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Medical 2-23-Intrapartal Nursing


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First stage of labor normal vital signs?
blood pressure:
less than 135 systolic and less that 85 systolic in adult 18 years or no more
than 15-20 mmHg rise in systolic pressure over baseline bp

pulse: 60-90 bpm

respirations: 14-22 min

pulse 95% or greater

temperature: 98-99.6F
First stage of labor normal weight?
25-35 lb greater than prepregnant weight
First stage of labor normal findings?
normal breath sounds, clear, and equal

fundus: at 40 weeks' gestation just below xiphoid process

edema: slight amount of dependent edema

hydration: normal skin turgor, elastic

perineum: tissues smooth, pink color; clear mucus; may be blood tinged with earthy or human odor
presence of small amount of bloody show that gradually increases with further cervical dilatation
First stage of labor normal labor status?
uternine contractions: regular pattern

cervical dilatation: progressive cervical dilatation from size of fingertip to 10 cm

cervical effacement: progressive thinning of cervix

fetal descent: progressive descent of fetal presenting part from station -5 to +4

membranes: may rupture before or during labor

findings on nitrazine test paper: pH 5.0 to 6.0
intact membranes

pH 6.5 to 7.5
ruptured membranes

amniotic fluid clear, with earthy or human odor, no foul-smelling odor
First stage of labor normal fetal status?
FHR: 110-160 bpm

presentation: cephalic 97%
breech 3%

position: left-occiput-anterior (LOA) most common

activity: fetal movement
First stage of labor laboratory evaluation..
hematologic tests..
12-16 g/dL
First stage of labor
lab evaluation..
hematologic tests
First stage of labor laboratory evaluation..
hematologic tests..
4.2 - 5.4 million/mm3
First stage of labor laboratory evaluation..
hematologic tests..
4500-11,000/mm3, although leukocytosis to 20,000/mm3 is not unusual
First stage of labor laboratory evaluation..
hematologic tests..
150,000 - 400,000/mm3
First stage of labor laboratory evaluation..
hematologic tests..
Serologic testing
STS or VDRL test?
First stage of labor laboratory evaluation..
hematologic tests..
all negative
Contractions Characteristics
in latent phase?
every 10-30 min x 20-40 sec; mild, progressing toevery 5-7 min x 30-40 sec; moderate
Contractions Characteristics
in active phase?
every 2-3 min x 40-60 sec; moderate to strong
Contractions Characteristics
in transition phase?
every 1.5 to 2 min x 60-90 sec; strong
Labor Progress Characteristics in primipara:
1.2 cm/hr dilatation
1 cm/hr descent
less than 2 hr in second
Labor Progress Characteristics in multipara:
1.5 cm/hr dilatation
2 cm/hr descent
less than hr in second stage
What kind of tape test to use in performing an intrapartal vaginal exam if there has been fluid leakage reported or noted?
Nitrazine pH test paper
When performing an intrapartal vaginal examination, perform exam during and between contractions because?
cervical effacement, dilatation, and fetal station are affected by presence of contraction
When performing an intrapartal vaginal examination, palpate the presenting part because?
doing that is necessary to assess the position of the fetus and to evaluate fetal descent
When performing an intrapartal vaginal examination, assess fetal descent and station by identifying?
position of posterior fontanelle
When performing an intrapartal vaginal examination, positioning hand with wrist straight and elbow tilted downward allows fingertips to point toward the ________ and find the __________.
When performing an intrapartal vaginal examination, position the woman with ________ flexed and abducted...put _____ of _____ together
When performing an intrapartal vaginal examination and woman has ruptured membranes, use ______ exam if she's not in active labor.
Before labor begins, what is cervix like?
long about 2.5 cm
sides feel thick
cervical canal is closed
(examining finger can't be
How does nurse gauge cervical dilatation?
places index and middle fingers against cervix and determines the size of the opening
Assess FHR prior to?
initiation of labor-enhancing procedures
ex: artificial rupture of membranes

periods of ambulation

medication administration

initiation of analgesia/anesthesia administration
Assess FHR following?
rupture of membranes
recognition of abnormal
uterine activity patterns,
such as increased basal
tone or tachysystole
evaluation of oxytocin
(maintenance, increase, or
decrease of dosage)
administration of medications
(at time of peak action)
expulsion of enema
urinary catheterization
vaginal examination
periods of ambulation
evaluation of analgesia
and/or anesthesia (main-
tenance, increase, or
decrease of dosage)
Define electonic fetal monitoring (EFM)?
provides continuous tracing of FHR..recording 2 successive FHBs...
ex: interval between 2 beats is 0.5 seconds, rate for one full minute would be 120 bpm
Define Leopold's maneuvers?
systematic way to evaluate maternal abdomen...difficult to assess on obese or hydroamnios...have woman empty bladder...complete procedure between contractions...includes 4 maneuvers
First maneuver of Leopold?
fetal head: firm, hard, round, moves independently

looking for what occupies fundus....
breech: feels softer and symmetric and has small bony prominences...moves with trunk
Second maneuver of Leopold?
(after finding what occupies fundus in first maneuver, head or breech butt)
Put on your breeches! :)
find fetal back and if it's on left or right side of abdomen...use deep, gentle pressure, using palms...
fetal back feels firm and smooth and should connect what was found in fundus with a mass in inlet... after back located, palpate fetal extremities on opposite side of abdomen
Third maneuver of Leopold?
(after finding back and extremities)
grasp underneath belly just above symphysis pubis with thumb and fingers of right hand and find which fetal part is lying above inlet...validates presenting part
Fourth maneuver of Leopold?
(after finding presenting part under belly...look for cephalic prominence which is the brow)
so, if first cephalic prominence palpated is on the same side as the back, head is not flexed...
if the first prominence found is opposite the back, head is well flexed
Advantages of telemetry?
continual strapped monitoring and woman can ambulate...monitors direct and indirect FHR, indirect monitoring uterine pressure, dual FHR monitoring twins
Define baseline rate?
refers to range of FHR observed between contractions during a continuous 10-minute period of monitoring...does not include rate during contractions; normal baseline 110 to 160
Mild tachycardia?
161 to 180 bpm
Severe tachycardia?
181 bpm and up
Possible causes of fetal tachycardia?
hypoxia..stimulates SNS
maternal fever..fetus
metabolism accelerates
betasympathomimetic drugs
have cardiac stimulant
maternal hyperthyroidism may
cross placenta stimulating
fetal anemia - heart rate
increases to improve tissue

an ominous sign if coupled with other FHR patterns
Define baseline variability?
a measure of the interplay .."push-pull" effect between SNS (which acts to increase heart rate) and PNS (which acts to decrease heart rate
Define fetal bradycardia?
FHR of less than 110 to 120 bpm continuing for 10 minutes or more...can be a benign or ominous sign
Define moderate bradycardia?
FHR of 80 to 110 bpm
Define severe bradycardia?
FHR of less than 80 bpm for 2 to 3 minutes
Causes of fetal bradycardia?
late (profound) fetal asphysxia...there is depression of myocardial activity

maternal hypotension...maternal hypotension results in decreased blood flow to the fetus

prolonged umbilical cord compression...fetal baroreceptors are activated by cord compression, which produces vagal stimulation, and in turn decreases FHR

felal arrhythmia..associated with complete heart block in the fetus
When is fetal bradycardia benign?
if average variability is present...AV is 6-25 bpm
When is fetal bradycardia ominous?
when it's with:
decreased variability 0-5 bpm
late decelerations
or both
Define long-term variability (LTV)?
refers to the larger rhythmic fluctuations of the FHR that occur from 3 to 5 cycles per minute with a normal range of 6 to 10 bpm...refers to difference between lowest FHR and highest FHR in each cycle within 1 minute...increased by fetal movement and decreasd or absent when fetus is in a sleep cycle...

classified into decreased/minimal
variability 0-5 bpm
moderate/average variability
6-25 bpm
marked variability
(saltatory) greater than
25 bpm
Define saltatory pattern (marked variability greater than 25 bpm)?
a type of LTV...characterized by rapid variations in FHR that have a bizarre appearance...
occurs with a cycle frequency of 2 to 5 per minute and amplitude greater than 25 bpm..etiology uncertain but not thought to be bad for fetus
Amplitude of LTV tracings are classified into?
0-5 bpm MV
6-25 bpm AV
greater than 25 bpm
Define sinusoidal patterns?
unusual...undulant sine wave that is equally distributed above and below baseline...FHR ranges between 120 and 160 bpm..amplitude 5 to 15 bpm (like AV)...oscillates in 2 to 5 cycles per minute...ominous for fetus
The sinusoidal pattern is associated with?
severe asphyxia
Rh isoimmunization
severe anemia
abruptio placentae
fetal-maternal hemorrhage
severe fetal acidosis

a transient sinusoidal pattern might be sign in a bening labor

pseudosinusoidal pattern might be seen in med administration

if ominous ones seen on external monitoring, switch to internal monitor and consider c-section
Define short-term variability (STV)?
refers to the differences between successive heartbeats as measured by the R-R wave interval of QRS cardiac cycle and therefore represents actual fluctuations from one beartbeat to the next...classified as either present or absent...accuracy on internal monitors only...indicates appropriate fetal CNS if listed as present, it's a good thing...oxygen deficit, then STV absent, bad...
Define accelerations?
<spontaneous ones occur with fetal monitoring and are reassuring>
<uniform ones may indicate partial umbilical cord compression (vein), benign pattern>
transient increases in FHR...nonperiodic ones are normally caused by fetal movement...if baby moves, heart rate goes up (exercise) quiets down then FHR goes when uterus contracts, baby moves and fetal heart rate increases...

may also be compression of cord during uterine contractions which cuts off maternal blood supply briefly causing FHR to compensate by increasing cardiac output
Define decelerations?
periodic decreases in FHR from normal baseline..can be early, late, variable according to when they occur in contraction cycle and to their waveform
Define early decelerations?

(For exam, know descriptions of early, late, and variable decelerations, nursing actions, and causes
ex: head compression vs uteroplacental insufficiency or cord compression
<causes vagal response to head compression>
due to pressure on fetal head as it progresses down the birth canal...<they have a uniform appearance that inversely mirrors that of the corresponding contraction>...benign at 4-7cm unless seen with lack of descent of fetal head
Immediate nursing interventions regarding late decelerations might include?
changing maternal position
providing oxygen to mother
via face mask
increasing administration of
IV fluids
stop pitocin (oxytocin) if
Define variable decelerations?
<variable in shape, occurrence and look like a "v"...may/may not occur with contractions>
vary in their onset, occurrence, duration, intensity, and waveform...visible abrupt decrease in FHR...may be <cord occlusion>, cord around neck, short cord...if it persists, then could be ominous....get acid-base status of fetus because c-section, forceps, or vacuum may be indicated

membrane rupture causes variable decelerations
Define prolonged decelerations?
<those in which the FHR DECREASES (BELOW BASELINE) from baseline for 2 to 10 minutes....may be seen with sudden occult or frank prolapse of cord, regional anesthesia due to maternal hypotension, abruptio placentae, uterine hypertonus, hyperstimulus, drug reactions, terminal fetal conditions, maternal seizures, maternal death....nurse should investigate...intervention may be as simple as position change
Define combined decelerations?
may be seen occasionally when two different deceleration patterns occur with the most ominous pattern first
"It is important for you to turn on your left side right now because the baby is having a little difficulty. I'll explain what is happening in just a few moments."
Look at the mother when speaking to her...not the machines. The mother is the central focus.
Doppler or intermittent fetal monitoring is used typically for?
<low risk patients>
<used to detect FHR>
The tocodynanometer is a device used to?
<assess uterine contractions
U/C's or UC's>
Components of the fetal monitor tracing?
<fetal heart rate/tones
*rate, presence of
periodic changes
*top line on monitor strip

uterine contraction pattern
*frequency, duration
*bottom line on monitor
strip paper
*looks like upside down

time interval
*in US, fetal monitor
paper printing speed is
3 cms per minute
Intensity can only be measured with which monitor?
What is resting tone?
<the uterine tone between UC (where is the bottom line when she is not contracting)>
How is intensity measured?
<in mmHG if using an IUPC...values are read from strip readout>
With an external monitor, intensity/pressure is assessed by ______ and reported as _______, _______,

mild, moderate, firm>
Fetal heart rate graph shows?
<FHR printed out as a continuous line on top graph of paper...
horizontal lines denote 10 bpm increments...
paper has FHR value printed periodically to assist in ready determination of FHR>
The FIRST thing to assess with FHR is the?
<baseline...determined by evaluating rate between UC and between any periodic change...normal baseline FHR is 120-160 bpm>
The SECOND thing to assess is?
variability...which is the fluctuation of heart rate in two periods of time

Short term variability (STV):
the "grass-like" appearance of the FHR baseline

Long-term variability (LTV): the "rollercoaster" appearance of the FHR tracing

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