Can a baby be delivered vaginally if it is transverse lie?NO!What does "fetal presentation" mean?The presenting part is the specific fetal structure lying nearest to the cervix. It is determined by the attitude or posture of the fetus.What does "mal presentation" mean?If the fetus isn't lying longitudinal, it is a mal presentation.If a baby's fetal lie is longitudinal, what will the presenting part most likely be?The head (cephalic) or the butt and/or feet (breech)If the baby's fetal lie is transverse, what will the presenting part most likely be?The shoulderExplain what fetal attitude meansFetal attitude is the baby's posture (the relationship of fetal parts to one another). **WITH PROPER FETAL ATTITUDE, THE HEAD IS IN COMPLETE FLEXION IN A VERTEX PRESENTATION AND PASSES THRU THE TRUE PELVIS EASILY.What does "the fetal position" mean?The fetal position is the location of presenting part in relation to the 4 quadrants of the pelvisWhy is it important for a nurse to address the pregnant woman's psychosocial aspects of care in addition to the physical aspects?Preparation of childbirth, both physically and mentally, helps the woman manage labor. This prep promotes in a sense of security and safety.Explain false labor-May have Braxton Hicks contractions- Irregular UC's that do not result in cervical change and are associated with false labor. (Often, contractions will stop with ambulation if it is false) -NO CERVICAL CHANGE -Annoying abdomen and groin discomfortExplain True Labor-True labor contractions occur at regular intervals and increase in frequency, duration, and intensity. -True labor contractions bring about changes in cervical effacement and dilation.What is the most important characteristic (sign) of true labor?The cervical changes which are dilation and effacement.Besides the contractions, what specific discomfort does a woman usually feel when starting true labor?Girdle like pain- Starts in low back, and radiates to the front. Feels like menstrual cramps at first.When does a mom go to the hospital? (include primigravida and multigravida)-1st pregnancy: Contractions 5 mins apart, lasting about 60 seconds each time. -2nd pregnancy on: Tend to send to hospital sooner or earlier than 5 mins apart. ALWAYS- *If water breaks (membranes rupture) *If there is decrease in fetal movement *If there is a placental abruption (non relenting pain *BleedingWhy is it ideal for a woman to deliver within 24 hours of the rupture of membranes?To reduce the risk of infection to mom and her fetus. Once membranes have ruptured, the protective barrier is lost.If using nitrazine (litmus) paper to see if a woman has ruptured membranes, what color will it turn if water has broke?The nitrazine paper (litmus) will turn dark blue if it is in fact amniotic fluid.Is amniotic fluid alkaline or acidic?ALKALINE!What is ferning?A sample of fluid in the upper vaginal area is obtained and the fluid is placed on a slide. If there is a ferrying pattern seen under the microscope, than it will confirm ROM.How can we tell by the pH of fluid whether it is amniotic or not?Normal vaginal fluid is slightly acidic, and has a pH between 4.5-7.5. Since amniotic fluid is alkaline, the pH would need to be higher than 7.5.How many stages of labor are there?4 StagesWhat are the 4 P's of labor?-Powers (contractions and pushing) -Passenger (fetus and aspects of position) -Passage (pelvis) -Psychological (response of the women)The first stage of labor has 3 phases (has to do with dialation). Name the 3 phases:Latent phase: up to 3cm dilation Active phase: 4-7cm dilation Transition phase: 8-9.9cmExplain the first stage of labor (effacement and dilation)-Stage 1 IS THE LONGEST STAGE. -It begins w/ onset of true labor and ends with complete cervical dilation and complete effacement. -Water usually breaks during first stageEpidurals can be given during the first stage of labor. Which phase of the first stage can an epidural be given?Epidural can be given during the ACTIVE PHASE (4-7cm dilated)Explain some of the nursing care you will provide to the pregnant patient upon admission:-Welcome family -Determine expectations; Review childbirth plan and discuss what the woman's expectations of labor are -Confidence; Review and reinforce relaxation and breathing techniques with pregnant patient. -Respect patient's values -Provide encouragement; Praise and notify of progression -Offer pharmacologic measures; Inform of availability -Remember the birth partner; Do not expect too muchYou are assigned to take care of a patient in labor. What will you be assessing in regards to the FETUS?*Fetal heart rate- You will either monitor intermittently or continuously if baby is on an electronic fetal monitor (EFM) *Assessment of FHR for 1 full minute after the rupture of membranes. *Amniotic fluid- assess color, amount, consistency, and odor whether it was SROM or AROMYou are assigned to take care of a patient in labor. What will you you be assessing in regards to the mother?*Assess maternal vital signs (TPR, BP, O2 sat) *Monitor contractions (palpation vs EFM) *Periodic vaginal exams to monitor labor progress *I&O- Assess for bladder distension, rectal pressure. MOM W/ EPIDURAL DOESN'T FEEL SENSATION TO URINATE (sometimes we cath the patient) *Assess mom and support person's response to laborIf you are palpating a contraction, what objective data are you able to obtain about the contraction?You are able to determine the frequency, duration, tone, and intensity of the contraction.What is one of the reasons we should be really worried if baby's heart rate decreases after mom's water breaks?Drop in fetal heart rate may mean that the baby's cord is prolapsed!Some women prefer to change positions during labor b/c they feel less pain. What can we do to make sure that mom is safe and comfortable if she decides to change position?-Make sure patient is safe! You need to make sure she won't fall -Provide privacy (may want to draw curtain if she's not in a flattering position)Explain the 2nd stage of labor (expulsion):-The second stage of labor begins when cervical dilation and effacement are complete. Birth of the baby occurs in stage 2! (2nd stage ends with birth of baby) -The forces of uterine contractions and mom's pushes helps get the baby out.How much blood does a mom usually lose during a normal labor?About 500mL (remember mom's blood increases about 50% or 1500mL during pregnancy, so don't worry)Why is it important to be aware of your body language in the delivery room?You want to appear calm, cool, and collected. Patient and support person may become alarmed if you look scared, rushed, frustrated, etc.Explain the 3rd stage of labor (seperation of placenta and membranes):separation and expulsion of the placenta and membranes.How long does it usually take for the placenta to separate from the uterine wall, and how long to actually come out of the vagina?-The placental separation from the uterine wall usually occurs within a few minutes after delivery. -Process of expulsion usually takes about 5-20 minsWhen you are looking at the cord, how many blood vessels should be there?Cord should have 3 blood vessels; 2 arteries and 1 vein.Explain the 4th stage of labor (physical recovery and bonding):The fourth stage begins with the delivery of the placenta and typically ends within 4 hours or with the stabilization of the mother.What does the fetal heart rate reflect?FHR reflects fetal oxygenationWhat is dystocia?Distocia is defined as a long, difficult, or abnormal labor. Dystocia is diagnosed when there is an alteration in the progress of labor related to cervical dilation and/or descent of the fetus.What is a dysfunctional labor?Abnormal uterine contractions that prevent normal progress of labor. (Normal UC's are every 4-5 mins and last for 45-60 seconds)Explain what a hypertonic uterine dysfunction isHypertonic uterine dysfunction is uncoordinated uterine activity. Contractions are frequent and painful, but ineffective in producing dilation and effacement.If you suspect that patient is experiencing a hypertonic uterine dysfunction, what are the expected assessment findings?-Painful, frequent, UC's w/ inadequate uterine relaxation between contractions -Little cervical changes -Fetal heart rate may be indeterminate or abnormal related to prolonged labor and inadequate uterine relaxationHow many contractions will a woman be having in just a few minutes if she is having hypertonic contractions?More than 5 contractions in just a few minutes.If a woman is experiencing a hypertonic uterine dysfunction, what dangers are her and her fetus at risk for?Risks for mom: Abruptio placenta Exhaustion related to prolonged labor Dehydration Risks for baby: Fetal intolerance of labor and asphyxia related to decreased placental profusionWhat is the main goal when administering tocolytics to a pregnant patient experiencing hypertonic contractions?To promote uterine rest an dto develop a normal pattern of UC's in the active phase.If you are her nurse, what are your nursing actions to manage the hypertonic uterine dysfunction?-Get her to rest to try and break the pattern of the abnormal and ineffective contractions. -Administration of tocolytic drugs such as tributilene if MD orders) -Promote relaxation; shower or bath, quiet, cluster care to provide minimal interruptions if patient falls asleep. -IV fluids or PO fluids (usually NPO, but if MD allows) -Inform provider about woman's response and progress in labor. -Assess FHR and UC'sExplain what a hypotonic uterine dysfunction isHypotonic uterine dysfunction occurs when the pressure of the UC's are insufficient in achieving cervical dilation and effacement.If you suspect that patient is experiencing a hypotonic uterine dysfunction, what are the expected assessment findings?-Decreased frequency, strength, and duration of uterine contractions -Little or no cervical change -Increased fear and anxiety levelsIf you are her nurse, what are your nursing actions to manage the hypotonic uterine dysfunction?-Assess fetal and maternal status (FHR, uterine act., etc) -Ambulate and change position to promote comfort and labor progress -Hydrate IV or PO (usually not PO, but if MD says ok) -Administration of IV fluids to maximize maternal fluid volume (prevents hypotension & increase placental profusion. -Administration of oxytocin if MD orders -Eval labor progress w/ SVEIf a woman is experiencing a hypotonic uterine dysfunction, what dangers are her and her fetus at risk for?Risks for mom: Exhaustion and infection related to prolonged labor *Extreme fear may result in catecholamine release, interfering w/ contractibility Risks for baby: Risk for fetal intolerance of labor AsphyxiaWhat is a precipitous labor?Precipitous labor is a labor that lasts less than 3 hours from onset to birthWhat kinds of woman are at risk for having a precipitous labor?-History of precipitous labor -History of multiparityWhat are the risks for mom and baby if she has a precipitous labor?Risks for mom: Uterine rupture Postpartum hemorrhage Cervical/vaginal lacerations Hematoma Risks for baby: Hypoxia Risk for CNS depression (if mom has just had pain medicationWhat are your actions as a nurse if your patient experiences a precipitous labor?-DO NOT LEAVE THE ROOM -Assess FHR and UC's. Tachysysole UC's may occur every 2 mins and last more than 60 seconds -Prepare for delivery -Be alert to verbal cues of impending birth ("I feel like I have to poop") -Anticipate postpartum and neonatal complicationsIf you are anticipating postpartum complications and neonatal complications following a precipitous labor, what kinds of things should you anticipate?-Postpartum hemorrhage; may need methergine or oxytocin to help uterus contract (helps w/ expulsion of blood and placenta) -Baby may have hypoxia or CNS depression; ancticipate NARCANWhat does "inadequate expulsive forces" mean, and in which stage of labor does this occur?Inadequate expulsive forces occur in the second stage of labor when the woman is not able to push or bear down.Who's at risk for having inadequate expulsive forces?Women who are under epidural anesthesia, b/c they may not feel the urge to push.What are the risks for mom and baby if she experiences inadequate expulsive forces?Risks for mom: Exhaustion Operative vaginal birth/CS, perineal trauma Risks for baby: Risk for FHR changes and asphyxiaHow can you as a nurse provide assistance and encouragement to a patient experiencing inadequate expulsive forces?-Encourage open-glottis pushing (minimizes Valsalva) -Changing maternal position to more upright to facilitate fetal descent. -Periods of rest (laboring down)Why don't we realize that a woman is having hypotonic contractions right away most of the time?Typically, the woman makes normal progress during the latent phase of labor, but during the active phase the contractions become weaker.When is it best to administer IV push pain meds for a woman in labor?During contractions! The spiral arteries supply the intervillous spaces, but are compressed during contractions. Since there is a decreased placental perfusion during contractions, the baby is less likely to get the drug.What is a placental reserve?Placental reserve is a term used to describe the reserve of O2 which is available to the fetus. This reserve allows the fetus to withstand the temporary changes in blood flow and oxygenation during labor contractions.Fetal monitoring can be done though auscultation and palpation of the uterus. What is an advantage? What is a disadvantage?Advantage= Mobility Limitation= It's not continuousFetal monitoring can be done electronically. What is an advantage? What is a disadvantage?Advantage= More data/permanent record Limitation= Mobility is limited, "high tech" atmosphereFHR can be auscultated w/ a fetoscope or a doppler. What data are we able to collect?Rhythm, and increase or decrease in fetal heart rate *Assessment of FHR variability is not possible thru auscultation method b/c it's intermittent.What is a toco transducer?It is a monitor that has 2 lines, the top shows the FHR and the bottom shows uterine activityWhen we are using electronic monitoring equipment, there are both external and internal pieces. What are they?External: Doppler ultrasound transducer (transducts the sound) and they tocodynamometer Internal: Scalp electrode, intrauterine pressure catheterWhat is the normal range for a FHR?110-160 BPMWhat is FHR if bradycardia?Less than 110bpm for at least 10 minsWhat is FHR if tachycardia?Greater than 160bpm for at least 10 minsWhat is an acceleration?Baby's heart increases 15bpm for at least 15 seconds *can be associated with fetal movement or contractionsWhat is an early deceleration?Early deceleration is a visually apparent gradual decrease in FHR below the baseline. They "mirror" the contraction. The lowest part of the deceleration occurs at the same time as the peak of the uterine contraction.What is a late deceleration?A late deceleration is a visually apparent gradual decrease of FBR below the baseline. The Nadir (lowest point of deceleration) occurs after the peak of contraction, and the heart rate does not recover until after the contraction is done.What is a variable deceleration?A variable deceleration is an abrupt decrease in FHR to less than 70 ppm lasting longer than 60 secondsHow can we treat variable decelerations if they are resulting from decreased amniotic fluid?An amnioinfusion!How is an amnioinfusion administered? What do we use?Room temperature normal saline is infused transcervically.What are contraindications of an amnioinfusion?Do not give amnioinfusion if there is infection, bleeding, or uterine abnormalities.If baby is having early decelerations during contractions, what may be the cause?Possible head compressionIf baby is having late decelerations during contractions, what may be the cause?Uteroplacental insufficiencyIf baby is having variable decelerations during contractions, what may be the cause?Umbilical cord compression. (This is good candidate for amnioinfusion.How long should the duration of a normal contraction last?45 to 60 secondsWhat are interventions used during times of early, late, and variable decelerations?-Stop any oxytocin infusion -Put mom on L side (to increase perfusion) -More fluids (increase IV) -To reduce cord compression during variable decelerations, reposition to knee/chest position. MAY NEED AMNIOINFUSIONHow does a woman's perception of things change during labor?Sleep deprivation is common during labor. A woman's perception of pain and the way she handles things get more difficult to deal w/ when she's exhausted. -Sometimes sedatives are helpful so mom can get a little sleep before all the pushing starts.What are some nonpharmacologic techniques that may be used during labor?Relaxation Cutaneous stimulation Mental Stimulation Breathing Thermal Stimulation Support person Counter pressure on backWhen is the best time for a nurse to teach nonpharmacologic pain control methods to an unprepared laboring woman?During the latent phase of labor (which is in the first stage).What is the difference between an epidural and a spinal?Epidural: Local Anesthetic; Injected into epidural space. Spinal: Local anesthetic injected into subarachnoid space in single dose.If a woman has an epidural and her BP drops, what do you do?Increase IV fluids, put patient on L side, administer O2 and call MD!When is it best for mom to get an IV push?During a contraction (less placental perfusion during contraction)Why do women get an IV prior to epidural?To increase fluid which will decrease risk of hypotension. We might give a bolus infusion to get it in there fast.What are we monitoring during and throughout epidural?*BP and FHR *Vital Signs *Assess effectiveness *Assess level of block *Monitor for nausea *Assess for headache p proce. *Assess for urinary retention (remember mom may not feel sensation to void if she's numb)Why do we need a higher block for a patient who is having a C-Section?B/c of the incision.General anesthesia is rarely used for vaginal births. In what situations would general anesthesia be used?C-Sections; emergencies, poor candidates for epidural, refusalList adverse effects of general anesthesia for patients in labor:Maternal aspiration; take caution by keeping mom NPO and giving bicitra . Respiratory depression for mom or infant. (More likely for infant -Uterine relaxation; increased risk for post partum hemorrhage b/c uterus needs to be able to continue contracting to expel placenta.What is bicitra?Bicitra alkalizes stomach content.What artificial methods are used to stimulate uterine contractions?-Amniotomy (artificial rupture of membranes) -Use of medications such as oxytocin or synthetic prostoglandins such as cervadilWhat are the risks associated with using artificial methods to stimulate uterine contractions?-Tachysystole -Uterine rupture -Maternal water intoxication (b/c we are increasing IV fluids during this time)Why is oxytocin always given piggyback w/ infusion pump?Quick shut off if needed!Can a patient with herpes simplex virus deliver vaginally?NO! Delivery must be C-SectionWhat are some reasons we would induce labor?-Preeclampsia -SROM -Chorioamnionitis (infection) -Maternal med cond's -Post term -Intrauterine growth restriction -If woman has had very fast labors (may want to induce prior to spontaneous labor so delivery can be controlled) -Gestational diabetes -Intrauterine fetal deathWhat are some contraindications that would cause us NOT to induce labor?-Placenta Previa -Cord prolapse -Malpresentation -Active herpes (mom) -Pelvic structure abnormality -Previous vertical C-section scarWhat are nursing actions for NON reassuring FHR patterns or for hypertonic uterine contractions if labor is being induced?-Reduce or stop oxytocin infusion -Increase primary IV -L lateral position -O2 @ 8-10L per minute -Notify MD (may need terbutiline)Why do we keep a mom who is being induced on strict I&O?We need to watch for fluid overload; water toxicity is possible b/c of the increased IV fluids)What are the risk factors associated with an amniotomy?-Increased risk for infection -Increased risk for cord prolapse -Increased risk for C-SectionWhat equipment will you need as a nurse if you are assisting with amniotomy?-Dry underpads (change underpad frequently) -Sterile glove -Sterile lubricantWhat nursing care will you provide after the amniotomy is performed?-Monitor FHR for at least one minute to make sure there is no cord prolapse -Chart quantity, color, and odor of amniotic fluid (may be greenish brown if baby's meconium is in there) -Take mom's temp every 2 hrs (to watch for infection) -Promote comfortWhat is a cephalopelvic disproportion (CPD)?Either the baby's size, shape, or position of the head prevents it from passing thru mom's pelvis, OR the size and shape of the maternal passage will not allow the baby's head to pass thru her pelvis.If a woman in labor has an intrauterine infection, what will your expected assessment findings be?-FHR is tachycardic (>160 for more than 10 mins) -Maternal temp 100.4 or greater -Tachycardia and tachypnea (mom) -Amniotic fluid that is cloudy, yellow, or foul smellingIf a woman in labor has an intrauterine infection, what should your nursing actions be?-Limit vaginal exams -Change wet underpads frequently -Perform perineal care -Monitor FHR and maternal vital signs -Observe amniotic fluid for amount, color, odorWhat is an operative vaginal delivery?An operative vaginal delivery is a vaginal birth that is assisted by; a vacuum extraction or forceps.What is the purpose of an operative vaginal delivery?To facilitate birth and shorten 2nd stage of laborIf a woman is going to have an operative vaginal delivery, what drug should you anticipate the doctor administering to the patient?Anticipate oxytocin- it shortens the 2nd stage of labor.How long can a doctor try to extract the fetus by vacuum or forceps?Do not exceed more than 3 tries. Max amount of each try is 15 minutes.What are the maternal risks associated with an operative vaginal delivery?-Vaginal and cervical lacerations -Hemorrhage -Bladder trauma -Extension of episiotomy -Perineal hematoma -Perineal wound infection -Uterine ruptureSometimes women who have had a C-section in the past can still have a vaginal delivery for future babies. What type of woman is a good candidate for having a vaginal birth after cesarean?Women who have had 1-2 previous c-section deliveries w/ a low transverse insicion and adequate pelvisIn what instances would a VBAC (vaginal birth after cesarean) be contraindicatedNO VBAC for women who have had: -Past C-section w/ a vertical incision -History of uterine rupture -Pelvic abnormalities -Inability to perform emergency C-sectionIf a woman is post term in her pregnancy, what medical actions should you anticipate?-Induction of labor -Cervical ripening agents such as cervadilWhat are the risks associated with having a post-term pregnancy? (Lasting 42 wks or more)-Cord accident due to decreased amniotic fluid -Decreased placental reserve due to calcified placenta -Meconium stained amniotic fluid (fetus can aspirate) -Fetal macrosomia (baby grows appx 1oz/day after term)Name some examples of situations that would be considered "obstetrical emergencies"-Shoulder dystocia (difficulty delivering the shoulders after delivery of the head) -Umbilical cord prolapse (when cord is lying below the presenting part of the fetus -Uterine rupture (partial or complete tear in uterine muscle) -Amniotic fluid embolism -DIC (Disseminated Intravascular Coagulation)What is the first sign of shoulder dystocia?Retraction of the head against the maternal perineum "turtle sign"What kinds of things can cause the fetus to experience shoulder dystocia during delivery?-Macrosomia -Maternal diabetes -Excessive weight gain -Post dated pregnancyIf your patient's fetus is experiencing shoulder dystocia, what should you anticipate that the MD will do?Anticipate an extension of the episiotomyWhat is McRobert's maneuver?Sharply flexing mom's thighs to her abdomen to straighten her sacrumWhat is Wood's corkscrew maneuver?Turns baby to rotate shouldersWhat if the extension of episiotomy and maneuvers don't work?Delivery by emergent C-Section will occur.What is a prolapsed umbilical cord?A cord that's lying below the presenting part of the fetusWhat would make you suspect that the cord is prolapsed?FHR - BRADYCARDIAWhat fetus' are at risk for having a prolapsed cord?-Fetus that remains at high station (not engaged) -Small fetus that fits poorly in pelvic inlet -Malpresentation (especially breech) -polyhydramnios (alot of fluid) -multiple gestationIf the fetus' cord is prolapsed, what are your actions as the nurse for this patient?-Occlusion of the cord may be partially relieved manually. -Change to knee-chest position or put bed in Trendelenburg position to try and relieve pressure of the occluded cord. -IV fluid hydration bolus -Administer tocolytic drugs as ordered -If cord is visible, apply warm saline soaked towels to cord -Address anxiety of woman.What is a uterine rupture?A uterine rupture is a partial or complete tear in the utertine muslceWhat type of women are at risk for having a uterine rupture?-Blunt abdominal trauma such as MVA, fall, etc -women who've had a h/o C-section or uterine surgery -multifetal gestation -uterine tachysystole (excessively frequent uterine contractions)What are the clinical manifestations of a uterine rupture?-Will have signs and symptoms of hypovolemic shock such as: hypotension (decrease in BP, dyspnea), tachypnea, tachycardia, and pallor -Woman will feel severe tearing sensation, buring "stabbing pain" in abdomen -Fetal distress (uteroplacental insufficiency, placental abruption, cord compression, asphyxia, and/or hypovolemia) -If the fetal presenting part is in the pelvis, loss of station may occur (can be detected w/ vaginal exam)As a nurse, what are your actions in order to stabilize a woman during uterine rupture?-Get assistance and notify provider right away -Stabilize woman with O2 and IV fluidsWhat will the MD proceed with delivery if uterus ruptures?Delivery by C-SectionWhat is an amniotic fluid embolism made up of?It's amniotic fluid that contains fetal cells, lanugo, and vernix which is drawn into the maternal circulation and carried to her lungs. Due to the high intrauterine pressure, it makes it possible for amniotic fluid to be forced into mom's veins.When can an amniotic fluid embolism occur?Can occur during pregnancy, labor and birth, or the first 24 hours after birth.What are the clinical manifestations of an amniotic fluid embolism?Chest pain, dyspnea, cyanosis, tachycardia, hypotension, hemorrhage, and cardiac respiratory arrest.What women are at risk of having an amniotic fluid embolism?What should you anticipate if a woman has an amniotic fluid embolism?Blood replacement and O2!What is a cesarean section birth?It is an operative procedure in which the fetus is delivered through an incision in the abdominal wall and uterusHow many pregnant couples experience birth thru C-section?Approximately 1/3 of pregnant couples experience C-section.What special needs are different for women who deliver C-section as opposed to women who deliver vaginally?-longer hospital stay -longer recovery time -increased pain -more negative emotions regarding the childbirth experience (especially if c/s was not planned)Define dystociaDystocia is defined as a long, difficult, or abnormal labor. It is diagnosed when there is an alteration in the progress of labor related to cervical dilation and/or descent of the fetus.What are some indications for C-Section birth?-Dystocia -Previous c/s or uterine surgery -malpresentation (ex: breech) -Fetal intolerance of labor (ex: prolapsed cord, distress) -Placental abnormalities (ex: previa, abruptio) -Uterine rupture -Maternal factors (ex: diabetes, preeclampsia)What are the 2 classifications of Cesarean births?-Scheduled or planned -Unscheduled or unplanned *Primary *Emergent *Repeat *Urgent *Non- urgent ***Care may vary based on classification***Labor and delivery nurses are responsible for care throughout a C-section experience. What are some of the different roles nurses have on an OB floor?-Primary nurse -Scrub nurse -Circulating nurse -Recovery nurseIf you are the pre-op nurse for a woman who is about to have a C-section, what are your nursing actions going to be?-Monitor vital signs for woman and fetus -Verify that she's been NPO for at least 6-8 hrs -Administer a preloading IV fluid dose of about 500-1000mL per MD orders -Give an oral liquid antacid to neutralize stomach acids -Review labs for signs of infection, and fluid and electrolyte balance -Insert Foley catheter -Shave abdomen/upper pubic region -Provide emotional support to mom and support part.Why do we give moms a loading dose of IV fluids prior to C-section?We want to increase the fluid volume and decrease the hypotension r/t anesthisiaWhat is the oral liquid antacid we administer to neutralize mom's stomach acids?BicitraWhat are the 2 regional anesthesia options that pregnant women have when having a c-section?-Spinal; This is the preferred method b/c it's faster to place and provides a full block sensory and motor block -Epidural; Women w/ epidurals may feel tugging and pulling during c/s b/c epidurals are not as dense and do not provide full sensory and motor blockWhat is the preferred anesthetic agent for spinal and epidural blocks?BupivacaineWhat are some contraindications for administering a regional anesthetic to a patient?-Patient refusal -Low platelet count -Maternal hypovolemia -Increased intracranial pressure (ICP)Why do providers rarely use general anesthesia on patients undergoing a C-section?There are increased risks if a woman is under general anesthesia. -Gastric aspiration can lead to pneumonitis (lung tissue inflammation) which is a potential complication of general anesthesia.What are some indications that general anesthesia is necessary for a woman having a C-section?-The womans refusal for regional anesthesia -If a rapid delivery is needed -If woman is experiencing severe hemorrhage -If woman is having seizures -If woman has a failed spinal anesthesiaWhat is a Pfannestiel incision?It is the preferred incision type for C-section births. It is a low transverse uterine incision referred to as a "bikini cut"What is a Classical cesarean delivery?The classical cesarean delivery technique is rare and is used in emergent c/s births when immetiate delivery is critical. A vertical midline incision is made to the abdominal wall.If you are an intraoperative nurse, and woman is ready to go to surgery, what are your nursing actions?-Assist woman onto operating table with rolled blanket under R buttock (displaces uterus to L which is better for oxygenation and perfusion) -Explain actions and offer emotional support to coupleIf you are assisting in the intraoperative phase, you will also perform the role of a circulationg nurse who collects "time out documentation". Explain what information you would verify during "time out".Verify patient name, procedure, sponge/instrument count, etc.What are some intraoperative complications that a woman may experience during a C-section?-Hemorrhage -Trauma to bladder, ureters, or bowel -Maternal respiratory depression and hypotension -Inadvertent injection of anesthesia into maternal blood stream -Mom may hear ringing in the ears or have a metallic taste in her mouthWhat are your nursing actions for the neonate during and following C-section?-Check to make sure you have all the equipment and supplies you will need for the newborn -Perform Apgar scoring at 1 and 5 minutes -Record the time of delivery of neonate and placenta -Place ID bands on neonate and parents ASAP -Ensure mother sees and touches neonate before leaving the roomWhat are some postoperative complications associated with a c-section?-Hemorrhage -DVT -Pulmonary embolism -Paralytic Ileus -Hematuria -Infection -Prolonged decreased sensation in legs -Post dural puncture headaches -Newborn respiratory depression (if drugs got to baby)What is it important to assess for in a woman who's had anesthesia?-Assess level of sensation bilaterally -Observe for side effects of anesthesia (check list form #169)If your patient had a c-section, what are your postoperative nursing actions?-Monitor VS's -Assess fundus and lochia -Assess abdominal dressing -Monitor urinary output via foley catheter -Monitor level of anesthesia -Assist woman w/ breast feeding -Encourage C & DB, incentive spirometer -Apply compression devices to lower extremities -SPLINT ABDOMEN WHEN REPOSITIONING -Monitor for return of sensation in lower extremities -Dangle @ bedside, monitor for dizziness -Assist w/ ambulationIn postpartum nursing care, we provide fundal assessment checks for uterine tone. Explain what supplies you will need and what you will do.You will need clean gloves for assessment. Ask patient to void before assessment. Assist her to the supine position with knees bent. Palpate for the location, position and tone of fundus. It should be firm, and midline- SHOULD BE @ LEVEL ACCORDING TO POST PARTUM DAY.If fundus is displaced, what are some interventions you can provide to correct the problem?-Assess the bladder for fullness, encourage voiding or straight cath per order - Reassess the fundus for position after interventionsIf fundus feels soft or boggy, what are some interventions you can provide to correct the problem?-Massage fundus with palm of hand -Administer oxytocin/methergine/hemabete as ordered -Have baby breast feed if this is part of mom's plan -Reassess fundus for firmness during and after interventionsWhat are "afterpains"? (This is a physiological change that occurs after birth sometimes)Afterpains are moderate to severe cramp like pains that are related to the uterus working harder to remain contracted and/or to the increase of oxytocin that is released in response to an infant suckling.Define LochiaLochia is a bloody discharge from the uterus that contains sloughed off necrotic tissue and undergoes changes that reflect the healing stages of the uterine placental site.What are the 3 names for lochia?-Lochia Rubra -Lochia Serosa -Lochia AlbaWhat is the lochia name for days 1-3? Explain expected findingsDay 1-3 Lochia Rubra: -Bloody w/ small clots -Scant to moderate amount -Increased flow upon standing or breast feeding -Odor is fleshyWhat is the lochia name for days 4-10? Explain expected findingsDay 4-10 Lochia Serosa -Pink and serosa (serous exudate, RBC's WBC's) -Scant amount -Odor is fleshyWhat is the lochia name for day 11 to 3 wks? Explain expected findingsDay 11 to 3 wks Lochia Alba -White in color (WBC's epitheleal cells) -Scant amount -Odor is fleshyWhat aspects of the lochia are you going to assess for and chart?-Assess amount, color, and odor -Monitor for number and size of clots -Odor should be fleshy, earthy or mustyWhat is going on with the cervix and vagina in the post partum period?-Cervix is formless, flabby, open wide, and edematous -Vaginal walls are edematous, few rugae -Perineal edema -Trauma; episiotomy, lacerations, hemorrhoidsWhen you are performing a vaginal and perineum assessment post partum, what should your expected findings be?-Mild edema -Minor ecchymosis -Approximation of the edges of episiotomy or lac -Mild to moderate painHow do you assess the woman's perineum if inspecting episiotomy/repair of laceration and hemorrhoids?Place patient in side lying position, and lift upper butt cheek.During your breast assessment, what are you checking for and charting?-Size, Symmetry, and shape (dimpling or thickening needs to be reported) -Inspect areola and nipples. Note redness, cracks, or blisters. Note flat or inverted nipples -Palpate breasts. They're soft and nontender for first couple of daysWhat does the colostrum look like and how does it change over time?First 24 hours has a skim milk appearance. Colostrum precedes milk production. Within 72-96hours milk will come in- monitor. Breasts will feel lumpy and have a feeling of filling. Monitor for engorgement on 3rd or 4th dayWhat can you teach a woman who is breast feeding to help promote breast comfort?For the breast feeding mother: Avoid soap on nipples If sore nipples, dab breast milk to area at the end of feeding, air dry Breastfeed every 2-3 hours, empty breasts to prevent milk stasis/plugged milk ductsWhat can you teach a woman who is not breast feeding to help promote breast comfort?Avoid breast stimulation; ex: hot showers, do not pump Wear a tight fitting bra, use ice packs if uncomfortableHow can a woman prevent plugged milk ducts?-Frequent breastfeeding -Empty breasts with each feeding -Change infant's position -Warm compresses -Massage breasts prior to feeding -Supportive braWhat is the expected blood loss during delivery in a vaginal delivery vs a C-Section?Vaginal: Loss of 400-500mL C-section: Loss of 1000mLWhy does a woman experience postpartum chills?Most women experience an episode of feeling cold and shaking the first few hours of birth, which is related to vascular instability.Following birth, mom's cardiac output increases b/c of the change in amount of blood she's circulating. How long does that last?48 hoursIf a woman has bradycardia following childbirth, what would her heart rate be?40-50 BPMBecause plasma volume decreases after giving birth, mom may experience diuresis or diaphoresis. At what time postpartum would this occur.Diuresis: W/in 12-24hrs postpartum Diaphoresis: During first few weeks postpartumIs it normal for a woman's WBC level to spike during first week postpartum?Yes, WBC level increases to 25,000/mm and returns to normal value within 1 weekFor every 500mL of bloodloss, how much is the hemoglobin and hematocrit decreased by? When do H&H levels return to normal?Hemoglobin decreases to 1-1.5g/dl Hematocrit dercreases to 3-4% Returns to normal range in 4-6 wksWhen do a woman's clotting factors return to normal?They decrease gradually. Fibrinogen returns to normal values in 2 weeksIt's normal for a woman's temp to increase to 100.4 for the first 24 hrs of delivery. But when would you expect infection?If temp is 100.4 or greater on 2 occasions AFTER that first 24 hours, suspect infection.What are typical vital signs of a postpartum patient?-BP remains same as predelivery. If she has orthostatic hypotension decrease of 15-20mm/Hg -HR remains normal or decreases for 48 hours RR 12-20 bpmWhat interventions can a nurse perform to prevent orthostatic hypotension?-Take vital signs before getting OOB for the first time and compare to baseline. -Compare CBC to the admission CBC -Slow position changeGive some examples of slow position changes-Sit at edge of bed before standing -Stand in place marching a few steps to get bearings, and to ensure feeling in the feet -OOB to chair before ambulation -Leave call light in place -Best to have a peer with you the first time.When you are documenting vaccines, what information must be included?-Manufacturer -Lot number -Experation date -Give information to patientExplain the indication, action, adverse reactions, and route/dose of RhoGamRhoGam -Indication: Administered to RH negative women who have given birth to an Rh positive neotate. -Action: Prevents productions of anti-Rh D antibodies -Adverse reactions: Pain @ injection site -Route/Dose: 300mcg IM w/in 72 hrs post birth.Is RhoGam documented as a blood product?YES (observe mom for 20 mins)What vaccines are you giving to mom prior to discharge if needed besides the RhoGam?Rubella: Get vaccine before D/C, and avoid pregnancy for 4 weeks Tdap vacine Hepatitis B if non-immuneWhat does the Tdap vaccine prevent you from getting?Tetanus diphtheria and pertussisWhat is the physiological reason women sometimes have diureses after giving birth.-Postpartal diuresis; occurs within 12 hrs of birth and aids in elimination of excess tissue fluids. Caused by decreased estrogen and oxytocin levels.Additional postpartum complications as bladder distension and incomplete bladder emptying may arise. What nursing interventions can you perform if these things happen?Bladder distension: May need straight cath or Foley cath.What can you do if the woman keeps trying to void, but can't go?You can soak a cotton ball in peppermint oil and put it in the hat. The vapors will relax the muscles and edemaWhat kinds of things put a woman at risk for having problems with her bladder after childbirth?-If she's had regional anesthesia -Edematous urethra -If the bladder gets to full from diuresisHow do you quantify the amount a woman has voided if she voids in the shower or in a sitz bath?Ask her if she went a little or if she went alotIf lochia increases, the first thing we check is the fundus. What if the fundus feels firm and it isn't boggy? What could be causing the increase in bleeding?A full bladder! If her bladder is full, the uterus is displaced.How much urine should a woman be voiding each time? What would indicate that her bladder is emptying properly?300-400mL per void indicates an empty bladderWhat interventions can you provide to promote bladder elimination?-Ensure adequate fluid intake (IV, P.O) -Running water, placings mom's hands in water, or pouring water over the vulva -Providing hot tea or fluids of choice -Use the peppermint oil on the cotton ball in the hat -Catheterize as ordered -TEACH KEGAL EXERCISESWhat postpartum patients are at risk for constipation?-Medications -Epidural -Iron Supplements -dehydrated patients -perineal discomfort -hemorrhoidsWhat interventions can you perform to promote bowel elimination?-Increase fluids -Ambulation (increase gastric motility) -Fiber -Stool softeners or laxitivesHow do we change the nutrition for a lactating mother after birth?-increase caloric intake by 500 calories per day -fluid intake of 2L per day -avoid foods that cause problems for the infantWhat foods should a lactating mom avoid?garlic, spicy/acidic foodsHow do we change the nutrition for a nonlactating mother?-increase protein and Vitamin C for healing -encourage healthy food choices -respect cultural preferencesWhen performing a lower extremity assessment to a new mom, we need to monitor circulation, motion, and sensation. What will you assess for when monitoring for problems with lower extremities?-Check for varicose veins -Monitor for signs and symptoms of thrombophlebitis -Monitor pedal edema -Assess deep tendon reflexes (APRN)If APRN is assessing deep tendon reflexes, what range is within normal limits?1+ to 2+ WNLHow can you teach a patient to promote venous return?-Encourage leg exercises and early ambulation -Teach patient to keep feet up while sitting in a chairWhat is thrombophlebitis?Inflammation of the wall of a vein with associated thrombosis, often occurring in the legs during pregnancyWhat are the signs of thrombophlebitis?-Calf tenderness -Redness -Edema -Warmth -Muscle pain -Swelling of the veinsIf a woman has a C-section, how long do you typically monitor her temp for signs of infection?VS as ordered and then every 4 hours for the first 24 hoursWhat IV therapy will a C-section mother receive after birth?Initial IV w/ pitocin, followed by D5 lactated ringers or lactated ringers only. Can be discontinued w/ good p.oWhat body systems will you specifically monitor post c-section?-Monitor lung sounds; turn, cough, deep breath -Monitor bowel sounds, flatus, and the incision/dressing.How should a new moms diet progress after c-section?Clear liquids to as toleratedIf a woman has a c-section, how long will we keep it in after surgery?Removal of foley catheter is usually the next day, or 12 hours later.How will we decide what a post c-section mom's activity level will be?Activity level will be dependent on the type of anesthesia she received.You will have a lot of health education to cover with mom before she is discharged. Name as many things that you will teach her before she is released.-Self-care -bowel elimination -Breast care -exercise -Incision -Sexual activity -Perineal care -Contraception -Rest and sleep -Care of newborn -diet -follow up appointment -s/s to report -Return demonstration -Verbalizes understanding -EvaluationYou are responsible for teaching a new mom to report certain signs and symptoms to the provider once she goes home. What signs and symptoms should she call the MD about?-Excessive or foul smelling lochia -Elevated temp -General malaise (not feeling well) -Pelvic or abdominal tenderness (can be infected) -Frequent voidings of <150mL and feelings of urgency, frequency, and dysuria -If nipples are tender, warm, reddened, or cracked -Leg painWhat are the different aspects that influence a new moms transition to parenthood?-How woman was parented -Her life experiences (easier if she's had experience w/ kids) -The pregnancy experience -The level of support from her partner, family, and friends -Woman's willingness to assume the roll of mother -The infant's characteristics: appearance and temperamentWhat are the 3 maternal phases that occur when becoming a mother?-Taking in phase: Mom's focused on her own needs. Wants to talk about her L&D. Is passive toward taking charge of the baby. -Taking hold phase: Mom meets own needs & focuses on baby's needs -Letting go phase-Assuming new role as parent/

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