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Medical 2-Labor Process Lecture 2


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#1 side effect of epidurals during it's administration is?
Three hours after epidural, she said she feels pressure in her perineal area. She's 9cm and 100% effaced..fetus at +2...these are signs of transition of stage 1 and the doctor has been notified that delivery is close because she can dilate to 10cm in one
some of the normal signs of transition are not exhibited because she's had an epidural...some signs she MAY NOT be showing after an epidural may be:
diaphoresis (sweating) because she's not working as hard
shaking of legs or all over
In response to late decelerations, which of the following actions would you carry out first?
turn on left's uterine insufficiency...turning increases tissue perfusion..turning is an immediate response the nurse can take...AFTER THAT..oxygen would be ordered and doctor notified...the rate can also be increased if she becomes hypotensive by turning her
Effects of epidural are starting to wear off...her contractions are every 1 1/2 to 2 minutes....the contractions are very strong and she's insisting she "wants to push". The nurse tells her not to push...the doctor comes in...don't ever clamp t
there's still a thickening just below the pubic bone...that's not uncommon with a first time considers her 100% effaced at plus 2...what is an appropriate statement when it's time to push if there's an anterior lip present?
The doctor would say, "Is it resistant enough where I can push it out of the way?"...if not, then she can't push yet.
Fetus can have amniotic embolic, what is it?
some of the fluid gets into the tissue and goes into the circulatory system. The amniotic fluid is not clear and it has little flecks of vernix caseosa, hair, and so it can cause death. So we don't want cervix to tear. The perineum can tear and be repaired.
The mother goes into a knee chest (Sims) position if doctor doesn't want her to?
If she had an epidural, what might her legs feel like when she gets close to delivery?
elephant legs
Knee chest position (Sims) is very good for 2 types of fetus...which ones?
baby with shoulder dystocia
(line backer shoulders...
so head comes and fetus
can't get shoulders back
...makes it hard for
fetus to get shoulders
through...knee chest
position allows a
corkscrew maneuver
and then break collar
also good position for
posterior fetus that
doctor wants to rotate
but not a very good
position for anterior
If someone besides doctor is allowed to cut cord, don't allow other person or scissors to touch sterile doctor. Dry newborn immediately and cover with blanket. Dry quickly and discard wet towel. Assess newborn while skin to skin with color
fingers on umbilical stuff
and count because it's
still beating at this
Respirations of immediate newborn are?
36 breaths a minute and newborn is can't cry if you don't have air...if newborn's not crying, that's bad
At immediate birth, give APGAR...a 1-5 minute assessment of the newborn basing it on 5 criteria. All of the 5 areas are given 2 points to two. A spin on the APGAR per lecturer is?
Pulse is heart rate
Grimace is reflex irritabil.,
crying, pulling away from
Appearance is color or
What percentage of newborns will have discolorations of
hands and feet in first 24 hours?

Why are newborns marked off for discoloration of hands and feet if it's considered normal?
almost all of them.

because it's still part of the APGAR criteria even though it's normal
With APGAR, if newborn has no flexion or is limp, he'd get a ______ score.
With APGAR, if newborn is semi-flexed, but not really tight..he might get a score of?
The pulse/heart rate is supposed to be 120 to 160...if APGAR assessment shows newborns heart rate is 100, then newborn would get a?
APGAR and grimace? If newborn is crying, but it's weak...and has to be stimulated...score is?
Color and APGAR...newborn is only cyanotic at hands and feet would be a score of?
1 point
In APGAR, if newborn has central cyanosis, circum cyanosis around the mouth or he's not turning pink, but turning blue, score is?
Color and newborn using intercostal muscles, are nares flaring, grunting, and respiratory effort looks difficult...mark off for that..or not breathing, then have to bag them. APGAR is given at 1 minute and most of the warming tables have a but
and will raise numbers
subconsciously it's a reflection of his ability, so the nurse scores the baby at one baby has moderate flexion...heart rate is 140...respiratory effort has some grunting and sighing with nasal flaring...color is acrocyanosis...heart rate is fine...appearance is okay if newborn moderately flexed...the pulse, the heart rate of 130 is 2...moderately crying is a 1..acrocyanosis only is a one and respiratory effort with use of accessory muscles 1...newborn would score 6 at one minute
In APGAR, the first score is given at one minute...the next score is given at 5 minutes...after hitting beeper once entire body is out...the beeper will sound at one minute and then sound again at 5 minutes automatically...look at newborn again at 5 minu
a 10 minute assessment is done if score is 6 or below
I've had babies where I've had a 2, a 4, and a 5..this baby's in NICU. Baby needs extra normal support. Would not go to normal newborn nursery.
most babies get a 7-9 score...rarely a 10 is given because it's common to have bluish discoloration of hands and feet
So for APGAR, newborn has pink with bluish discoloration- 1 point
flexion - 2 point
heart rate 120 - 2 points
respiratory effort -2 point
crying - 2
Score is 9
Mother has a sudden gush of blood after infant born and lengthening of umbilical cord. What's happening?
separation of placenta

(doctor says push and mother doesn't realize she has placenta to deliver)
Placenta has been expelled...the doctor starts not push...a lot of times 10 units of oxytocin or pitocin will be added to IV, nurse will open it up so uterine begins to contract...cannot put that in until placenta's been delivered...if you
stimulate contractions
Another thing that can be done to simulate contractions after delivery is?
massage them
put baby to breast
Know how to figure milliunits of pitocin...KNOW THAT for math question..
So if I have 10 units of pitocin and a 1000 and the rate's going at 60mls per hour, how many milliunits is that per minute?

(Need to know how to convert units into m
Two things about pitocin that are important?
1) Pitocin increases the risk for water intoxication of the pregnant if using it for induction...

2) it also increases the risk for hyperbilirubinemia for the infant if the person's been induced

3) the other thing is that it has a very short half life...means if infusion is stopped, what happens to the effect of the drug? wears off quickly which is good if there is a bad fetal monitoring and stimulation of uterus needs to be stopped...but it's bad if given for postpartal bleeding and a person is nice and firm and nurse goes down the hall for an hour and nurse comes back and person has bled out because pitocin has a very short half life
What's it called when the baby has a cone-shaped head?
Largest heat loss in newborn occurs at?
so stocking caps are used
radiant warmer
Newborns can't make Vitamin K in the gut, so it's given to them. Vitamin K helps with?

(given in vastus lateralis)
For the eyes, give erythromycin ophthalmic ointment because?
they get exposed to a lot of things, especially vaginal helps protect them from gonorrheal and chlamdyial infections which can cause blindness...we used to use silver nitrate...silver nitrate is very stains skin and can irritate eyes, but it's very cheap...erythromycin is a lot more expensive, but it treats both chlamydia and gonorrhea, whereas, silver nitrate is typically for the gonorrheal
Baby is wrapped in a warm blanket and placed in mother's arms and this is starting the fourth stage of labor. The first stage is 0-10, second stage is from 10cm to delivery, and third stage is deliver to expulsion of placenta which is usually short, abou
placenta acreda which means instead of adhering to the uterine wall, it is actually GROWING into the uterine wall...usually results in HYSTERECTOMY...that's abnormal and for next test.
Nurse wants to determine the position and the firmness of fundus. The uterus is the only organ of the body that stretches to this maximum capacity and it has to go and involute back to it's normal when assessing the fundus, what do we want to l
we want it to be firm, so if it's firm, it can't bleed..want it midline and NOT to the side...
do we want it 3 fingerbreadths above the umbilicus or do we want it 2 fingerbreadths below the umbilicus? below is the right answer...if it's above then she has a full bladder

bogginess is softening of the uterus due to inadequate contraction of the muscle tissue, positioning out of midline, heavy lochia flow, or presence of nurse monitors uterine status every 8 hours or more frequently
Define bogginess?
bogginess is softening of the uterus due to inadequate contraction of the muscle tissue, positioning out of midline, heavy lochia flow, or presence of nurse monitors uterine status every 8 hours or more frequently
After birth, where should the uterus be?
2 fingerbreadths below the umbilicus ..if it's above then she has a full bladder
The baby has been born, the uterus is midline, fundus feels boggy at one fingerbreadth below the umbilicus, what would the nurse do?
massage uterus
When woman return homes the following morning and it's been 11.5 hours after her delivery, she's complaining of being tired, she goes to the bathroom and is voiding 350 which is normal, she had to be catheterized once after delivery and was able to void
massage stomach
peri-wash (warm water)
pain medication beforehand
pee in the shower

if sitting pulls on it and causes it to tighten up and the woman can't pee and the thing is that the nurse wants her to start peeing...
so what's causing the pain? what does the nurse need to do to get mom to go to the bathroom without's hard to catheterize a site that looks like hamburger meat...the familiar landmarks are not also increases the risk for infection
So, assessment has been performed, mom now knows about vaginal discharge that occurs, what is the vaginal discharge called that she's going to have FIRST?
lochia rubra (meaning "discharge red"

(discharge yellowish-red)

(discharge white, albino-white)
The 3 lochia classifications
transition slowly as the fundus begins to?
If Mom overexerts herself, the lochias may revert. She may go from lochia alba back to lochia serosa. When uterus goes back to normal size after delivery, it's called?
As the uterus grows during pregnancy, it is measured...grows 1cm per week per gestation after 20 weeks...same thing with after delivery, it should be at the _____ or _____ to ______ fingerbreadths below the umbilicus and it should go down one fingerbread
1 to 2
How should uterus decrease size after delivery?
it should go down one fingerbreadth per day for 20 days, it shouldn't even be a pelvic organ anymore, it should be back into below the symphysis pubis.
What are the advantages of breastfeeding?
not likely to have allergies
to mom's milk
breastfeeding even 6 weeks
allows babies to get more
antibodies and have better
resistance to infection,
but they don't necessarily
sleep better
What are disadvantages of breastfeeding?
don't sleep as well because newborn digests quickly and is hungry more often
Attitude is how the head is?
(think attitude...if snobby, then may not deliver)

during vaginal exam....small little triangle is posterior...the diamond is anterior...if vaginal exam nurse is feeling the diamond, then the baby's head is extended...nurse wants to feel the the triangle...the small little posterior triangle means good flexion...think attitude!..
If the fetus is in a minus station, he's floating...if pluses, then descent is's the presenting part that is above or below the ischial spine...if fetus has caput or swelling tissue, that's just the soft spot which may still be at zero...b
With Leopold's maneuver, nurse will be palpating for the long axis of the baby's body on the go left, then right and see if long axis can be felt...then go top and see if can palpate soft or hard...if soft then butt is up... if hard, then he
station or dilation (these are internal measurements)

Fetal head is larger than chest. There are how many cms difference between both?
normal fetal head will be 1-2 cms larger than the chest...if it's not, then there may be problems such as alcohol fetal syndrome or microencephaly, or thorax pulmonary problem
Getting engaged, is hitting _____ station.
Cardinal movements...As fetus descends from zero station, we want flexion...engage, descent, flexion so that fetus is presenting narrowest part as widest part of body first...what happens after descend and flex, internal rotation happens's he
Restitution is when fetal head is emerging, and ________ occurs here.

think resuscitation and restitution, because it's when the mouth and nose appear that I can suction them.
What is indirect Coombs test?
Indirect Coombs' test
The indirect Coombs' test checks for antibodies against red blood cells circulating in your blood but not attached to your red blood cells. The indirect Coombs' test is commonly done to detect antibodies in a recipient's or donor's blood prior to a transfusion.

A slightly different form of this test, the Rh antibody titer, is done early in pregnancy to determine a woman's blood type. A woman with Rh-negative blood can produce antibodies against her baby's blood if the baby has Rh-positive blood. This condition is called Rh sensitization and does not occur unless the baby's blood mixes with the woman's blood usually at delivery. The Rh antibody titer test detects the presence of anti-Rh antibodies in the pregnant woman's blood. Pregnant women with Rh-negative blood often have this test done early in pregnancy. Repeated testing throughout the pregnancy may be needed so steps can be taken to protect the baby.


Risks of a blood test
There is very little risk of complications from having blood drawn from a vein.

You may develop a small bruise at the puncture site. You can reduce the risk of bruising by keeping pressure on the site for several minutes after the needle is withdrawn.
Rarely, the vein may become inflamed after the blood sample is taken. This condition is called phlebitis and is usually treated with a warm compress applied several times daily.
Continued bleeding can be a problem for people with bleeding disorders. Aspirin, warfarin (Coumadin), and other blood-thinning medications can also make bleeding more likely. If you have bleeding or clotting problems, or if you take blood-thinning medication, tell your health professional before your blood is drawn.

Antibody tests are done to detect antibodies against red blood cells.

No antibodies are detected. This is called a negative test result.

indirect Coombs' test for Rh factor (Rh antibody titer) in a pregnant woman means that she has not developed antibodies against the blood of her baby if her baby has Rh-positive blood. This means that Rh sensitization has not occurred.
Abnormal test results
Direct Coombs' test. The detection of antibodies attached to your red blood cells indicates that your blood has antibodies against red blood cells in your bloodstream. This is called a positive test result. This can be caused by a transfusion of incompatible blood or may be associated with conditions such as hemolytic anemia, systemic lupus erythematosus (SLE), hemolytic disease of the newborn (HDN), lymphoma, mycoplasma infection, advanced stage cancer, or infectious mononucleosis.
Indirect Coombs' test. A positive test result, or the detection of antibodies against red blood cells from a donor, may indicate that your blood is incompatible with the donor's blood and you cannot receive blood from that person. If the Rh antibody titer test is positive in a woman who is pregnant or is planning to become pregnant, it means that her immune system has formed antibodies against Rh-positive blood (Rh sensitization). She will be tested to determine the blood type of her baby. If the baby has Rh-positive blood, close monitoring throughout the pregnancy is needed to prevent serious damage to the baby's red blood cells caused by the mother's immune system. If sensitization has not occurred, it can usually be prevented by an injection of the Rh immune globulin vaccine.
What Affects the Test

Factors that can interfere with your test and the accuracy of the results include:

A previous blood transfusion, a dextran injection, or a recent X-ray that required the use of contrast material given intravenously (IV).
Being pregnant within the past 3 months.
Medications. These include penicillin, ampicillin, cephalosporins, sulfa medications, tuberculosis medications, insulin, quinidine, levodopa, methyldopa, captopril, chlorpromazine, indomethacin, procainamide, tetracyclines, and phenytoin (Dilantin).
What To Think About

A newborn baby (whose mother has Rh-negative blood) may have a direct Coombs' test to determine the presence of antibodies against the baby's red blood cells. The test results indicate whether the mother has formed harmful antibodies and transferred them through the placenta to her baby. If the test is positive, the baby may need a transfusion with compatible blood to prevent anemia.

Author Jan Nissl, RN, BS
Editor Susan Van Houten, RN, BSN, MBA
Associate Editor Tracy Landauer
Primary Medical Reviewer Patrice Burgess, MD

- Family Medicine
Specialist Medical Reviewer W. David Colby, MSc, MD, FRCPC

- Infectious Disease
Last Updated August 9, 2004

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Last updated: August 09, 2004

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What is direct Coombs test?
Direct Coombs' test
The direct Coombs' test checks for antibodies attached to your own red blood cells. The antibodies may be those your body produced because of disease or those you received in a blood transfusion. The rare condition of having antibodies against your own red blood cells is called autoimmune hemolytic anemia.

The direct Coombs' test also may be done on a newborn baby whose mother has Rh-negative blood. The test results determine whether the mother has formed harmful antibodies and transferred them through the placenta to her fetus.

Direct Coombs' test. A negative test result means that your blood contains no antibodies that are already attached to your red blood cells.
Indirect Coombs' test. A negative test result means that your blood is compatible with the blood you are to receive by transfusion. A negative
Coombs test preparation?
No special preparation is needed before having this test.
How is Coombs test done?
How It Is Done

The health professional drawing blood will:

Wrap an elastic band around your upper arm to stop the flow of blood. This makes the veins below the band larger so it is easier to put a needle into the vein.
Clean the needle site with alcohol.
Put the needle into the vein. If the needle is not placed correctly or if the vein collapses, more than one needle stick may be needed.
Attach a tube to the needle to fill it with blood.
Remove the band from your arm when enough blood is collected.
Apply a gauze pad or cotton ball over the needle site as the needle is removed.
Apply pressure to the site and then a bandage.

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