Upgrade to remove ads
Only $2.99/month

OB Nursing: Final Exam

Terms in this set (108)

Cervical Ripening: Mechanical Methods
Transcervical catheter placement (foley bulb) or hydrophilic inserts into the cervical canal, where they absorb water and expand, gradually dilating the cervix
Dilapan
Synthetic dilator - a dry, sterile sponge that is inserted into the cervix several hours before the procedure
Lamicel
A synthetic polyvinyl sponge containing 450 mcg of magnesium sulfate. It expands to form a soft sponge, it has a local softening reaction but the true mechanism is not clear
Laminaria tents
A small tube made of dried seaweed that is inserted into the cervix 8-24 hours before the procedure. Most of the cervical dilation happens within the first 6 hours, with maximum dilation occurring 12 to 24 hours after it is inserted
Augmentation Method: Stripping the Membranes
Done by MD or CNM
Insert gloved finger as far as possible into cervical canal and rotate finger 360 degrees X2
This separates the amniotic membranes lying against the lower uterine segment from the lower uterus
This motion is thought to release prostaglandins
May cause discomfort, cramping, scant bleeding and blood discharge
Stripping the Membranes (augmentation) may cause labor in _____ hrs?
May cause labor; may begin within 24-48 hours
A procedure done to ripen the cervix to make it more likely to dilate
Cervical Ripening
Cervical Ripening is performed on
Done on the morning of induction, or the day before
Labor Induction
Labor is not induced if term gestation and fetal lung maturity are not determined
Bishop scoring system - Five factors to estimate cervical readiness for labor (pg. 628)
Used to Determine whether induction is indicated
Bishop Scoring Scale
System in which points are added or subtracted based on cervical dilatation, effacement, consistency, position, and station of the presenting fetal part. Likely successful induction if score is 8 or over
Induction is the
Artificial stimulation of uterine contractions before the onset of labor
Augmentation is the
Stimulation of spontaneous contractions that are considered inadequate because of failed cervical dilation and fetal descent
What to Assess After SROM or AROM
Baseline fetal heart rate, 20-30 min prior and at least 1 minute afterwards
Amount/Color/Smell/Cord position.
Document carefully all of the above information including a follow-up SVE (sterile vaginal exam)
Amniotomy
Breaking of the bag of water
Indications for Amniotomy
To induce labor or stimulate labor. Permit internal electronic fetal monitoring. 1 million women had this done in 2000
Risks of Amniotomy
Prolapse of the umbilical cord. Umbilical cord may slip down in the gush of fluid. Infection (Birth within 24 hours is desirable) and Abruption Placentae
Amniotomy is contraindicated if presenting part is not ______?
engaged
Pt is at higher risk for abruption placentae if the pt has _______ due to greater uterine distension and pressure changes
Hydramnios
Abruption:
the area of placental attachment shrinks as the uterus collapses with discharge of the amniotic fluid. The placenta then no longer fits its implantation site and partially separate
Oxytocin (Pitocin) considerations
Powerful and impossible to predict the response
Synthetic compound identical to the natural hormone from the posterior pituitary
Oxytocin
Stimulates uterine smooth muscle, resulting in increased strength, duration, and frequency of uterine contractions
Oxytocin
Indications for Oxytocin
Augmentation, Induction, Maintenance of firm uterine contraction after birth to control postpartum bleeding, Management of inevitable or incomplete abortion
Oxytocin (Pitocin) for Administration:
Induction/Augmentation
Administration:
IVPB
Proximal port
Start slow (usually 1mU/min), increase by 1-2mU/min: try to get mom into a labor pattern of contractions every 2-3 minutes, lasting 40-60 seconds
Infusion pump
Continuous fetal monitoring
Pitocin Administration
Maternal Contraindications
Severe preeclampsia
Risk for uterine rupture
Multigravida ≥ 4, previous major surgery on uterus, over-distention of uterus
Cephalopelvic disproportion
Malpresentation
Preterm infant
If non-reassuring FHR patterns emerge:
Reduce or stop pit
Keep woman on her side to increase placental blood flow
Give 100% O2 by face mask at a rate of 8L/min to increase the woman's O2 sats and make more O2 available for the fetus
The physician may order a drug to reduce uterine activity like terbutaline or magnesium sulfate
Signs of Tachysystole
Contraction longer than 90-120 seconds
Contractions occurring less than 2 minutes apart or relaxation of less than 30 seconds between contractions
Uterine resting tone about 20 mmHg
FHR pattern of late decelerations
Nursing Actions for Tachysystole
Reduce or stop oxytocin infusion
Increase rate of primary non-additive infusion
Keep laboring woman in lateral position
Give oxygen by snug face mask, 8-10L/min
Notify physician or nurse-midwife
Version
Changing the position of the fetus from breech to cephalic presentation
May be external or internal version
External Version is _______ guided
ultrasound
Given tocolytic drug (terbutaline 0.25 mg SQ to ?
relax the uterus
Internal Version
Unexpected and urgent procedures
The physician reaches into the uterus with one hand and, with the other hand on the maternal abdomen, maneuvers the fetus into a longitudinal lie (cephalic or breech) to allow for vaginal delivery
Indications for Vacuum or Forceps Delivery
Any life-threatening condition to the mother or fetus which can be relieved by birth
Prolonged second stage
Exhaustion
Vacuum-Assisted Birth
Assistance of delivery by placing a suction cup device over the occiput of the fetal head
A hand pump is used to create suction (green zone) to hold the vacuum cup on the fetal head
Traction is applied intermittently
A vacuum release allows for removal of the cup
Hospital policies state only three "pop-offs" or applications
Episiotomy Assessment and Care
Assessment with REEDA
Redness
Edema
Ecchymosis
Discharge
Approximation
Care
Ice packs
Sitz bath
Analgesic spray and PO meds
Perineal hygiene and spray bottle, tucks pads
Indications for C-Section
Labor failure to progress
CPD
Repeat c-section
Breech/transverse lie presentation
Active genital herpes
Placental previa
Placental abruption
Prolapsed umbilical cord
PIH
Non-reassuring fetal status
Any life-threatening condition related to the mother or infant
Majority of cesarean births in the US performed due to previous cesarean birth & shoulder dystocia
C-section babies are more at risk for what complications?
TTN (transient tachypnea of the newborn)
Injury, such as laceration, bruising, fractures, or other trauma
2 incisions are made in C-sections
Abdominal wall (skin incision)
Midline vertical incision
Pfannenstiel incision
Uterine Wall
Low transverse
Low vertical
Classic, a vertical incision into the upper uterus
Skin incision may not match the uterine incision
Vaginal Birth After Cesarean (VBAC)
"Once a cesarean always a cesarean" is no longer the standard of care
If a woman has a hx of previous cesarean birth, she will be offered scheduled repeat c-sections
To minimize risk of uterine rupture
Low transverse uterine incisions reduce the risk of rupture
If have a classical uterine incision, VBAC is contraindicated
For VBAC, use of drugs for induction or augmentation is contraindicated
Increases risk of uterine rupture
Women should discuss VBAC with their providers to determine if a trial of labor is appropriate
Causes of Labor Pain
Dilation & stretching of the cervix
Pressure & pulling on adjacent organs
Hypoxia of the uterine muscle (tissue ischemia)
Pressure from the presenting part on the vagina & perineum during birth
Characteristics of Childbirth Pain
Part of a normal process
Several months to prepare
Labor pain has a foreseeable end
Labor pain is intermittent, not constant
Ends with the birth of a baby!
Major source of birth pain is
stretching of the cervix and lower uterus
T/F Best time to learn pain management techniques is prior to labor
True
Help Laboring Women RELAX! It's important because it...
Promotes uterine blood flow, thereby improving fetal oxygenation
Promotes more efficient uterine contractions
Reduces the tension that increases pain perception and decreases overall pain tolerance
Reduces tension that may inhibit fetal descent
What is the: Bradley Method also known as "husband-coached childbirth" (1917-1998)
The Bradley Method emphasizes deep breathing & relaxation exercises, massage & partner support to control the pain
12 weeks of classes
Lamaze Method developed by Ferdinand Lamaze in the 1950's focuses on?
stressed controlled breathing and focus & distraction techniques to help control perception of pain during labor
Breathing Patterns:
First phase: cleansing breath, then paced breathing: slow paced
Second phase: Modified paced (faster)
Third phase:
Pattern-paced breathing - "hee-hoo"
Pant blow breathing to help control the urge to push - prevent injury to cervix and fetal head
If epidural given too early, it can impair the woman's
natural urge to push
Regional Anesthesia
Commonly used to provide analgesia for labor pain
Loss of sensation from a large area of the body owing to blockade of neural impulses
Major advantage is that the woman can participate in the birth yet still have good pain control
Most Common Types of Regional Analgesics
Lumbar Epidural block
Spinal Block
Combined Spinal-Epidural Block
Pudendal block
Disadvantages of Epidural
Disadvantages:
Confined to bed
VS frequently
Maternal hypotension
May interfere with pushing. Why? (it is numb - doesn't feel the urge to push)
T/F Check BP immediately after epidural insertion
True
Spinal Block
Rarely used for spontaneous vaginal delivery
Likely used in low or midforceps deliveries and vacuum extraction
Often used for c-section deliveries, esp. when the woman hasn't had an epidural
Injection of a single dose of medicine into the subarachnoid space
There is then loss of sensation and motor function below the level of the block
Intrathecal Opioids
Variation of a subarachnoid block or spinal
Difference lies in the type of medication (opioid instead of a local anesthetic) placed just inside the dural sac
Advantages of Intrathecal Opioids
Rapid onset
Pt may ambulate with this type of anesthesia
Does not produce the hypotension as with other types of anesthesia
Disadvantages
Does not last as long as labor
Causes respiratory depression, itching, nausea, and vomiting (Duramorph/Astromorph)
Educate pt that contractions will feel like pressure either in abdomen or rectum rather than pain
Treatment (Spinal headache)
Replace fluid lost
Bedrest
Analgesics
IV caffeine for vasoconstriction
Blood patch
Causes blood to clot and plugs the dura
Increases intraspinal pressure thereby increasing pressure of CSF around the brain
Prolonged second stage defined as more than
3 hours in nulliparous women and 2 hours in multiparous women
Pudendal Block
Provides perineal anesthesia for second stage of labor, birth and episiotomy repair
Can be used for vaginal delivery, forceps delivery, and also vacuum delivery (especially when there isn't an epidural)
Administered through the vagina by placing a local anesthetic in the area of the pudendal nerve
Local Anesthesia
Injecting the perineal tissues with 10-20 cc of a local anesthetic (lidocaine) to facilitate cutting or repair of the perineum and vagina
Least likely to have complications
Loss of sensation from a small area of the body
Goals of a Doula
A positive birth experience
To understand mom, her prior experiences, fears, and hopes
To guide mom towards a positive birth, where she has an active role in all decisions and experiences an environment of safety
To support mom's partner for a positive family experience and essential couple bonding
To understand and respect the emotional and physical labor process unique to each mom
To learn from each unique birth to become a better doula
Substance Abuse in Pregnancy: Infant Characteristics
Infants born to substance abusers often have the following characteristics:
Poor feeding
Can't coordinate suck, swallow
Poor sleep
Difficulty handling physical stimulation (holding)
Hyperactive reflexes
High-pitched cry
Substance Abuse in Pregnancy: Nursing Care Management
Screen all pregnant women
Be matter-of-fact & nonjudgmental
Assess woman's understanding of impact of use on pregnancy
Focus on ongoing assessment & patient teaching
Discuss strategies to help quit & treatment options
Postpartum:
Tox screen the baby
Collect first urine, "bag" the baby
If positive, refer to social services
Nursing Role in Adolescent Pregnancy: Communication
Techniques:
research has shown that the most effective methods of communication with adolescents are frequent, brief, informational chats during teachable moments using interactive communication techniques
Contraceptive counseling should focus on practical advice instead of repeated education on why contraception is important
Sexual Assault Reporting
Health care providers are mandatory reporters of all forms of abuse, including sexual abuse
Immediate medical attention provides the best medical protection and legal evidence
Evidence will be collected and other injuries will be documented. (Pt may have to return 2X as bruising is most evident 24 hours after the event)
Medical attention is confidential and extremely important
Advocates are available for support through medical procedures
Remind Victim of Sexual Assault NOT to:
Wash
Shower
Change clothing
Douche
Cycle of Violence
Although intimate partner violence may be random, there is often a pattern
The violence occurs in a cycle that consists of three phases:
Tension building
Battering incident
Honeymoon
T/F African American mothers are more likely to experience fetal demise than other populations
True
T/F congenital malformations are the most common cause of miscarriages and still borns
True
Phases of Bereavement
1. Shock & Numbness
"this is all a bad dream"
Parents have difficulty making choices. Usually lasts about 2 weeks
2. Searching & Yearning
Searching for answers
Mom might feel phantom fetal movements & hear baby crying, may feel like they're "going crazy"
Lasts from 2 weeks after loss to 4 months, longest phase
3. Disorientation
Usually seen as depression
During first week, but may last months to years
Intensifies and subsides
Regrieving may happen especially during holidays & birthday anniversaries
4. Reorganization
Numbness wears off, reality of loss
18 months to 2 years
Signs of Normal Labor
❧Bloody show
❧Pain beginning in the back and coming around to the front of the abdomen
❧Pain that does not diminish with rest
Pain that intensifies with walking (usually but not always)
❧Cervical change
❧Regular contraction pattern
Hypotonic dysfunction:
most common
With hypotonic uterine dysfunction, the woman initially makes normal progress into the active stage of labor; then the contractions become weak and inefficient or stop altogether
❧Coordinated contractions but are too weak & infrequent to be effective
❧Active phase of labor
❧Mom usually comfortable because uterine contractions may be weak & not painful
❧Persist hypotonic labor produces fatigue & frustration for mother.
❧Fetal hypoxia usually NOT associated with hypotonic labor.
Medical measures for dysfunctional labor
❧Maternal pelvis & fetal presentation evaluated
❧Augmentation techniques
❧Amniotomy
❧Pitocin infusion
❧reduced placental perfusion caused by excessive uterine contractions is the most common risk of pitocin labor augmentation
❧If unsuccessful, may result in cesarean birth
T/F Hypertonic Dysfunction is less common than hypotonic labor dysfunction and is characterized by contractions that are uncoordinated and ineffective
True
Managements of hypertonic dysfunction:
❧Pain relief- primary intervention
❧Warm showers or baths promotes rest & relaxation
❧Massage, imagery, music
❧Anesthesia & analgesic administration
Shoulder dystocia:
Delayed or difficult birth of the shoulders may occur as they become impacted above the maternal symphysis pubis
❧As soon as the head is born, it retracts against the perineum - "turtle sign"
Interventions for Shoulder Dystocia
❧McRobert's maneuver (extreme crunch)
❧Suprapubic pressure
❧Requires urgent intervention
There is increased risk of ❧Umbilical cord compression decreases fetal circulation
❧What fetal assessments would the nurse perform?
Macrosomia (>4000 g or 8 lb, 13 oz) (8.8 lbs)
❧Head & shoulders may not be able to pass through pelvis
❧Distension of uterus reduces strength of contractions.
❧Small pelvis or abnormally shaped pelvis may not be able to deliver an average size infant
❧Fetal position as it descends through her pelvis alters the ease with which she completes the second stage of labor
Define PROM and PPROM:
PROM is the rupture of the sac before the onset of true labor
PPROM: Preterm premature rupture of membranes occurs before 37 weeks of gestation.
Associated with preterm labor
Preterm labor is defined as labor beginning after
20 wks gestation & before 37 wks gestation
Prematurity is the #1 cause of
neonatal mortality as well as long-term neurologic disabilities in the US - 1 in 8 babies are born premature
Calcium channel blockers
Nifedipine for tocolytics
(procardia) calcium essential for smooth muscle contractions so blocking calcium prevents muscle from contracting
If a woman experiences sxs of PTL for more than 15 minutes Teach:
Empty her bladder
Lie down on side
Drink 3-4 8 oz. cups of water
Palpate uterus for contractions & call if occur 10 min apart or less for 1 hr
Soak in warm tub bath with uterus completely submerged
Call provider if symptoms persist
Betamethasone/dexamethasone
❧Before birth reduces the severity of complications associated with immature gestation such as RDS (Respiratory Distress Syndrome). Lowers chance for intraventricular hemorrhage in premature infants.ndicated for 24 to 34wks gestation
❧Delay birth for up to 24 hrs after woman begins steroid therapy to obtain benefits from medication administration.
❧Dosage 12 mg x 2 doses 12 or 24 hrs apart, IM
T/F The key intervention in cord prolapse to relieve pressure on the cord without compression of the blood vessels and to expedite delivery.
true
Types of Cord Prolapse
Complete: cord visible at vaginal opening
Prolapsed : not visible but may be palpated on vaginal examination as it pulsates
Occult prolapse: cord slips along side the fetal head or shoulders; prolapse can not be palpated or seen
Therapeutic Management of Cord Prolapse
Nursing priority it to relieve pressure on the cord to restore blood flow after prolapse.
Vaginal exam to push head off cord. Place mom on hands & knees; knee-chest
Prepare for c/s unless vag. delivery can happen quickly.
O2 per mask/ increase iv fluids
Variations of uterine rupture
❧Complete: direct communication between uterine & peritoneal cavities
Incomplete: rupture into the peritoneum covering the uterus or into the broad ligament but not into the peritoneal cavity
Dehiscence: partial separation of an old uterine scar. May be little or no bleeding.
Uterine Inversion:
Occurs when uterus completely or partially turns inside out usually during third stage of labor, or in postpartum
Anaphylactoid Syndrome
Otherwise known as AMNIOTIC FLUID EMBOLISM
Anaphylactoid Syndrome occurs when
amniotic fluid that contains fetal particulate matter (skin cells, vernix, hair, meconium) is drawn into the maternal circulatory system & is carried to the lungs & obstructs pulmonary vessels leads to DIC (Disseminated Intravascular coagulation- clotting mec
Postpartum Hemorrhage:
Most common complication in the PP period
One of three leading causes of maternal morbidity and mortality in the U.S.
Early PPH vs Late PPH
Early: May occur within the first 24 hours of delivery
The first 2 hours being the most crucial
Late: Occurs 7 - 14 days after delivery and before 6 weeks PP
T/F uterine atony is the most common cause of PPH
True
Postpartum infections are manifested by a
fever (100.4 F or greater) on at least 2 of the first 10 days postpartum AFTER the first 24 hours
T/F the organisms involved in mastitis is not passed in the mothers milk
True
Postpartum Blues
Affects 70%-80% of new mothers
Usually does not last longer than 2-6 weeks
Periventricular Leukomalacia:
brain injury involving an ischemic infarction of the white matter of the brain, CP develops in most cases
Intraventricular Hemorrhage (IVH)
Occurs primarily in premature infants less than 34 weeks gestation
Graded 1 through 4
Diagnosed by Head US
Signs and Symptoms of RDS
Tachypnea >60/min
Retractions (Intercostal and substernal retractions)
Expiratory Grunt
Respiratory acidosis
Increase in CO2, Decrease in O2
Nasal Flaring
On CXR can resemble pneumonia
Cyanosis
As RDS worsen infant may become flaccid, apneic and decrease breath sounds.
Nursing Management for RDS
Management
Ventilator or Nasal CPAP Support
Surfactant
Nutritional Support
Appropriate Thermoregulation Support
Quiet and non-stress full environment
Patent Ductus Arteriosus (PDA)
Persistence of connection between main pulmonary artery and the aortal
Fetal patency is functional, diverts blood away from fluid filled lungs
Incidence is inversely related to gestational age
Occurs 3 times more commonly in females than in males
Symptoms include systolic murmur tachycardia, tachypnea, crackles and hepatomegly. Can lead to cyanosis and mottling.
PDA management
Management:
❧Fluid Restriction
❧Indocin or Ibuprofen
❧Surgical Ligation
Tetralogy of Fallot
Cyanotic heart defect a ventricular septal defect
The aorta is positioned over the ventricular septal defect, stenosis of pulmonary valve and hypertrophy of left ventricle.
Signs and symptoms: Respiratory difficulties, cyanosis, tachycardia, tachypnea and diaphoresis
Necrotizing Enterocolitis:
Signs and symptoms:
Bloody stools, not tolerating feedings, increase in abdominal girth, bile like residuals or emisis, blue colored abdomen
-Notify MD/NNP immediately
-Medical Management: NPO, CBC, Blood Cultures, Antibiotics, KUB, exploratory lap if suspect perforation
Diagnosis is confirmed by x-ray
Decrease incident with BF
Skin of Premie
Preterm skin fragile
The more premature the infant is the more fragile the skin
Source of water loss
Nursing Management
Humidified isolette
Aquafor or similar barrier
Choose appropriate leads and move pulse ox probe periodically
Be careful with photo therapy lights and overhead heaters
Physiologic Jaundice:
benign (due to increase biliruben production due to breakdown of fetal RBC and immature liver) Jaundice post 24 hours birth
Pathological Jaundice:
jaundice appears before 24 hours or persists post 7 days. >13mg/dl
YOU MIGHT ALSO LIKE...