Prework Week 2
Week 2 Pre Work Assignment
Chapter 8-Prework
Labor triggers
Fetal
triggers
Maternal
triggers
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Stretching of uterine musclesà
prostaglandin release.
Low backacheà relaxation of
pelvic joints.
Estrogen increasesà stimulates
uterine response.
Progesterone is withdrawn.
Oxytocin levels surge from
stretching uterus.
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Placenta agesà begins to deteriorate
à triggers contractions.
• Prostaglandin synthesis by fetal
membranes and deciduaà stimulate
contractions.
• Fetal cortisol, produced by fetal
adrenal glands, rises and acts on the
placenta to reduce progesterone and
increase prostaglandinà stimulates
uterus to contract
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5 P’s of Labor List and explain
Power
Passenger
Passageway
(the contractions)
(the fetus)
(the pelvis and birth
canal)
Position
(maternal postures
and physical positions
to facilitate labor)
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Psyche
(the response of the
woman)
Powers
o Uterine contractions causes effacement (shortening and thinning of the cervix) during the first
stage of labor and dilation of the cervix (enlargement or widening of the cervical opening and
canal) that occurs once labor has begun and the fetus is descending.
o Involuntary urge to push and voluntary bearing down in the second stage of labor helps in the
expulsion of the fetus.
Passenger
o Consists of the fetus and the placenta.
o Size of the fetal head, fetal presentation, fetal lie, fetal attitude, and fetal position affect the ability
of the fetus to navigate through the birth canal.
Passageway
o The birth canal is composed of the bony pelvis, cervix, pelvic floor, vagina, and introitus (vaginal
opening).
Position
o The client should engage in frequent position changes during labor to increase comfort, relieve
fatigue, and promote circulation.
o Position during the second stage is determined by maternal preferences, provider preferences, and
the condition of the mother and the fetus.
Psychological Response
o Maternal stress, tension, and anxiety can produce physiological changes that impair the progress
of labor.
Type of Bony Pelvis
o Gynecoid (Most common type and found in about 50% of women)
o Android
o Anthropoid
o Platypelloid (Least common type and found in about 3% of women)
Cephalopelvic disproportionà condition in which size, shape, or position of the fetal head prevents it from
passing through the lateral aspect of the maternal pelvis or when the maternal pelvis is of a size or shape
that prevents the descent of the fetus through the pelvis.
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Premonitory Signs of Labor (5) -ATI
o Backache à constant low, dull
§ Caused by pelvic relaxation
o Weight loss
§ 1 to 3.5 lb
o Lightening
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Fetal head descends into true pelvis about 14 days before labor.
§ Feeling that the fetus has “dropped”à easier breathing, but more pressure on the bladder.
o Contractions
§ Begins with Braxton Hicks (irregular)
§ Contractions eventually become regular and increase in strength.
o Increased Vaginal Discharge/Blood Show
§ Expulsion of cervical mucous plug
§ Brownish or blood-tinged mucous plugà onset of cervical dilation and effacement.
o Energy Burst
§ “Nesting”
o Gastrointestinal Changes
§ Nausea, vomiting, indigestion.
Mechanisms of Labor/Cardinal movements
o Engagement
§ Occurs when the greatest diameter of the fetal head passes through the pelvic inlet.
§ Referred to as 0 station.
o Descent
§ The movement of the fetus through the birth canal during the 1st and 2nd stage of labor.
o Flexion
§ When the chin of the fetus moves toward the fetal chest; flexion occurs when the
descending head meets resistance from maternal issues.
o Internal rotation
§ The rotation of the fetal head, aligns the long axis of the fetal head with the long axis of
the maternal pelvis; occurs mainly during the second stage of labor.
o Extension
§ Facilitated by resistance of the pelvic floor that causes the presenting part to pivot
beneath the pubic symphysis and the head to be delivered; occurs during the second stage
of labor.
o External rotation
§ The sagittal suture moves to a transverse diameter and the shoulders align in the
anteroposterior diameter. The sagittal suture maintains alignment with the fetal trunk as
the trunk navigates through the pelvis.
o Expulsion
§ The shoulders and remainder of the body are delivered.
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Ferguson’s Reflex
o Physiological response of the woman, activated when the presenting part of the fetus is at least +1
station; it is usually accompanied by spontaneous bearing down efforts
Leopold’s maneuver
o A series of four maneuvers used to palpate a gravid uterus to determine fetal position,
presentation, and size.
o Abdominal palpation of the fetal presenting part, lie, attitude, descent, and the probable location
where fetal heart tones can be best auscultated on the client’s abdomen.
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4 Stages of Labor
§ Identify and describe the physical changes for each stage
Stage 1
Stage 2
Stage 3
Stage 4
•Progression of cervical changes
•It begins with onset of true labor and ends with complete cervical dilation (10cm) and
complete effacement (100%).
•Three Phases: latent (0-3cm), active (4-7cm), transition (8-10).
•Cervical dilation is complete
•Ends with the birth of the baby
• Women in the second stage may have a burst of energy, be focused, and may feel like
they are able to actively participate by facilitating birth with active pushing efforts.
•Begins immediately after the delivery of the fetus and involves separation and expulsion
of the placenta and membranes.
•Begins after the delivery of the placenta and typically ends within 4 hours or with the
stabilization of the mother.
•This stage begins the postpartum period.
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Pain management during labor
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Pharmacological
o Analgesia
§ Sedatives (barbituates)
• Can be used during the early or latent phase of labor to relieve anxiety
or induce sleep.
§ Opioid analgesiscs (meperidine hydrochloride, fentanyl, butorphanol,
nalbuphine).
• Act in the CNS to decease the perception of pain without the loss of
consciousness.
• Butorphanol and nalbuphine provide pain relief without causing
significant respiratory depression in mother and fetus.
§ Metoclopramide
• Can control nausea and anxiety.
• Does not relieve pain.
§ Puodenal block
• Local anesthetic (lidocaine, bupivacaine) adminstered transvaginally
into the space in front of the puodenal nerve.
§ Epidural block
• Local anesthetic bupivacaine, along with an analgesic, morphine or
fentanyl injected into the epidural space at fourth and fifth vertebrae.
§ Spinal anesthesia (block)
• Local anesthetic that is injected into the subarachnoid space into the
spinal fluid at the third, fourth, or fifth lumbar space.
Non-Pharmacological
o Cognitive Therapies
§ Childbirth preparation methods (Lamaze, patterned breathing exercises) promote
relaxation and pain management.
§ Doulas
§ Biofeedback
o Sensory Stimulation Strategies
§ Aromatherpy
§ Breathing techniques
§ Imagery
§ Music
§ Use of focal points
§ Subdued lighting
o Cutaneous Stimulation Strategies
§ Therapeutic touch and massage
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Back rubs
§ Walking
§ Rocking
§ Effleruge
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Light, gentle circular stroking of the client’s abomen with fingertips in
rhythm with breathing during contractions.
§ Sacral counterpressure
• Consistent pressure is applied by the support person using the heel of
the hand or fist against the client’s sacral area to counteract the pain in
the lower back.
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Epidural
PRE
Assess and document
baseline blood pressure,
pulse, respiratory rate,
and temperature.
Assess FHR to confirm a
normal FHR pattern; if
indeterminate or
abnormal, report to
physician.
Pre
Encoruage patient to
void before initiation of
epidural anesthesia.
INTRA
Assist the anesthesia
provider with
placement of patient
in the lateral position
with head flexed
toward chest, or
sitting with head
flexed on chest,
elbows on knees and
feet supported on
stool.
POST
Monitor vital signs every
5-15 minutes.
Intra Post
Assess for hypotension
and respiratory distress.
Monitor for pruritus.
Monitor for nausea and
vomiting.
Assess the woman for
urinary retention.
Monitor for uterine
contractions as uterine
activity may slow down for
up to 60 minutes.
Monitor for signs and
symtpoms of
intravascualar
injection:tinnitus,
mettalica taste in mouth,
dizziness,
hypertension,loss of
consciousness.
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Episiotomy
o An incision in the perineum to provide more space for the presenting part at delivery.
§ Median/midline episiotomy is at midline and tends to heal more quickly with less
discomfort.
§ A medilateral episiotomy is cut at a 45-degress angle to the left or right and may be used
for a large infant. It tends to heal more slowly, causes greater blood loss, and is more
painful.
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Lacerations
o First Degree
§ Laceration extends through the skin of the perineum and does not involve the muscles.
o Second Degree
§ Laceration extends through the skin and the muscles of the perineum but not the anal
sphincter.
o Third Degree
§ Laceration extends through the skin, muscles, perineum, and external anal sphincter.
o Fourth Degree
§ Laceration extends through skin, muscles, anal sphincter, and the anterior rectal wall.
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What is the priority nursing actions immediately after delivery of the newborn?
o Neonate is placed on skin-to-skin on mothers abdomen.
o Await the delivery of the placenta.
o Encourage the woman to breathe with contractions and relax between contractions.
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o Assess maternal vital signs every 15 minutes.
o Administer pain medications.
How do you assign Apgar? (memorize the box)
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Normal vital signs for the newborn:
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Respirations: 30-60
Heart Rate: 120-160 bpm
§ Rate increases to 180 bpm when crying.
§ Rate decreases to 100 bpm when asleep.
Blood Pressure:
§ 50-75/30-45 mmHg
Temperature: 97.7- 99 F
Chapter 9 Pre-work (you may use outline format)
Define:
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Electronic Fetal Monitoring (EFM)
o A technique for fetal assessment based on the fact that the FHR reflects fetal oxygenation.
Fetal Scalp Electrode (FSE)
o Applied to the presenting part of the fetus to directly detect FHR.
Tocodynamometry
Intrauterine Pressure Catheter (IUPC)
o Placed in the uterine cavity to directly measure uterine contractions.
Amnioinfusion
o Room temperature saline solution is introduced trans-cervically via an IUPC to correct FHR
decelerations associated with cord compression and/or decreased amniotic fluid.
Define FHR tracings criteria:
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Three-Tier FHR Interpretation System
o Category I Normal
Baseline rate 110–160 bpm
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Baseline variability moderate
Late or variable deceleration absent
Early decelerations absent or present
Accelerations absent or present
Category II Indeterminate
Bradycardia not accompanied by absent variability
Tachycardia
Minimal baseline variability
Absent baseline variability not accompanied by recurrent decelerations
Marked baseline variability
Absence of induced accelerations after fetal stimulation
Recurrent variable decelerations with minimal or moderate variability
Prolonged decelerations ≥2 minutes but ≤10 minutes
Recurrent late decelerations with moderate variability
Variable decelerations with other characteristics such as slow return to baseline “overshoots”
or “shoulders”
Category III Abnormal
o Absent variability with any of the following:
Recurrent late decelerations
Recurrent variable decelerations
Bradycardia
Sinusoidal pattern
Normal fetal baseline range?
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What is variability? And what does it mean?
o Baseline variability refers to the fluctuations in the baseline FHR that are irregular in amplitude
and frequency.
§ Absent
Amplitude range is undetectable
§ Minimal
Amplitude range undetectable less than or equal to 5 bpm
§ Moderate
Amplitude from peak to trough 6 bpm to 25 bpm.
Moderate variability predicts a well-oxygenated fetus with normal acid-base
balance.
What is an acceleration at term >38 weeks gestation and < 38 weeks’ gestation
o Visually apparent, abrupt increase in FHR above the baseline.
§ The peak of the acceleration is greater than or equal to 15 bpm over baseline FHR for
greater than 15 seconds and 2 minutes.
§ Before 32 weeks’ gestation acceleration is greater than 10 bpm over the baseline FHR for
greater than 10 seconds.
What is an early deceleration?
o Visually apparent, usually symmetrical, with gradual decrease and return of FHR associated with
UC.
o Fetal head subjected to pressure during UCà this pressure stimulates vagal nerve
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What is a variable? And what does it mean/complications to the fetus
o A visually apparent abrupt decrease in the FHR.
§ Umbilical cord occlusion
§ Umbilical cord compression triggers a vagal response that slows the FHR, usually related
to decreased cord perfusion.
What is a late deceleration and why is it bad for the fetus?
o A visually apparent gradual decrease of FHR below the baseline.
o Lowest part of the deceleration occurs after the peak of the contraction.
o Sign of fetal intolerance to labor.
Normal fetal heart rate?
o 110-160 bpm
• Define a bradycardia
o Slow heart rate <110 bpm for 10 minutes or more.
• Labor contractions: What is uterine frequency?
o True labor contractions occur at regular intervals and increase in frequency, duration, and
intensity.
o False labor contractions are irregular with little or no cervical changes.
o Uterine Frequency
§ Time from beginning of one contraction to the beginning of another.
• What is duration of a uterine contraction?
o Time from the beginning of the contraction to the end of a contraction.
• What are the variables for a Category I à Baseline is normal
o Baseline FHR of 110 to 160/min
o Baseline FHR variabilityà moderate
o Accelerationsà present or absent
o Early accelerationsà present or absent
o Variable or late decelerationsà absent
What are the variables for a Category IIIà Abnormal FHR
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Absent variability with any of the following:
Recurrent late decelerations
Recurrent variable decelerations
Bradycardia
Sinusoidal pattern
Identify VEAL/CHOP
Variable
Cord compression
Early decelerations
Head compression
Accelerations
Okay
Late decelerations
Placental insufficiency
Medications: Indication, S/E, Contraindications, Mechanism of Action
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Terbutaline
o Indication: Relax the uterus
o Common Side Effects: Tachycardia of mother and fetus
o Contraindications: Hypersensitivity to adrenergic amines.
o Mechanism of Action: Beta 2 adrenergic agonists suppresses uterine activity.
Nifedapine (Procardia)
o Indication: Controls hypertension rapidly, increases cardiac index, and increases urinary output.
o Common Side Effects: Hypotension, headache, dizziness, and nausea.
o Contraindications: Hypersensitivity
o Mechanism of Action: A calcium channel blocker that is used to suppress contractions by
inhibiting calcium from entering the smooth muscle.
Oxytocin
o Indication: Labor induction and augmentation. Control PPH after placental expulsion.
o Common Side Effects: Uterine tachysystole, headache, palpitations, nausea and vomiting.
o Contraindications: Active genital herpes, fetal distress, prolapsed umbilical cord, placental
abnormalities.
o Mechanism of Action: Stimulates uterine smooth muscles that produces intermittent contractions.
Has vasopressor and antidiuretic properties.
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Methylergonovine (Methergine)
o Indication: To prevent and treat hemorrhage that occurs in the postpartum period or following a
spontaneous abortion.
o Common Side Effects: Nausea, headache, weakness, palpitations, and cramping.
o Contraindications: Induction of labor, threatened spontaneous abortion, and hypertension.
o Mechanism of Action: It causes strong uterine contractions by stimulating smooth muscle in the
uterusà this helps stop bleeding in the postpartum period or following a surgical procedure or
spontaneous abortion.
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Carboprost Tromethamine (Hemabate)
o Indication: PPH that has not responded to oxytocin or methylergonovine therapy.
o Common Side Effects: Diarrhea, nausea, vomiting, and fever.
o Contraindications: Acute pelvic inflammatory disease and hypersensitivity.
o Mechanism of Action: Acts as a prostaglandin analogue à causes uterine contractions.
Fetopelvic Position
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Baseline
o Where baby is most comfortable
Variability à fluctuation of baselineà tells you how oxygenated the baby is
§ Absentà no fluctuation à baby dying
§ Minimal fluctuationà less than 5àbaby needs more oxygen
§ Moderate à 6 to 25 à baby is oxygenated
Accelerationsà increase of 15 beats lasting 15 secondsà super oxygenated
Decelerations à
o Early Decelerationsà starts when contraction starts and ends when contraction endsà head is
coming down nothing wrong à seen when mom is more than 5 cm
o Late decelerationà start at peak of contractionà uteroplacental insufficiency
o Variableà stubborn don’t care about contractions just happen à usually when water breaks à
due to compressed cord
§ Drops down 15 beats lasting for 15 seconds
Each small box is 10 sec
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Each line across is 10 sec
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Category 1 à
o 110-160 baseline
o Moderate
§ THESE ARE BOTH NEEDED TO BE CATEGORY 1
o Accelerations & early decelerations are a BONUS (DON’T HAVE TO BE PRESENT)
Category 2 à
Category 3 à absent variability and bradycardia less than 110
Absent variability + recurring variables or lates
Frequency à The start of one contraction to the start of very next contraction (IN MINUTES)
Duration à Start of one contraction to end of the same contraction (IN SECONDS)
THREE THINGS:
2 breaks before 11:30
SIGN OUT AT 1400
Complete 2 Evaluations
SEND HER EMAIL
A sentence stating I completed the evaluation
Attach files
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