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Exam 3 Knowledge Checks (Intrapartum, Perfusion, Preeclampsia)
Terms in this set (114)
How do labor contractions cause the cervix to efface and dilate? How do they cause fetal descent?
Effacement and dilation of the cervix occur because contractions pull the cervix upward over the fetus and amniotic sac while pushing the fetus and amniotic sac downward against the cervix. The muscle fibers of the upper uterus become shorter to maintain these forces between contractions. In addition, the uterus changes shape and becomes more elongated and narrow to maintain pressure of the fetus and amniotic sac against the cervix.
What differences in effacement are expected in the parous woman compared with the woman who has not previously given birth?
The cervix of the nullipara effaces more before it dilates. The cervix of a multipara is usually thicker than that of a nullipara during the entire labor.
What changes occur in the maternal cardiovascular, respiratory, gastrointestinal, urinary, and hematopoietic systems during labor?
Maternal changes occurring during labor include the following:
a. Cardiovascular system—A slight increase in blood pressure and decrease in pulse rate occur as each contraction temporarily stops blood flow to her uterus. Supine hypotension may occur if she lies on her back because the heavy uterus compresses her inferior vena cava and reduces blood flow to her heart.
b. Respiratory system—The depth and rate of respirations increase.
c. Gastrointestinal system—Gastric motility is reduced during labor, which can result in nausea and vomiting. Controversy exists on whether laboring women should be allowed to eat or drink during labor. Concerns surround the risk for vomiting and aspiration of undigested foods in the event general anesthesia is required. Evidence supports allowing low-risk laboring women some form of oral intake. The American Society of Anesthesiologists supports oral intake of clear liquids in low-risk laboring women.
d. Urinary system—The sensation of a full bladder is reduced.
e. Hematopoietic system—Leukocyte counts are as high as 20,000 to 30,000/mm3, and levels of clotting factors are elevated.
Why are intermittent rather than sustained uterine contractions important?
Uterine contractions temporarily decrease blood flow to the placenta. If the contractions were sustained, the fetus could not receive freshly oxygenated blood and nutrients and dispose of waste products through the placenta.
How does the normal process of vaginal birth benefit the newborn after birth?
Labor and vaginal birth primarily benefit the newborn by increasing absorption of fetal lung fluid. They also cause compression of the upper airways, causing some lung fluid to be expelled. These effects reduce the amount of lung fluid remaining in the newborn's respiratory tract when breathing begins. Labor also stimulates the fetus to secrete catecholamines, which help speed clearance of the lung fluid after birth, stimulate cardiac contraction and breathing, and aid in temperature regulation.
What are the two powers of labor?
The power of labor during the first stage involves uterine contractions. Powers during the second stage include uterine contractions, augmented by the woman's voluntary pushing efforts.
What are the three divisions of the true pelvis?
The three divisions of the true pelvis are the inlet, midpelvis, and outlet.
Why is the vertex presentation best during birth?
The vertex presentation, in which the fetal head is fully flexed forward, allows the smallest diameter of the fetal head to enter the pelvis. It also more effectively dilates the cervix.
For each fetal position listed, describe the fetal landmark. Where is this landmark located in relation to the mother's pelvis: ROP? OA? RSA? LMA?
ROP: The fetal landmark is the occiput, indicating a vertex presentation. It is located in the mother's right posterior pelvic quadrant. OA: The fetal landmark is the occiput, which is located in the mother's anterior pelvis and is not directed toward her left or her right. This is often the presentation just before birth. RSA: The fetal landmark is the sacrum, indicating that the fetus is in a breech presentation. It is located in the mother's right anterior pelvis. LMA: The fetal landmark is the mentum, or chin, indicating that the fetus is in a face presentation. The chin is in the mother's left anterior pelvis.
If the fetus is in the face presentation, why is using the occiput to determine position within the pelvis not possible?
If the fetus is in the face presentation, the occiput is not accessible to the examiner's fingers during vaginal examination. For this reason the fetal chin (mentum) is used to describe the position (such as RMA [right mentum anterior]).
What are some signs and symptoms that a woman might experience before labor begins?
The woman may note several changes as labor approaches: increased strength and frequency of Braxton Hicks contractions, lightening, increased vaginal mucus, bloody show, an energy spurt, and a small weight loss.
What are the differences between true and false labor? Which difference is the most significant?
False labor tends to differ from true labor in three major ways. True labor is characterized by contractions that progressively become more frequent, last longer, and are more intense. The discomfort of true labor begins in the lower back and sweeps to the lower abdomen, whereas the discomfort of false labor is more often in the abdomen or groin and is often simply annoying. In true labor, progressive effacement and dilation of the cervix occur, which is the most significant difference from false labor.
Why does the fetus enter the pelvis with the sagittal suture aligned with the transverse diameter of the woman's pelvic inlet?
The transverse diameter of the pelvic inlet is slightly larger than the inlet's anteroposterior diameter. The anteroposterior diameter of the fetal head (in line with the sagittal suture) is slightly larger than the transverse diameter. Therefore the fetal head best fits the pelvis if the sagittal suture is aligned with the pelvic transverse diameter at entry.
Why does the fetal head turn during labor until the sagittal suture aligns with the anteroposterior diameter of the mother's pelvic outlet?
Because the woman's pelvic outlet is usually slightly larger in its anteroposterior diameter than its transverse diameter, the fetal head turns in the mechanism of internal rotation so that the sagittal suture aligns with the anteroposterior diameter as the fetus descends.
How do maternal behaviors change during each phase of first-stage labor and the second stage?
During the first stage, latent phase, the woman is often sociable, excited, and somewhat anxious. During the first stage, active phase, the woman becomes less sociable and is inwardly focused. During the first stage, transition phase, the woman may become irritable and temporarily lose control. During the second stage, the woman usually concentrates her energy toward pushing her baby out and interacts little with others. She often regains a feeling of control and active participation in the birth during the second stage.
What are typical characteristics of contractions during each phase of first-stage and second-stage labor?
Contractions vary among women, but the general pattern includes increasing frequency, duration, and intensity throughout labor. In the first stage, latent phase, contractions gradually increase until they are about 5 minutes apart, lasting for 30 to 40 seconds with mild to moderate intensity. In the first stage, active phase, contractions increase to about 2 to 5 minutes apart with a duration of about 40 to 60 seconds and moderate to strong intensity. In the first stage, transition phase, contractions are strong with a frequency of 1 ½ to 2 minutes apart and a duration of 60 to 90 seconds. In the second stage, contractions are strong and about 2 to 3 minutes apart and have a duration of about 40 to 60 seconds.
What four signs may indicate that the placenta has separated?
Signs that the placenta may have separated include a spherical uterine shape, the rising of the uterus upward in the abdomen, protrusion of the umbilical cord farther outward from the vagina, and a gush of blood.
What complications may occur if the uterus does not contract firmly and remain contracted after the placenta is expelled?
Hemorrhage may occur if the uterus does not remain contracted after birth of the placenta because open blood vessels at the site will not be compressed by the interlacing muscle fibers of the uterus.
How does the pain of childbirth differ from other kinds of pain?
Childbirth pain differs from other painful experiences because it is part of a normal process, the woman has time to prepare for it, it is self-limited and intermittent, and it ends with the birth of the baby.
How can excessive pain adversely affect a laboring woman and her fetus?
Excessive, unrelieved labor pain may result in a stress response (diverting blood flow from the uterus and compromising fetal oxygenation), maternal acid-base imbalance, and fetal acidosis. It may increase the length of labor. Poor pain relief can lessen the joy of childbirth for the woman and her partner and may have lasting psychological effects.
How may physical and psychological factors interact in a woman's labor pain experience?
Physical and psychological factors interact to alter the ability to tolerate pain. For example, relaxation and working with the forces of labor enhance the chance that the woman who has a large baby and a small pelvis will give birth vaginally.
What four sources of pain are present in most labors?
Four sources of pain present in most labors are cervical dilation, uterine ischemia, pressure and pulling on pelvic structures, and distention of the vagina and perineum.
How can each of the following physical factors influence the pain a woman experiences during childbirth: Labor intensity? Cervical readiness? Fetal position? Maternal pelvis? Fatigue?
Physical factors that influence pain include the following:
a. A short, intense labor may be more painful because dilation, effacement, and fetal descent occur rapidly.
b. A cervix that does not efface or dilate easily is likely to be associated with a longer and more uncomfortable labor.
c. An abnormal fetal position may cause a longer labor as the woman's body maneuvers it into a better position. Back pain is especially noticeable if the fetus is in an occiput posterior position.
d. Variations in the mother's pelvic size or shape may result in abnormal fetal presentations or positions and in a longer labor because the fetus does not fit through the pelvis easily.
e. Fatigue reduces the woman's pain tolerance and ability to use coping skills.
What psychosocial factors influence a woman's experience with labor pain?
Psychosocial factors that influence labor pain include culture, anxiety and fear, previous experiences, preparation for childbirth, and the mother's support system.
How does the gate-control theory of pain relate to nonpharmacologic methods of pain control?
The gate control theory of pain assumes that a gating mechanism in the dorsal horn of the spinal cord controls the transmission of painful impulses to the brain for interpretation. Pain impulses are transmitted through small-diameter fibers, whereas other sensations, such as tactile sensations (e.g., massage, heat, cold), are transmitted more quickly through large-diameter fibers. Therefore the impulses transmitted through the large-diameter fibers interfere with, or "close the gate," to transmission of pain impulses. Impulses from the brain, such as responses to auditory stimuli (listening to music, for instance), can also impede pain transmission.
What are some nursing actions to encourage relaxation during labor?
Nursing actions to promote relaxation include arranging for environmental comfort, maintaining the woman's general comfort, reducing factors that cause anxiety and fear, and using specific relaxation techniques such as helping the woman focus on relaxing specific tense muscles.
How can the nurse reduce a laboring woman's anxiety or fear?
Accurate information and a focus on the normal aspects of childbirth help reduce anxiety and fear. Avoid referring to the woman as a client or patient because these words are associated with illness in a hospital. Call her and her partner by the names they requested when admitted. Empowerment of the birthing partners helps them see themselves as competent to give birth successfully.
How might each of these cutaneous stimulation techniques be used to aid relaxation during labor: Self-massage? Massage by others? Counterpressure? Warmth or cold?
Self-massage might include effleurage, rubbing the hands together, or patting or banging the hands on the rail. Massage by others helps relax tense muscles and aids relaxation. Counterpressure, which may include sacral pressure or other variations, is often used to reduce back pain when the fetus is in an occiput posterior position. Acupressure uses directed pressure for pain management. Warmth relaxes muscles, promoting relaxation. Warmth may be in the form of a shower, tub bath, or whirlpool. Cool often feels better to the laboring woman who may be hot, or she may want cool only in a local area or ice in her mouth.
When hydrotherapy is used during labor, why are these cautions required: Adequate maternal hydration? Control of water temperature?
Hydration must be adequate to offset the diuresis that often occurs with immersion in water. Diuresis could reduce placental perfusion if plasma volume is low. Water temperature must be controlled to prevent hyperthermia or hypothermia, which could raise the mother's metabolic rate, increasing her oxygen and glucose consumption. These changes could reduce oxygen and glucose delivered to the fetus. Hyperthermia in the mother increases fetal body temperature and increases fetal demand for oxygen.
Why is it important to avoid advancing to more complex breathing techniques sooner than needed?
The more complex breathing techniques are more effective for greater pain, but they are tiring. Advancing from simpler to more complex breathing techniques too quickly can cause the mother to become fatigued when she most needs to use these methods.
What is the purpose of a cleansing breath?
The cleansing breath has four purposes: (a) to release tension; (b) to increase oxygen intake to combat myometrial hypoxia; (c) to clear the woman's mind so she can focus on relaxing through the contraction; and (d) to signal her labor partner that a contraction has begun.
Is there a valid reason why a woman should push as soon as her cervix is completely dilated? Why, or why not?
Lengthy pushing in the second stage has shown greater maternal fatigue, more operative births, and nonreassuring fetal heart rate (FHR) patterns and does not significantly shorten the second stage. Strenuous directed pushing has shown a greater risk for structural and neurogenic injury to a woman's pelvic floor. Closed glottis pushing delivers less blood to the placenta, possibly resulting in fetal hypoxia and nonreassuring fetal heart monitor patterns.
How can drugs taken by the expectant mother affect the fetus?
Drugs taken by the mother can affect the fetus directly, such as by decreasing fetal heart rate variability, or indirectly, such as by causing maternal hypotension that reduces placental blood flow and fetal oxygen supply.
How do changes in the following maternal body systems affect pharmacologic pain management: Cardiovascular system? Respiratory system? Gastrointestinal system? Nervous system?
Aortocaval compression should be offset by placing a wedge under the woman's hip if a supine position is required. Tilting the patient table during surgery reduces compression until the infant is born. The woman is more sensitive to general anesthesia and may have a greater fall in oxygenation when general anesthesia is induced. Reduced peristalsis and tone of the sphincter at the junction of the esophagus and stomach can lead to regurgitation and aspiration of gastric contents, primarily with general anesthesia. Lower doses of anesthetic agents will be needed for epidural or subarachnoid blocks.
Why is it important to know about a woman's intake of drugs, botanical medicines, legal substances (such as alcohol), and illegal drugs?
Drugs (prescribed, over the counter, or illicit), botanical preparations, and alcohol may interact with one another. These interactions may be harmful to the woman, the fetus, or both. Knowledge of exactly what drugs she uses allows the safest choices in pharmacologic pain-relief methods.
What is the primary adverse effect of opioid administration? How can this effect be reduced?
Neonatal respiratory depression is the primary drawback to the use of opioid analgesia. This effect can be reduced by timing the dose to reduce the amount transferred to the fetus (which varies according to the drug) and by giving the narcotic in small, frequent IV doses at the beginning of the contraction. Naloxone (Narcan) is the drug that may be given to reverse opioid-induced respiratory depression in the neonate, with bag-and-mask ventilation being the initial method to oxygenate the infant.
What is the preferred order of resuscitation for the newborn who has respiratory depression? Does naloxone have any use in an adult?
Airway management (i.e., bag-and-mask ventilation) takes precedence over use of naloxone for the newborn, and the drug is no longer routinely given to the baby for respiratory depression. Naloxone may be used to reverse opioid-induced respiratory depression in the adult. The respiratory depression may be from systemic or epidural administration of opioids.
What are two major advantages of using regional pain management techniques during childbirth?
The two major advantages of regional pain management are that the woman can have pain relief and remain alert.
What is the major adverse effect of the epidural block or SAB? How can the fetus be affected? How may this effect be reduced?
Epidural and subarachnoid blocks can cause maternal hypotension. The fall in blood pressure may result in reduced placental blood flow, compromising fetal oxygen supply. Giving the woman IV fluids before the block reduces this effect. Other less serious adverse effects are bladder distention, prolonged second stage of labor (epidural), and postdural puncture headache (usually only subarachnoid block).
What are common side effects of epidural or intrathecal opioid analgesics, and how are these managed?
Epidural or intrathecal opioid analgesics may cause nausea, vomiting, itching, or a combination of these. They may also result in delayed respiratory depression (up to 24 hours), depending on the drug used. Management includes promethazine for nausea and vomiting; diphenhydramine, naloxone, or naltrexone for itching; and pulse oximetry and monitoring of respirations while the opioid is given and up to 24 hours after administration ends, depending on the drug.
What are the major adverse effects of general anesthesia? What measures reduce the risks?
Maternal regurgitation with aspiration of acidic gastric contents is the major potential adverse effect of general anesthesia. The risk may be reduced by limiting intake to clear fluids, giving drugs to raise the gastric pH, giving drugs to reduce gastric secretions or speed emptying of the stomach, and using cricoid pressure (Sellick maneuver) to block the esophagus while the endotracheal tube is being inserted. Respiratory depression, primarily in the infant, is minimized by delaying general anesthesia until the surgery team is prepared and by keeping the anesthesia level as light as possible until the umbilical cord is cut.
What techniques are commonly taught in childbirth preparation classes during the third trimester?
Childbirth preparation classes during the third trimester focus on self-help measures, what to expect during birth, and how to prepare for the birth of the baby. Specific techniques include pharmacologic and nonpharmacologic pain control.
How is the woman in labor helped by having a labor partner?
Having a support person during labor increases a woman's satisfaction by helping her cope with stress, focus on her learned techniques, and feel that her experience is being shared.
What are the various roles the support person might take?
Various support roles include active assistance and physical care, verbal encouragement, minimal physical assistance, and presence without active involvement.
What high technology method is primarily used in the United States to assess FHR and UA?
The electronic fetal monitor (EFM) is used to assess fetal heart rate (FHR) and uterine activity (UA) during labor for women. Intermittent auscultation (IA) of the FHR and palpation of uterine contractions is the safe and acceptable low-technology method of assessing the labor in low-risk women.
Describe maternal blood flow to the uterus and placenta.
Maternal blood flow to the uterus and placenta originates primarily in the uterine arteries, as well as the internal iliac and ovarian arteries. Maternal arterial blood pressure maintains oxygen- and nutrient-rich blood flow to the uterus and placenta. Blood enters to the intervillous spaces of the placenta via spiral arteries. The intervillous space allows for exchange of substances, such as oxygen, without mixing of maternal and fetal blood. Simultaneously, maternal blood carrying away carbon dioxide and fetal waste products drains from the intervillous spaces through endometrial veins and returns to maternal circulation for elimination.
Which umbilical cord vessel(s) carry(ies) deoxygenated blood back from the fetus to the placenta?
The two umbilical arteries carry deoxygenated blood from the fetus to the placenta.
What are the advantages and limitations of each fetal monitoring method?
Intermittent auscultation promotes the laboring woman's mobility and creates a more natural atmosphere. However, assessment of the fetus is intermittent—significant events may not be detected, periodic and nonperiodic changes in fetal heart rate (FHR) cannot be determined, the patient may be intolerant of the clinician's touch during contractions, and contractions cannot be assessed objectively. Continuous electronic fetal monitoring provides more data, is often expected by parents, and can assist the nurse to better observe more than one woman. It allows the nurse to devote more time to coaching the woman and her partner. Its primary drawbacks are reduced maternal mobility, adjustments to the equipment, and its technical atmosphere. When using external transducers (ultrasound/tocotransducer), the FHR may be doubled or halved in cases of fetal bradycardia or tachycardia, the maternal heart rate may be recorded as fetal data if the ultrasound transducer is placed over maternal arterial vessels, obese women and preterm or multifetal gestations may be difficult to monitor, and the tocotransducer does not accurately assess the intensity of contractions or resting tone of the uterus between contractions. Internal monitors (fetal scalp electrode [FSE]/intrauterine pressure catheter [IUPC]) are not usually affected by maternal position changes (although the IUPC needs to be recalibrated with maternal position changes) and accurately measure all parameters of uterine activity. However, they require cervical dilatation, and ruptured fetal membranes can cause trauma and infection.
What three descriptive terms are used to characterize UA with palpation?
When palpating uterine contractions, the fingertips are used to indent the uterus at the peak of the contraction. The descriptive terms used are "mild", "moderate" and "firm", or "strong". A mild contraction can be compared with the tip of the nose—easily indented. A moderate contraction is compared with the chin—it can be slightly indented. A firm or strong contraction is compared with the forehead—unable to indent.
Which grid on the paper tracing or computer monitor is used to record FHR and UA data?
The FHR records on the upper grid of the monitor paper or computer tracing; the uterine activity records on the lower grid.
Which EFM sensor uses heart motion to measure FHR?
The ultrasound transducer, or external electronic fetal monitor (EFM), detects fetal heart motion to measure fetal heart rate (FHR). A handheld Doppler device uses the same technology. Using a fetoscope or Pinard stethoscope, the listener hears the fetal heart sounds. An internal fetal scalp electrode measures, processes, and records the R to R interval of the fetal QRS complexes.
What are two factors that may affect tocodynamometry accuracy?
The accuracy of the uterine activity (UA) data from a tocodynamometer may be affected by the position of the toco on the maternal fundus, the amount of maternal tissue (adipose) between the toco and uterus, and the maternal position.
What is the significance of FHR accelerations?
Fetal heart rate (FHR) accelerations, whether spontaneous or evoked, are predictive of adequate oxygenation and a fetal pH that rules out acidemia.
Describe the differences among early, late, and variable decelerations.
Late decelerations are visually apparent and usually symmetric in shape, with a gradual decrease and return of the fetal heart rate (FHR) to baseline. Late decelerations occur when the onset of the deceleration to the nadir is equal to or greater than 30 seconds, and the nadir of the deceleration occurs after the peak of the contraction. Late decelerations that occur in the presence of fetal heart rate variability indicate transient fetal hypoxia caused by an interruption along the oxygen pathway. Once corrective measures are initiated, they will typically resolve. Late decelerations are more concerning when they are recurrent and associated with tachycardia and a loss of variability. If uncorrected, hypoxic stress will lead to acidemia and neonatal depression.
Early decelerations are visually apparent, are symmetric in shape, and have a gradual decrease and return to FHR baseline that mirrors a uterine contraction. The deceleration onset, nadir, and recovery coincide with the beginning, peak, and ending of a contraction. The onset of the deceleration to the nadir is equal to or greater than 30 seconds. Early decelerations are thought to represent a vagal response during fetal head compression. Early decelerations are benign and not associated with an interruption of fetal oxygenation.
Variable decelerations are visually apparent, abrupt decreases from onset to nadir of a deceleration. The onset of the deceleration to the nadir is less than 30 seconds. The decrease is at least 15 bpm below the baseline, with the deceleration lasting at least 15 seconds and no longer than 2 minutes from onset to the return to baseline. Deceleration shape, depth, duration, and timing in relationship to contractions may vary. Variable decelerations are suggestive of an interruption of oxygenation at the level of the umbilical cord where cord vessels may be compressed. Generally, variable decelerations are not associated with significant hypoxia or acidosis as long as they are intermittent and accompanied by normal baseline rate and variability. If cord compression is recurrent or prolonged, interruption in fetal oxygenation can progress to hypoxemia, hypoxia, metabolic acidosis, and final metabolic acidemia if corrective measures are not successful.
Define frequency, duration, intensity, resting tone, and relaxation time.
Frequency is the time (minutes) from the onset of one contraction to the onset of the next contraction. Uterine activity may also be quantified as the number of contractions in a 10-minute window of time, averaged over 30 minutes. Duration is the time (sec) from the onset of one contraction to the end of the same contraction. Intensity is the strength of the contraction at its peak. It is measured by palpation as mild, moderate, strong, or firm. It is quantified in mmHg with the use of an intrauterine pressure catheter (IUPC). Resting tone is the amount of pressure (tone) in the uterus at rest. Normal resting tone is palpated as soft or relaxed or measured with an IUPC as approximately 10 mmHg. Relaxation time is the amount of time from the end of one contraction to the beginning of the next contraction.
Which category is interpreted as being predictive of abnormal fetal acid-base status?
Category III FHR is an abnormal pattern that is predictive of abnormal fetal acid-base status at the time of observation.
Describe the ABCD management approach used in fetal monitoring.
The ABCD management approach is a standardized approach to fetal heart rate (FHR) management.
• A—Assess oxygen pathway and identify the cause of FHR changes, both maternal and fetal
• B—Begin corrective measures
• C—Clear obstacles to delivery
• D—Determine a delivery plan
List the corrective measures that may be considered to correct a category II or III FHR pattern.
Corrective measures that may be considered to correct a category II or III fetal heart rate (FHR) pattern include maternal repositioning, IV fluid bolus, administering oxygen, reducing uterine activity (UA), correcting maternal hypotension, performing amnioinfusion, and modifying second-stage pushing efforts.
How does an IV bolus of fluids benefit fetal oxygenation?
An IV fluid bolus benefits fetal oxygenation because it improves maternal cardiac output, which improves uteroplacental perfusion, resulting in improved fetal oxygenation.
What response should be elicited when performing fetal scalp stimulation? What does this tell you about fetal oxygenation?
Fetal scalp stimulation should elicit an acceleration of the fetal heart rate (FHR). This confirms fetal oxygenation and a normal fetal acid-base balance at the time of the acceleration.
What is the purpose of umbilical cord blood gas sampling? Which umbilical cord vessels reflect oxygenated and deoxygenated blood.
Umbilical cord blood gas sampling is a direct method of assessing the level of oxygenation and fetal acid-base after delivery in situations in which a category II or III pattern is observed. Blood from the umbilical vein is oxygenated, coming from the placenta to the fetus. Blood from the umbilical arteries is deoxygenated, returning from the fetus to the placenta.
What are potential obstacles that may be encountered during the "C" part of the ABCD approach? Describe measures to overcome these obstacles.
Potential obstacles to be considered during the "C" part of the ABCD approach include operating room and equipment availability; availability of staff (obstetrician, surgical assistant, anesthesiologist, neonatologist, pediatrician, nursing staff); considerations regarding the mother (consent, anesthesia options, laboratory results, need for blood or blood products, need for an IV, urinary catheter and abdominal prep, what is required for a speedy transfer to the operating room [OR]); considerations regarding the fetus (how many, estimated fetal gestational age and weight, presentation and position, known or anticipated anomalies), and finally, considerations about the monitoring of labor—are adequate data provided to allow appropriately informed management decisions? Measures to overcome these obstacles include preparing the OR; notifying relevant staff; reviewing the mother's medical record for consents, laboratory results, and prenatal data; verifying the status of the patient's IV; inserting a urinary catheter; and prepping her abdomen for surgery if ordered.
What communication skills can the nurse use to establish a therapeutic relationship when the woman and her family enter the hospital or birth center?
The nurse should show warmth, concern, and friendliness when the woman and her family enter the hospital or birth center. Determining the woman's and family's expectations about birth, conveying confidence, assigning a primary nurse, and respecting cultural values are specific skills that the nurse can use throughout labor. In addition, a nonjudgmental attitude facilitates communication and shows respect to the woman as an individual.
How can the nurse incorporate a couple's cultural practices into intrapartum care?
The nurse should try to identify and incorporate beneficial or neutral cultural practices into care during labor and birth by asking about specific practices that are important during birth and facilitating communication by obtaining a fluent interpreter who is acceptable to the woman and her family.
What are the three assessment priorities when a woman comes to the intrapartum unit?
The nurse should promptly evaluate the maternal and fetal conditions and the nearness of birth when a woman comes to the hospital or birth center. Prompt assessments should include checking the maternal vital signs, fetal heart rate and patterns, and progress of labor.
What FHR characteristics (when auscultated) are normal?
A lower limit of 110 bpm and an upper limit of 160 bpm with a regular rhythm are normal. When assessing fetal heart rate (FHR) with a continuous electronic fetal monitor, accelerations and the absence of decelerations from the baseline also are normal.
What observations suggest that a woman is going to give birth very soon? What should the nurse do in that case?
Impending birth should be suspected if the woman is grunting, bearing down, sitting on one buttock, or urgently signifying that her baby is about to be born. In that case, the nurse should abbreviate the initial assessment and collect other information after the birth.
Why would the nurse defer asking a woman about a history of domestic violence?
Women often bring several people with them to the birthing room and want them to stay during admission. Caution is prudent when asking for sensitive information, such as prior pregnancies, sexually transmitted infections (STIs), and potential abuse, when others are present. The woman's partner and other visitors may be unaware of her history. Delay asking intimate information until the woman is alone for confidentiality, safety, and accuracy. A victim of domestic violence is unlikely to answer truthfully when others are around.
What data are collected to determine the current status of the woman's labor?
The current status of the woman's labor is determined by the contraction pattern (frequency, duration, and intensity), status of the amniotic membranes (ruptured or intact), and the cervical exam (dilation, effacement, and fetal station).
What observations suggest that the woman may need additional help with pain management during labor?
The woman may specifically request other pain management measures, including epidural analgesia or other medication, express ineffectiveness of nonpharmacologic measures, show muscle tension during and between contractions, have a tense facial expression, and express an inability to tolerate the pain.
What are three risks associated with amniotomy?
Three major risks of amniotomy are prolapsed umbilical cord, infection, and placental abruption.
Why is the FHR assessed before and after the membranes rupture?
The fetal heart rate (FHR) is assessed before the membranes are ruptured to identify whether the fetus has a normal rate and pattern and to establish a baseline. It is checked after the membranes are ruptured to identify patterns that suggest umbilical cord compression and other problems.
What maternal and fetal signs are associated with chorioamnionitis?
Signs of chorioamnionitis include fetal tachycardia (often the first sign), elevated maternal temperature, and amniotic fluid that has a foul or strong odor, or a cloudy or yellowish appearance.
Describe the significance of each of the following types of amniotic fluid: greenish, cloudy, yellowish, foul-smelling.
Greenish, meconium-stained fluid may be seen in response to transient fetal hypoxia, postterm gestation, or placental insufficiency. The newborn may need suctioning at birth if the fluid is stained with meconium. Fluid with a foul or strong odor, cloudy appearance, or yellow color suggests chorioamnionitis (inflammation of the amniotic sac, usually caused by bacterial and viral infections).
Why are frequent vaginal examinations undesirable during labor?
Frequent vaginal examinations may cause infection because microorganisms from the perineal area can be introduced into the uterus.
How might maternal hypotension or hypertension affect the fetus?
Hypotension reduces blood flow to the placenta and therefore reduces fetal oxygenation because it diverts blood away from the uterus to better supply the mother's brain, heart, and kidneys. Hypertension may result in vasospasm that can reduce exchange of oxygen, nutrients, and waste products in the placenta. Fetal hypoxia and acidosis can be the ultimate result of maternal hypotension and hypertension.
What position should the woman avoid during labor? Why? What should you do if the woman must be in this position temporarily?
The supine position should be avoided because it causes the woman's uterus to compress her aorta and inferior vena cava (aortocaval compression), reducing blood flow to the placenta. If she must be in the supine position for a procedure such as catheterization, a small pillow or folded blanket under one hip shifts her uterus to maintain placental blood flow.
What general measures can make the woman more comfortable during labor? How can the nurse support the woman's labor partner?
General physical comfort measures during labor include soft, dim lighting; a comfortable temperature; maintenance of cleanliness; mouth care; observations for a full bladder; positions for comfort; and a warm bath or shower. Caring for the support person includes respect for the couple's wishes about partner involvement in the birth process. The nurse should provide support that the partner cannot and should consider physical needs for food and rest.
Why is watching the perineum as a woman pushes important?
Shortly before birth, the woman's perineum bulges and the fetal head becomes visible as the mother pushes. At this time birth can occur suddenly.
What precautions are taken to enhance the safety of oxytocin administration for the woman and fetus?
Five precautions that promote safe oxytocin induction or augmentation of labor include the following:
a. Dilution of the oxytocin in an isotonic solution
b. Piggybacking the oxytocin solution into the port of the primary nonadditive (maintenance) IV line that is nearest the venipuncture site
c. Starting the oxytocin infusion slowly
d. Increasing the rate of infusion gradually
e. Monitoring uterine contractions and fetal heart rate (FHR)
How may oxytocin administration differ if labor is being augmented rather than induced?
Labor may be augmented if it stops or contractions become ineffective. The woman whose labor is augmented with oxytocin usually needs less of the drug than the woman whose labor is being induced, because her uterus is more sensitive to its effects.
What signs may indicate a nonreassuring fetal response to oxytocin stimulation?
The fetus may have an adverse reaction to oxytocin, manifested by nonreassuring fetal heart rate (FHR) patterns such as tachycardia, bradycardia, decreased variability, and pathologic (late, variable, or prolonged) decelerations.
What are the signs of excessive uterine activity?
More than 5 contractions in a 10-min period, increased resting tone of the uterus, and relaxation time of less than 60 seconds between contractions in first-stage labor and 45 to 50 seconds in second-stage labor are signs of increased uterine activity.
How can induction of labor with oxytocin contribute to postpartum hemorrhage?
Administration of oxytocin for a prolonged time may lead to postpartum hemorrhage because the fatigued uterus cannot contract properly to compress bleeding vessels at the placenta site (uterine atony).
What are the similarities in the uses of vacuum extractors and forceps? What are the differences? Do limits exist for the number of attempts with these instruments?
Forceps and vacuum extraction are used to provide traction to assist the mother in rotation, expulsion, or both of the fetal head. Special forceps (Piper) can be used to deliver the aftercoming head of the fetus in a breech presentation, but a vacuum extractor can be used only with a cephalic presentation. Forceps may cause fetal injury such as facial bruising and nerve injury. The vacuum extractor may create an artificial caput called a chignon. No more than three "pop-offs" should be done, and these should not be followed by forceps attempts at vaginal birth.
Why should the nurse add a urinary catheter to the instrument table if a forceps-assisted or vacuum extractor-assisted birth is expected?
Catheterization before forceps or vacuum extractor are used eliminates a full bladder, which would reduce available room in the pelvis. Emptying the bladder also reduces the risk of bladder injury.
A woman has a vacuum extractor-assisted birth with a median episiotomy. What nursing interventions can make her more comfortable?
Use of cold immediately (for the first 12 hours) after episiotomy reduces pain, edema, and formation of hematomas. The nurse should also observe for continuous, bright red bleeding that suggests a vaginal wall laceration. Warmth after at least 12 hours of cold application promotes resolution of the edema and hematoma.
What newborn injury is suggested by an asymmetric facial appearance when the infant cries?
The infant with an asymmetric facial appearance when crying may have facial nerve injury, usually a temporary condition that sometimes occurs when forceps are used to assist birth.
Why is the low transverse uterine incision preferred for cesarean birth?
The low transverse uterine incision is less likely to rupture during another pregnancy than either of the two vertical incisions. There are, however, valid reasons for the use of vertical incisions.
What should a woman who expects a cesarean birth be taught about the operating room? The recovery room or the PACU?
The woman expecting a cesarean birth should be taught about the following regarding the operating room and recovery area:
a. Preoperative procedures, such as skin preparation and insertion of an indwelling catheter.
b. Personnel who will be present and their functions.
c. The narrow table, safety strap, and positioning measures.
d. When her partner or support person can come in.
e. If a regional anesthetic is planned, she will be awake and feel pulling and pressure sensations but should not expect pain. If a general anesthetic is planned, all preparations will be made before anesthesia is induced, but the surgery will not begin before she is asleep and she will not awaken during it.
f. In the recovery area, use of oxygen, pulse oximeter, and automatic blood pressure cuff for vital signs; checking of her fundus, incision, lochia, and pain-relief needs.
How does labor dystocia differ from tachysystole?
Labor dystocia usually occurs during the active phase of first-stage labor (6 cm cervical dilation or more). Uterine contractions become weaker, shorter, and less frequent. It is not painful because the contractions decrease, although the woman may become tired. Tachysystole can be either spontaneous or induced and is defined as excessive uterine activity. Tachysystole is more than five contractions in 10 minutes (averaged over 30 minutes). In addition to tachysystole, contractions lasting 2 minutes or longer, contractions with less than 1 minute resting time between, or failure of the uterus to return to resting tone between contractions via palpation, or intraamniotic pressure above 25 mmHg measured by an intrauterine pressure catheter (IUPC) may be of concern. Contractions may be uncoordinated and erratic in their frequency, duration, and intensity. The mother becomes very tired because of nearly constant discomfort.
Why should the nurse monitor the laboring woman's bladder frequently?
Bladder distention during labor can occupy available room in the woman's pelvis, thus impeding labor progress and fetal descent. In addition, it is a potential source of discomfort.
Why is psychological support during labor important for effective physiologic function?
Psychological support reduces stress that otherwise can consume energy the uterus needs, inhibit uterine contractions, reduce placental blood supply, impair the woman's pushing efforts, and increase the woman's pain experience.
Using traditional thought based on Friedman's curve, what is the dilation and fetal descent rate expected for a nulliparous woman during the active phase of labor? For the parous woman? How has new data effected this belief?
Based on Friedman's curve, the average nullipara's cervix dilates about 1.2 cm per hour and expected fetal descent is 1 cm per hour. The average parous woman's cervix dilates about 1.5 cm per hour, with minimal descent of 2 cm per hour. Research by Zhang et al found that labor may take over 6 hours to progress from 4 to 5 cm and over 3 hours to progress from 5 to 6 cm of dilation. Nulliparas and multiparas appeared to progress at a similar pace before 6 cm. They concluded that allowing labor to continue for a longer period before 6 cm of cervical dilation may reduce the rate of cesarean deliveries.
What is the priority nursing care for a woman in prolonged labor?
Nursing care for the woman who has prolonged labor is similar to that for dysfunctional labor. Promoting comfort, energy conservation, position changes, and assessments for related complications such as infection should be done.
What are the maternal and fetal risks when labor is unusually short?
Trauma is the primary maternal risk of a precipitate labor and may include uterine rupture, cervical lacerations, and hematomas. Fetal risks may include trauma, such as intracranial hemorrhage or nerve damage, and hypoxia due to intense contractions with a short relaxation period, which reduces the time available for gas exchange in the placenta.
How does PROM differ from PPROM?
Premature rupture of the membranes (PROM) occurs before true labor begins and may occur at any gestational age. Preterm premature rupture of the membranes (PPROM) occurs before 37 weeks of gestation and may be accompanied by contractions. PPROM is more likely to be associated with preterm labor and birth.
What is the relationship of infection to PROM?
Infection may be both a cause and a result of premature rupture of the membranes, particularly if birth is not desired because of fetal immaturity.
What is the usual therapeutic management of PROM if the woman is at or near term? What if the gestation is preterm?
Labor may be induced if the woman is at or near term and it does not begin spontaneously. The physician must consider multiple factors such as risk for infection (mother and fetus/newborn) and risk for preterm complications if the fetus is preterm.
What are the nursing considerations for a woman with PPROM?
The nurse should assess the woman's vital signs and fetal heart rate (FHR) and teach her to avoid inserting anything into the vagina, avoid breast stimulation, maintain activity restrictions, and note any uterine contractions or foul odor to vaginal discharge. Teach her how to observe fetal kick counts or other fetal activity. Temperature should be taken at least four times per day.
What symptoms of preterm labor should be taught to women at risk?
Symptoms of preterm labor often are vague. They include uterine contractions that may often be painless, the fetus "balling up," menstrual-like cramps, backache, pelvic pressure, changed or increased vaginal discharge, abdominal cramps, thigh pain, and a sense of "feeling bad."
Why is it important to identify preterm labor early?
Early identification of preterm labor enables management that may delay birth and allow further maturation of the fetus or permit transfer to a facility equipped to care for an immature infant. Corticosteroids may be given to the mother of a fetus between 24 and 34 weeks of gestation to accelerate maturation of the lungs before preterm birth.
What four classifications of drugs may be used to stop preterm labor contractions?
Classifications of drugs to inhibit preterm contractions include magnesium sulfate, calcium channel blockers such as nifedipine, prostaglandin synthesis inhibitors such as indomethacin, and beta-adrenergics such as terbutaline.
What is the purpose of giving corticosteroids to a woman who is in preterm labor at 27 weeks of gestation? Why is it important that birth be delayed at least 24 hours?
To accelerate maturation of the fetal lungs, corticosteroids are given to the woman who is likely to deliver prematurely. The greatest benefits occur if steroids are in the mother's system at least 24 hours before birth. The newborn who delivers before 24 hours after the mother receives corticosteroids may also benefit.
What are three risks to the fetus or neonate when pregnancy lasts longer than 42 weeks?
The three potential fetal or newborn risks are reduced placental function and umbilical cord compression before birth and meconium aspiration after birth.
What is the immediate management of prolapse of the umbilical cord?
If umbilical cord prolapse occurs, the priority of care is to reduce compression and restore normal blood flow through the cord by elevating the presenting part while giving the mother oxygen to maximize her blood oxygen concentration. At the same time, the nurse should summon help to expedite delivery, usually by cesarean birth.
How can contractions stimulated with drugs such as oxytocin or misoprostol increase the risk for uterine rupture?
Stimulated contractions are potentially more powerful than natural ones and may cause the pressure in the uterus to exceed the uterine wall's ability to withstand that pressure.
What are the primary complications of a uterine inversion? How are they managed?
Shock and hemorrhage are rapidly developing complications of uterine inversion. They are managed by rapid IV fluid and blood replacement, often using two IV lines. A drug that relaxes the uterus is given to allow uterine replacement to its proper position, and general anesthesia may be needed. Oxytocin is given after the uterus is returned to the proper position. Hemodynamic monitoring may be required to ensure stabilization.
What are important nursing considerations for each kind of intrapartum emergency: Prolapsed umbilical cord? Uterine rupture? Uterine inversion? Amniotic fluid embolism?
For intrapartum emergencies, nursing considerations include the following: Prolapsed umbilical cord—Relieve pressure on the cord to restore adequate blood flow through it until the baby can be delivered. Uterine rupture—Attempt its prevention by cautious intrapartum use of uterine stimulants and close monitoring of uterine contractions. Uterine inversion—Avoid pressure on the poorly contracted fundus after birth; assess for and correct shock. Amniotic fluid embolism—Provide cardiorespiratory support and hemodynamic monitoring and observe for coagulation deficits.
What kinds of fetal injury may occur with maternal trauma during pregnancy?
The fetus may suffer direct injury such as skull fracture or intracranial hemorrhage related to maternal injuries such as pelvic fracture, penetrating wounds, or blunt trauma. Fetal injury from indirect causes includes placental abruption and disruption of placental flow because of maternal hemorrhage or shock.
What are the symptoms of postpartum depression, and how does it differ from postpartum blues?
The symptoms of postpartum depression differ from those of postpartum "blues" in their intensity and persistence. In postpartum depression, the symptoms are present daily for at least 2 weeks. They include anxiety, feelings of guilt, agitation, fatigue, sleeplessness, feeling unwell, irritability, difficulty concentrating or making decisions, confusion, appetite changes, loss of pleasure in normal activities, crying, sadness, depression, suicidal thoughts, and being less responsive to the infant.
How can nurses intervene for postpartum depression?
Nurses can demonstrate caring, provide anticipatory guidance, help the mother verbalize her feelings, and make appropriate referrals.
What is the therapeutic management for postpartum psychosis?
Postpartum psychosis usually requires hospitalization, psychotherapy, and appropriate medication.
How is postpartum blues different from postpartum depression? How can nurses intervene for this common emotional response?
Postpartum blues may be related to emotional letdown, discomfort, fatigue, and anxiety about parenting and body image. It is characterized by irritability, fatigue, tearfulness, mood swings, and anxiety. The symptoms are usually unrelated to events, and the condition does not seriously affect the mother's ability to care for the infant. With postpartum depression, the depression becomes severe, lasts longer than 2 weeks, or interferes with the mother's ability to cope with daily life. Nurses can provide reassurance to the mother and teach the family about postpartum blues and warning signs of postpartum depression. Many facilities or providers conduct a screening for depression before discharge.
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