light food, resting and walking. Take shower and rest then walk. If mother is in true labor-with walking contractions will progress.

 

 

Woman should be informed that she will not be admitted is she is 3 cm or less dilated.

 

Assess time and onset of contractions and progress in terms of frequency, duration and intensity

Location and character of discomfort from contractions (e.g. back pain, suprapubic discomfort)

Persistence of contractions despite changes in maternal position and activity (walking or lying down)

Presence and character of vaginal discharge and show

Status of membranes-ROM?

Bloody show-mucousy/bloody

Admission asses-anything not found in prenatal record

Birthplan

 

1. ID beliefs/practices of selected cultures about labor and birth

Mexico-woman may be stoic about discomfort until second stage, then may request pain relief;fathers and female relatives may be present

China-stoic response to pain;fathers usually not present;side lying position preferred for labor and birth-because this position thought to reduce infant trauma.

Japan-natural childbirth methods-may labor in silent may eat during labor;father may be present

India-natural childbirth preferred;father is usually not present female relatives usually present.

Iran-father not present;female support

 

1. Describe the nursing responsibilities for a woman receiving analgesia or anesthesia during labor.

 

Marked hypotension, impaired placental perfusion, and an ineffective breathing pattern may occur during spinal anesthesia. Before induction of the spinal anesthetic (block), the woman’s fluid balance is assessed, and IV fluid usually is administered to decrease the potential for hypotension caused by sympathetic blockade (vasodilation with pooling of blood in the lower extremities decreases cardiac output).

 

After induction of the anesthetic maternal BP, pulse, resp and FHR and pattern must be checked and documented Q 5-10 min. If s+s of maternal hypotension or fetal distress develop, turn woman to lateral position or place pillow or wedge under hip to displace uterus

Maintain IV infusion or increase as needed.

Administer O2 by face mask at 10-12 L/min

Elevate woman’s legs

 

1. ID methods of labor induction.

Both chemical and mechanical methods are used to induce labor. IV oxytocin and amniotomy are the most common. Prostaglandins are used as well. Less common methods are stripping membranes, nipple stimulation, and acupuncture.

 

Chemical agents-

Prostaglandin E1 and E2 can be used before induction to “ripen” (soften and thin) the cervix

Oxytocin-a hormaone naturally produced by the posterior pituitary gland;it stimulates uterine contractions. It may be used either to induce labor or to augment a labor that is progressing slowly because of inadequate uterine contractions.

Mechanical methods-

Mechanical dilators ripen the cervix by stimulating the release of endogenous prostaglandins

Baloon catheters can be inserted into the cervical canal to ripen and dilate the cervix.

Amniotomy- AROM

Common augmentation methods include oxytocin infusion, amniotomy, and nipple stimulation.

Noninvasive methods such as emptying the bladder, ambulation, and position changes, relaxation measures, nourishment and hydration, and hydroptherapy should be attempted before invasive interventions are initiated.

 

1. Describe nursing management of the woman whose labor is being induced.

Encourage woman to void before beginning protocol to prevent discomfort and remive a barrier to labor progress

Obtain a 15-20 min baseline FHR strip to ensure adequate assessment of FHR and pattern and contractions

Position woman in side lying position and administer oxytocin using IV

Regulate oxytocin to evaluate woman’s response and to prevent hyperstimulation and fetal hypoxia-if hypertonicity or signs of fetal distress are detected, d/c oxytocin immed! Turn woman on her side to increase placental blood flow.

Monitor maternal v.s. Q 30-60 min to assess for oxytocin induced hypertension

Monitor FHR and contractility pattern Q 15 min.

Monitor I+O-to assess for urinary retention and prevent water intox.

Monitor progress of labor-dilation, effacement, and station

Prepare mother for increase in contractions once oxytocin is started

Review relaxation techniques, breathing, massage

Ask if wants anything for pain.

 

1. Discuss the actions, side effects and precautions in the use of oxytocin to induce labor

See above

 

1. Describe the reasons for the use of forceps and the vacuum extractor and possible maternal and fetal complications.

Reasons-forceps

Used to assist in the birth of the fetal head.

Maternal indications for forceps assisted birth include the need to shorten the second stage of labor in the event of dystocia or to compensate for the waoman’s deficient expulsive efforts(if she has been given an epidural) or to prevent worsening a dangerous condition (cardia decompensation)

Fetal indications include birth of a fetus in distress or in certain abnormal presentations;arrest of rotation; or delivery of the head in a breech presentation.

Complications-forceps

The mother is assessed for vaginal and cervical lacerations;urine retention, which may result from bladder or urethral injuries; and hematoma formation in the pelvic soft tissues which may result form b.v. damage.

The infant should be assessed for bruising or abrasions as the site of the blade applications, facial palsy resulting from pressure of the blades on the facial nerve and subdural hematoma.

Reasons-vacuum

A birth method involving the attachment of a vacuum cup to the fetal head and using negative pressure to assist in the birth of the head.

Indications for use are similar to those for forceps.

 

Complications-vacuum

Maternal complications are uncommon but can include perineal, vaginal, or cervical lacerations and soft-tissue hematomas

Fetal complications include cephalhematoma, scalp lacerations, and subdural hematoma.

 

1. ID the components of routine preoperative, intraoperative, and postoperative nursing care for a cesarean delivery.

 

 

 

1. Discuss the nurse’s responsibility when caring for the client undergoing VBAC

 

 

 

1. ID the most common causes of dystocia as they relate to the mechanics of labor.

Dystocia is defined as long, difficult, or abnormal labor. It is suspected when there is an alteration in the characteristics of uterine contractions, alack of progress in the rate of cervical dilation, or lack of progress in fetal descent or expulsion.

1. ineffective uterine contractions or maternal bearing down efforts-most common cause of dystocia
2. alterations in pelvic structure
3. abnormal presentation, position, anomalies, excessive size, and number of fetus’s
4. maternal position during labor and birth
5. psychologic responses of mother to labor

 

1. ID three primary clinical characteristics of amniotic fluid embolism

 

 

1. ID factors that influence the course of labor.

1. passenger-fetus
2. passageway-birth canal
3. powers-contractions
4. position of the mother
5. psychological response

 

 

 

 

 

 

 

 

1. Describe the anatomical structure of the pelvis.

The true pelvis is the most significant part in L&D. It consists of the inlet, midpelvis, and outlet.

1. The inlet is where the baby has engaged. If the baby engages in the inlet we have a good sense that the baby will fit through the pelvis. The inlet is the smallest diameter anterior and posterior.
2. the outlet is the ischeal spine-it is the smallest diameter . When the baby reaches this part of the pelvis it is at 0 station.

The pelvis is measured when the woman comes into the office in the first trimester. It is measured again before delivery. The measurements will be larger in labor because the joints are relaxed.

 

The Gynecoid pelvis is the most ideal pelvis for child bearing-50% of women have this pelvis.

 

1. Describe the internal pelvic measurements.

Inlet-12.5-13 cm

Midplane-10.5 cm-the largest plane and the one of the greatest diameter

Outlet->8cm-the outlet presents the smallest plane of the pelvic canal.

 

1. Differentiate between fetal lie, attitude, presentation, and position.

Attitude

This is the relationship of fetal parts to each other.

Is the head:

1. flexed-chin to neck-ideal position
2. deflexed (military)-straight
3. extended (mentum)-neck back.

Lie

The relationship of the long axis of the fetus to the long axis of the mother. The baby is born at longitudinal lie. Breech would be considered longitudinal lie as well. Transverse is another lie-when transverse the presenting part is the babies shoulder.

 

Presentation

This is the part of the fetus that enters the pelvis first.

Can either be:

1. vertex of cephalic-forehead, face, chin/mentum
2. breech
3. shoulder

LOA (Left occipital anterior) is the easiest delivery. This is when the back of the baby’s head is facing the left part of the pelvis.. The landmark on the baby’s head is the posterior fontanel-find out if it is on the left or right side of the mother’s pelvis.

 

LOP (Left occipital posterior) this position is not ideal-birth will be harder. The baby will be born face up. The nurse can facilitate helping the baby change positions by changing the mother’s position.

 

For both the LOA and LOP-will find the FHR in different places on the mother’s abdomen. When baby is in LOA, the fetal tones will be below the umbilicus toward the umbilicus. When the baby is in ROP, the fetal tones will be below the umbilicus but rotated out to the side. This is a red flag that baby is posterior.

 

The letters mean  Left or Right side of pelvis;  scapula, occiput (head is in flexed position), mentum (extension position), breech; anterior/posterior/transverse-more ideal to be anterior.

 

24. ID the major bones, fontanels, sutures, and diameters of the fetal skull

The fetal skull is composed of two parietal bones, two temporalbones, the frontal bone and the occipital bone. These bones are united by the membranous sutures;sagittal, lamboidal, coronal, and frontal. The membrane filled spaces called fontanels are located where the sutures intersect.

The two most important fontanels are the anterior and posterior ones. The larger of these, the anterior fontanel, is diamond shaped, is about 3 cm by 2 cm, and lies at the junction of the sagittal, coronal, and frontal sutures. The posterior fontanel lies at the junction of the sutures of the two parietal bones and the occipital bone, is triangular and is about 1 cm by 2 cm.

 

25.Summarize theories proposed to explain the onset of labor.

1. changes in the maternal uterus
2. changes in cervix
3. pituitary gland
4. hormaones produced by the normal fetal hypothalamus, pituitary, and adrenal cortex
5. progressive uterine distension
6. increasing intrauterine pressure
7. aging of the placenta
8. increasing myometrial irritability- this is a result of increased concentration of estrogen and prostaglandins as well as decreasing progesterone levels.-the coordination of these factors result in occurance of strong, regular, rhythmic contractions

 

1. ID premonitory signs of labor.

1. Uterine contractions occurring Q 10 min or more frequently persisting for 1 hour or more
2. uterine contractions may be painful or painless
3. Lower ab cramping similar to gas pains may be accompanied by diarrhea
4. dull intermittent low back pain
5. painful menstrual like cramps
6. suprapubic pain or pressure
7. pelvic pressure or heaviness-feeling that baby is pushing down
8. urinary freq
9. change in amount of discharge-
10. ROM

 

 

1. Differentiate the signs of true versus false labor.

 True Labor

Contractions-occur regularly, lasting longer, and occurring closer together.

Contractions become more intense with walking

Usually felt in the lower back and radiate to lower part of ab.

Cervix shows progressive change-softening, effacement and dilation-bloody show

The presenting part of the fetus becomes engaged in the pelvis

 

False Labor

Contractions occur irregularly

Contractions stop with walking or position change

Contractions can be felt in the back or abdomen above the navel

Contractions stopped by use of comfort measures

Cervix may be soft, but no sig change in effacement or dialtioon or evidence of bloody show

Fetus presenting part is not engaged in pelvis

 

1. Discuss the cardinal movements that are involved in the process of labor and birth.

1. engagement and descent-LOA
2. flexion-forces head to flex even more chin into neck-this flexion permits the smaller subocipitobregmatic diameter (9.5 cm) rather than the larger diameters to present to the outlet.
3. internal rotation to occipitoanterior position OA- the maternal pelvic inlet is widest in the transverse diameter;therefore the fetal head passes the inlet into the true pelvis in the occipitotransverse position. The outlet is widest in the anteroposterior diameter;for the fetus to exit,the head must rotate. Internal rotation begins at the level of the ischial spines but is not completed until the presenting part reaches the lower pelvis. As the occiput rotates anteriorly, the face rotates posteriorly.
4. extension-as baby comes-lower head extends-when the fetal head reaches the perineum for birth, it is deflected anteriorly by the perineum. The occiput passes under the lower border of the symphosis pubis first and then the head emerges by extension;first the occiput, then the face and finally the chin
5. external rotation-beginning-because babies shoulders turn, the head turns too. The head will turn in position. After the head is born, it rotates briefly to the position it occupied when it was engaged in the inlet. The 45 degree turn realigns the infant’s head with her back and shoulders.