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OB Nursing Intrapartum 01/28/09 st time mom need to come to the hospital when contractions are 1 regular and 5 minutes apart. 2nd time mom and thereafter needs to come to the hospital when contractions are regular and 10 minutes apart. (Because the road has already been paved) OR If they start to bleed. Losing the mucous plug & have the bloody show. (pink tinged discharge, can be brown (textbook def.)) (Truth: red) Mucous plug falls out when cervix starts to dilate (@ 2cm) ***Toco-monitor- leads on fundus- measures contraction. Pg. 121 fig. 6-4

I= Increment A= Acme D= Decrement Frequency- Time between the beginning of one contraction to the beginning of the next contraction. * Must be longer than two minutes!!* Duration- beginning of a contraction to the end of that contraction. * should last no more than 90 seconds!!* Interval- time between contractions (uterine relaxation). * Should be at least 60 seconds. No sooner!!* Intensity- strength of contraction. The higher the peak the stronger the contraction. -If any of these #s are off, it increases the risk of uterine rupture.

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Pg. 135 1. Early Deceleration: drop in babys Heart rate, in the early part of a contraction, This is a reassuring pattern (by the end of the contraction, the heart rate returns back to baseline). Normal finding- due to fetal head compression (stimulates vagal response) 2. Late Deceleration: drop in babys HR, in the late part of a contraction, (@ the peak or 30 seconds into contraction) After the uterus is relaxed, babys HR stays low. Will not go back up to baseline. Non-reassuring pattern. Could be caused by: Uteroplacental insufficiency (UPI): reduced blood flow (supply) from the placenta. (fetal hypoxia/acidosis) 3. Variable Deceleration: Drop in babys HR, occurring anytime during a contraction ( HR will be seen @ 60-70 bpm) W, V, and U shaped patterns. (Bad, Worst, Non-reassuring pattern) Could be caused by: Cord Compression Nuchal Cord (cord @ babys neck) Nursing Intervention for Deceleration: *Early: Nothing *Late: (L) side, administer O2 (10-12L/min. face mask),Discontinue pitocin drip, Call Dr. *Variable: Trendelenburg position or any position where the hips are higher than the head. (Knee-Chest position)-> Helps to relieve the pressure placed on the cord. (L) side, administer O2 (10-12L/min. face mask),Discontinue pitocin drip, Call Dr. Intensity can be measured by feeling the fundus. Walk fingers from side until you reach the center-> Feels like a rock. Types of intensity upon palpation: 1. Mild: Firm but some indention (nose) 2. Moderate: (chin) 3. Firm: (forehead) Contractions during the 1st stage of labor causes cervical dilation. Pain caused by cervical dilation.

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OB Nursing 4 Stages of Labor 1/28/09 Stage 1: Dilation: From the beginning of true onset of labor and contractions until the cervix is 10cm dilated (100% effaced (thin & short)). Can last up to 24 hours. *First Stage of labor is divided into 3 phases: 1. Latent (prodromal) Phase: 0-3 cm cervical dilation Contractions 5-10 min. apart Lasting @ 15-40 seconds in duration No epidurals or pain meds at this point (slows & stops labor) V/S q 1-2 hours Good time to teach pt. Pain is caused by cervical dilation 2. Active Phase: 4-7 cm cervical dilation Contractions 2-3 min. apart Lasting 40-60 sec. in duration Give pain meds in this phase; may have an epidural (@ 5cm.) Pt. normally is concentrating on contractions 3. Transition Phase: (shortest phase and hardest phase) 8-10 cm cervical dilation Contractions every 2-3 min. Lasting 60-90 sec. in duration *should not last more than 90 sec.!!* Women lose control-- may act out No pain meds (Demerol IV) B/c delivery is within a few hours. Meds could depress infants respiration. V/s q 10-30 min. Take B/P between contractions. Check for FHT over babys back (using Leopolds Maneuver) Normal rate is 120-160 bpm (toco-monitor) Location of the heart rate: Breech Presentation: Above umbilicus Cephalic Presentation: Below umbilicus Accelerations: Increase in FHR from the baseline (ANS) Variability- Changes in FHR beat-to-beat. 1. Short term: Measured by internal monitor; most reliable measure of fetal well being. (Variations beat-to-beat;

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minimal 3-5 beats) 2. Long term: (over 10 min time) 0-2 bpm and loss of variability-- L side, O2, Notify MD/charge nurse *Amniotomy- Manual ROM (rupture of membranes);complication is cord compression (Alice clamp/Amniohook) *Amniotic fluid should be 800 mL; clear to straw color with white flex (vernix). Characteristic odor; Nitrazine paper (yellow paper that measures pH) is inserted into vagina and turns blue when it comes in contact with amniotic fluid. *Nurse should note time membranes ruptured, color, odor of the fluid. *Always check FHT when membranes rupture. Any time the water breaks, your 1st priority is to assess the FHT!! (in case baby compresses the cord) Green amniotic fluid: indicates meconium is present (sign of fetal distress) common in breech presentation or post term babies. Wine colored Fluid: ? Abruptio placenta or blood Foul odor: infection Friedmans chart: chart the progress of labor. Deals with how fast the cervix is dilating. During labor pt. may become dehydrated (mouth breathing); fluids are allowed in early labor (ice chips, etc.) ?NPO--? C-section Full bladder interferes with uterine contractions and cervical dilation, Decreases the progression of labor and creates ineffective uterine contractions. *make sure to have patient keep their bladder empty; check pt. q 2 hours to void. If foley catheter-> it must be removed when pushing. Walking increases true labor--as long as membranes (bag of waters) are intact and the head is engaged. *with Braxton Hicks- walking will lessen contractions-> means false labor. Lie in Left lateral position while in labor. Effleurage: slight stroking movement by the fingertips over the abdomen can cause distraction during contractions (tennis balls- for back pain) Gate closing mechanism. Posterior presentations cause BACK PAIN! (LOP/ROP). Pelvic Rock/Pelvic Tilt to help with back pain. Baby can still be born w/ posterior presentation- extremely painful. Squatting and hands-knees position to turn baby to anterior position. If pt. complains of wanting to have a BM, the nurse should check cervical dilation. This is a complaint that indicates the

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baby is coming. (*Delivery is imminent) other S/s: Bulging perineum, increased bloody show. Pushing during 1st stage is a no-no!! can cause maternal exhaustion, fetal hypoxia, and can tear the cervix. Second Stage of Labor: From 10 cm dilated to delivery of baby (lasts an avg. of 1h 30min for muligravidas) (2h total) Delivery V/S q 15 min Contractions may last up to 90 seconds (but no longer) Contractions every 4-5 min. or 1-2 min. Pushing Phase--(breathing) no pushing in the 1st stage of labor Push should resemble urination -> not BM The act of pushing expedites the delivery process, it doesnt prevent it. Pt. should not hold breath when pushing- use open-glottis breathing; Holding breath when pushing can cause vagal stimulation. Episiotomies (lacerations of the perineum) are given to prevent tissue trauma. Episiotomies are measured in degrees 1-4 with 4 being most severe. Crowning occurs when the whole circumference of the head can be seen in the vagina with contractions. After delivery, the fundus can be palpated @ or slightly below the umbilicus at the midline. Third Stage of Labor: From delivery of the baby to delivery of the placenta. Delivery of the Placenta Normally takes less than 20 min. Dont pull on cord to hasten delivery- can cause an inverted uterus S/S of placenta separation: Uterus rises above umbilicus, forms round global shape, small gushes of blood Lengthening of the cord Causes of Placenta Separation: Strong contractions after baby comes out-> breaks off the uteran wall. Shiny Schultz: Fetal side; Shiny; Most commonly seen

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Dirty Duncan: Maternal side; rough; red; has incidence of retained placenta fragments (some cotalydones stay in uterus-> inhibits uterine contractions Umbilical Cord always checked 3 vessels (1 vein, 2 arteries) Notify MD if not. If fundus is above or to the left or right of the umbilicus- Bladder is full. ** Check uterus to make sure it is firm (should feel like a grapefruit). Immediately after delivery the uterus is located 1-2 cm below or at the umbilicus in midline. If boggy (relaxed) support the uterus with one hand, and massage the fundus. Estimate blood loss. (Overstimulation of uterus can cause relaxation. ** Shaking and chills are a normal physiological response after delivery-Provide blankets. Mother/infant bonding time. EES ointment to eyes prevent blindness caused by gonorrhea/chlym. (ophthalmia neonatorium). Blood loss for 3rd stage is 500 mL at time of delivery Blood loss for C-sections is less than 1 L. Airway #1 for the infant after delivery; identification band placed in the delivery room before transport to the nursery. Cord clamped in 2 places after delivery. APGAR scoring: Done at 1 and 5 min. Respiratory Rate, HR, Color, Muscle tone, and irritability. (Max score is 10.

Reflexes, 7+ is normal) *Most infants receive no more than 9 due to acrocyanosis (bluish discolorations of the hands and feet) Acrocyanosis is a normal finding. *

Stage 4 of Labor: 1-4h postpartum Recovery **Major risk in this stage is hemorrhage!!** Monitor for S/S of hypovolemic shock V/S--Bradycardia is normal. May be 40 bpm (transient pulse) DO NOT WANT TO SEE TACHYCARDIA (SIGN OF HEMORRHAGE) V/S q 15 min till stable Check fundus, should be in mid-line and firm (grapefruit) If not

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firm, support and massage the fundus. Have pt. void frequently (full bladder prevents effective contraction of uterus to prevent bleeding) (4-6h to void) Table 1013 Fundal massage Encourage breastfeeding (Stimulates production of Oxytocinuterine contraction- prevents hemorrhage) Inspect perineum after delivery- lateral position preferred. Icepacks to perineal area for comfort. Pitocin (Oxytocin) is given to stimulate labor contractions. Side effects: Hypertension, fluid retention, and uterine rupture (monitor BP/sustained uterine contraction) Prostaglandin E-2: softens the cervix (causes cervical changes) for the induction of labor. Lochia: is the vaginal discharge after delivery. Vitamin K: is given in the nursery in the Vastus lateralis to prevent hemorrhage because the small intestines are sterile. (Vitamin K is produced in the intestines) C-Section: general anesthesia for emergency; lack of bonding. If cut up and down: cannot have a VBAC. Increases the chances of uterine rupture. Classical Vertical through skin and uterus. *Skin cut does not mean uterus is cut the same direction.* *Pfannenstiels incision- made along the pubic hairline.* (may be done due to position of baby, herpes lesions, cephalopelvic disproportion (CPD), abruptio or placenta previa.) CPD- babys head cannot fit through the pelvis. Same nursing care- just a surgery pt. with dressing/staples. Keep uterus firm/check if boggy/ fundal massage while supporting the fundus. *The pt. goes from a delivery pt. to a surgical pt.* Mechanisms of Labor: Effacement: Thinning and shortening of the cervix (%) Dilation: Enlargement for the cervical opening (1-10) Stations: Presenting part of the fetus to the Ischial spines

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0- Part is at the Ischial spines (exact spines) Negatives- Baby is floating; not engaged in the pelvis Positives- Past Ischial spines (+5 visible on the pelvic floor) *Engagement occurs when at zero station* Example:

Cardinal Movements: Exact order through vagina 1. Engagement 2. Descent 3. Flexion 4. Internal Rotation 5. Extension 6. External Rotation 7. Expulsion Cardinal Movements: In Depth 1. Engagement: Presenting part passes through Ischial spines. 1st indication of pelvic adequacy (head is too large to fit in the pelvis) 2. Descent: Baby descends into toward the pelvis. 3. Flexion: Allows narrowest portion of the head to enter the pelvic outlet (flexion of head caused by pressure against the pelvis) 4. Internal Rotation: Turning of the head to the side in order for the head to pass through the Ischial spines. 5. Extension: Allows head to pass under syphilis pubis; presenting part is visible at the vaginal opening; apply gentle pressure against the head of the fetus to prevent too fast of an expulsion (traumatize maternal tissues). 6. External Rotation (restitution):

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Head rotates to align with shoulders (internal rotation of the shoulders occur at the same time). 7. Expulsion: Delivery; anterior shoulder first under syphilis pubis; then head is supported and lifted, to allow delivery of posterior shoulder; rest of body slips out of the birth canal. Baby is normally born face down.

OB Nursing All about the fetus! 2/2/09 Ischial Spines Table 6-2 P. 131 False v. True labor- know difference! False labor is prodromal Precipitant delivery (< 3h) not good- Could cause cervical tear.FalseContractions are irregular Walking lessens contractions, makes them go away Abdominal Pain No Bloody Show No change in effacement/dilation of cervix

TrueContractions are regular Walking increases contractions, when engaged Back pain radiating to the abdomen Bloody Show Effacement/Dilation of Cervix

Dilation is measured in cm Effacement is measured in % (thinning and shortening of the cervix) The Passenger P. 122 Size of fetal head: 13-14 in Anterior fontanel: diamond shaped- closes 12-18 mo.- pulsates Posterior fontanel: Triangle shaped- closes 2-3 mo. Molding: cranial bones overlap to come through the pelvis.

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Lie Position of the baby in relation to the mothers spine. 1. Longitudinal: fetus parallel with mothers spine 2. Transverse: (Shoulder presentation) fetus perpendicular to mothers spine. Attitude Flexion and extension related to position of fetal extremities (including the head) to itself. Flexion is most common and best. (all balled up in flexion) Presentation Part of the baby that enters the pelvis 1st. 1. Cephalic: Head 1st. 2. Vertex: Head is flexed entering pelvis 1st 3. Military: Head is neither flexed nor extended 4. Brow: Head is partially extended 5. Face: Head is fully extended Breech 1. Frank Breech: Butt down; legs in the air. Legs flexed @ hips and extending towards shoulders. Most common breech presentation. 2. Full/Complete Breech: Butt 1st legs flexed (Indian style). 3. Footling Breech: One or both feet present 1st in the cervix. Position Location of presenting part in mothers pelvis 3 letters: 1st letter: Right or Left 2nd letter: Reference points (type of presentation) O= Occiput M= Mentum (chin) S=Sacral 3rd letter: Reference points A=Anterior P=Posterior T=Transverse Box 6-1 pg. 126 Vertex LOA: Left, Occiput, anterior- L side facing mommys spine. ROA: Right, Occiput, Anterior- R side facing mommys spine. ROP: Right, Occiput, Posterior- R side pelvis, head down, face up LOP: Left, Occiput, Posterior- L side pelvis, head down, face up * Prolonged, harder labor!!* ROT: Right, Occiput, Transverse- R side pelvis, head 1st, ear forward LOT: Left, Occiput, Transverse- L side pelvis, head 1st , ear forward LSA: Left, Sacral, Anterior- L side pelvis, butt 1st, ear forward

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LMA: Left, Mentum, Anterior- L side pelvis, face 1st, facing forward Signs of Impending Labor Braxton Hicks contraction Increased vaginal discharge Bloody show Rupture of membranes Energy spurt (nesting) Weight loss The initiation of labor is unknown!! Epidural= Hypotension Tears: Perineal tears and lacerations Tears- jagged 1st degree: Superficial tear 2nd degree: Involves SQ tissue 3rd degree: slices/tears to the anal sphincter 4th degree: slices/tears THROUGH the anal sphincter D/t CPD- cephalo-pelvis disproportion. Anxiety and Fear can slow or stop labor. Tocolytics: relaxes the uterus. Ex. Magnesium Sulfate (drug of choice to stop pre term labor. Monitor for fluid overload, tachycardia, hypotension) Beta-adrenergic Drugs stop labor 8. Ritadrine (yutopar): Hypotension, Fluid retention, increased blood sugar and K+ levels. Causes maternal and fetal tachycardia. 9. Indomethocin: S/E- causes ductus arteriosus to close. Can give but runs the risk of early closure of shunt. Epigastric pain. 10.Nifedipine (procardia): lowers BP 11.Brethine (terbutaline): commonly used (given SQ) relaxes smooth muscle. Opens bronchioles. Decreases BP; tachycardia Steroids 12.Corticosteroids Betamethazone (Dexamethazone) Given IM to mother during labor- 2 injections, 24h apart to help build surfactant in fetal lungs. Used for the Premature baby so it will have less chance of Respiratory complications. Used for pre-term labor (@ 3435 wks.) if anticipating a few days before delivery. Also relaxes smooth muscle around vessels.

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Shoulder dystocia Occurs when fetal shoulder gets caught on pubic bone. 13.Can break clavicle 14.McRoberts Procedure: Flex mommys hips to abdomen, butt comes off the bed, shoulder dislodges, baby comes out. 15.Suprapubic pressure Oxytocin Challenge Test=Contraction Stress Test Premature Rupture of Membranes (PROM) BOW breaks without contraction of uterus- only have 24h after membranes rupture to get the baby out otherwise infection can occur. Can also cause chorioanmioitis: inflammation of the uterus. Hypotonic uterine contractions: slow, ineffective- Failure to progress (C section) Hypertonic Uterine contractions: excessive, hard contractions. Decreased O2 to the fetus. Cervix dilates 1.2 cm/hr with 1st baby. Fractured pelvis is the most common reason of shoulder dystotia. Fibronectin: protein found in amniotic fluid. If found in vagina, means the BOW has ruptured. Bishops score- determines if induction is feasible for woman. If they qualify for induction. Manual version: Dr. turns the fetus externally from abdomen. For posterior position: Back pain: Pelvic rock, Squats, Hands/Knees position. Prolapsed cord: push up on baby to relieve pressure on cord. Trendelenburg, Hands/knees position. Pitocin causes Fluid retention. Brandells Retraction Ring (Ring found where uterus and cervix meet) Indicates uterine rupture. Indention of the ring can be palpated. (C/o shoulder pain)

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Know C-section incisions: P. 181 Low vertical Low transverse- most common Classic- used for emergencies and placenta previa- Once youve had a classical you can never have a VBAC! Increases the risk of uterine rupture. Blood patch: used for women who has an epidural. 5-10 mL of blood is injected into epidural site to seal it off so no fluids drain out. Also reduces Spinal Headache. **After 40 weeks gestation, the placenta starts to decrease in functioning ability!!** Hydroamnios: Increased amniotic Fluid. Commonly caused by: Diabetes, GI obstruction in the fetus (not swallowing enough amniotic fluid). Oligeoamnios: Decreased amniotic fluid. Risk of prolapsed cord due to renal problems in fetus (cant excrete what theyre swallowing). **Massage 1st, Pee 2nd!** Forceps Delivery Complications: Intracranial Hemorrhage Facial Nerve Paralysis Vacuum Complications: Increased intracranial pressure (ICP) Bleeding in the brain Counter traction is placed on babys head as it is being born. If it comes out too quick, it can cause head injury (brain) and tear the woman. Monial infection= yeast infection Baby comes out: Immediately Clamp the cord and cut. Clamps in two places: @ umbilicus and @ 4 in in front of it- cut between the clamps. IUGR: Intrauterine Growth Retardation: fetus doesnt grow as expected. Due to PIH; Decreased adequate blood flow.

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If mommy gets mag, NO AMINOGLYCCOSIDES for baby!!! Ch. 6,7,8 test no earlier than Thursday!!