Antepartum and Labor and Delivery

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Stages of Labor: -Dilation (w/3phases)
-Elpulsion
-Placenta
-Physical Recovery
Phases of Stage 1: Dilation: -Latent
-Active
-Transition
Phase 1: -Phase 1: Latent
*Cervix: begin - 4cm
*Contraction freq: 10-20 then 5" regular
*Intensity: Mild to mod
*Duration: 30 sec
Phase 2: -Phase 2: Active
*Cervix: 4 - 7cm
*Contraction freq: 3 - 5"
*Intensity: mod to strong
*Duration: 45sec
Phase 3: -Phase 2: Transition
*Cervix: 8 - 10cm
*Contraction freq: 2 - 3"
*Intensity: strong
*Duration: 60 - 90 sec
Indications of Pregnancy: -Presumptive
-Probable
-Positive
Presumptive: -Amenorrhea
-N&V
-Fatigue
-Urinary frequency
-Cervical color changes
-Brease and skin changes
-Quickening
Probable: -Abdominal enlargement
-Braxton-Hicks Contractions
-Palpation of fetal outline
-Positive pregnancy test
-hCG: human chorionic Gonadotropin
Positive: -Auscultation of fetal heart sounds (18-20 wks)
-Doppler 10-12 wks
-Fetoscope 18wks
-Fetal movement
-Visualization of fetus by ultrasound
Terms: -Hegar's Sign: softening of the uterus
-Goodell's sign: softening of the cervix
-McDonald's sign: Uterus flexed
-Chadwick's sign: color change in the cervix, vagina, and labia (bluish)
-Ballottement: during vaginal exam the cervix is tapped, fetus floats upward and then returns to cervical area
Routine Lab Tests for Pregnancy: -CBC, UA, BG
-ABO and Rh typing
-Hgb electrophoresis
-VDRL/FTA: syphilis
-Rubella Titer
-TB skin test
-Cervical culture
-Pap
-HIV
-Hep B
-AFP: alpha fetoprotein to detect for fetal anomalies
Luteinizing Hormone: -Anterior Pituitary Gland
-Target organs: ovaries and testes
-Action: Stimulated final maturation of follicle
-Causes ovulation
-Stimulates transformation of graafin follicle into corpus luteum
Follicle Stimulating Hormone: -Anterior Pituitary
-Ovaries
-Stimulates production of estrogens, progesterone
-Stimulates growth and maturation of graafin follicles before ovulation
Progesterone: -Ovary, corpus luteum, placenta
-Acts on uterine and breasts
-Stimulates secretion of endometrial glands, in preperation for possible embryo
-Pregnancy induces growth of cells of fallopian tubes and uterine lining to hourish embryo
-Decreases contraction of uterus
-Prepares breasts for lactation but inhibits prolactin secretion
Prolactin: -Anterior Pituitary
-Female breasts
-Stimulates secreion of milk
-Sucking of breast by infant stimulates prolactin production
-Estrogen and progesterone from placenta have inhibiting effect on milk production
Oxytocin: -Posterior Pituitary
-Uterus, female breasts
-Stimulates in uterus contractions during child birth and postpartum contractions to compress uterine vessels and control bleeding
-Stimulates let-down or milk ejection reflex during breast feeding
Dip Stick Urine: -Protein: for PIH
-Glucose: for Diabetes
-UTI
hCG: -Human chorionic gonadotropin
-Causes the corpus luteum to persist and secrete estrogens and progesterone
Metabolic Changes: -Average wht gain is 30lbs
-Caloric needs: 2500 a day
-Protein: 60g per day
-Vitamins: B6, D, E & folic acid
Negal's Rule: -Subtract 3 months and add 7 days to 1st day of last normal menstral period
Umbelical Cord: -2 veins
-1 artery
GTPAL: -Gravida, term, preterm, abortions, and live births
Gravida: -Number of pregnancies
Para: -Number of pregnancies that have progressed past 20 weeks
Umbilicus Cord: -Contains:
*2 arteries
*1 vein
PIH: -Pregnancy Induced Hypertension
-BP > 140/90 OR > 30 baseline SBP OR > 15 DBP
-S/S:
*seizures
*headaches
*spots in front of eyes
*pariorbital edema
*stroke and other complications
Nursing Priorities with PIH: -PEACE
-P: promote bedrest
-E: ensure high protein diet
(d/t proteinuria)
-A: antihypertensives drug (Apresoline does not cross placenta barrier)
-C: convulsion (prevent w/Mg sulfate, antidote calcium gluconate)
E: evaluate physical parameter (complications of mg sulfate)
Bleeding Conditions: -Spontaneous Abortion: termination of the pregnancy prior to 20wks gestation
-Inevitable abortion: vaginal bleeding with cramping, cervical changes and rupture of membranes (not reversible)
-Incomplete abortion: D&C usually needed (<6wks >14wks)
-Habitual abortion: SAB in >3 consecutive pregancies
Differential Diagnosis: -Ectopic pregnancy
-Implantation bleeding
-Molar pregnancy: hydatidiform mole proliferation of the chorionic villi
Placenta Previa: -Placenta implants in the lower part of the uterus
-S/S: painless. bleeding, sometimes found by ultrasound
-Types include:
*Total
*Partial
*Marginal
-C-section must be preformed
Abruptio Placenta: -Seperation of the placenta before delivery
-Can be caused by cocaine use, trauma
-S/S: sometimes vaginal bleeding, abdominal pain, board-like abdomen, uterine tenderness, concealed bleeding, may be noted by pain, fetal distress and shock symptoms in the mother
-DIC: disseminated intravascular coagulation
*may occur as a sequela to abruptio
-C-section required
Toxoplasmosis: -Protozoan found in cat liter that can cause severe fetal damage
Amniocentesis: -Aspiration of amniotic fluid for exam
-Usually done at 15-18wks
Midtrimester Amniocentesis: -To examine fetal cells for any chromosomal abnormalities
Third trimester Amniocentesis: -Done to determine fetal maturity or to diagnose fetal hemolytic disease
Eary Amniocentesis: -Usually done between 11-14wks
Non Stress Test: -To assess fetal well being
-Assess ability of fetal heart to speed up in response to fetal movement
-Requires 30 - 40 minutes
-Response is a good thing
Gestational Diabetes vs DM: -GD:
*multiple risk factors
*FBG > 140
*Obesity, high birth wght, previous preg. or birth
-DM:
*no oral insulin
*Mom Type 1 is at risk for DKA or SAB
*Pt education for hyper/hypo glycemia
Magnesium Sulfate Toxicity: -BURP
-B: blood pressure decreased
-U: Urine output decreased
-R: Respirations decreased
-P: Patella reflex absent
Danger Signs of Pregnancy: -CABS
-C: Chills and fever, cerebral disturbances
-A: Abdominal pain
-B: Blurred vision, blood pressure, bleeding
-S: Swelling, sudden escape of fluid
Auscultation of Fetal heart sounds: -18-20weeks
-Doppler: 10-12weeks
Preterm Labor: -Labor that occurs between 20 and 37 weeks of gestation
*may be due to DES exposure which will cause birth defects
-Fetal factors:
*multiple pregnancy
*hydraminos: too much amniotic fluid
*fetal infection
*plecenta previa
*abruptio placenta
Tocolysis: -Medication to stop labor
-Examples:
*Mag sulfate
*Beta-adrenergic: yutopar
*Prostaglandin synthesis inhibitors
*Calcium channel blockers
-
Magnesium Sulfate: -6-8mg/dl is effective range
Betamethasone: -Corticosteroid
-Acceleration of fetal lung maturation
-12mg IM for 2 doses, 24 hours apart
-Up to 34wks
Onset of Labor: True: -**Cervix progressive effacement and dilation (most important sign)**
-Contractions are consistent and increase in intensity and frequency
-Discomfort in lower back to abdomen
***Contractions start in the fundus and do down the uterus
Dilation: Cervix progresses from 0-10cm in diameter
Effacement: The thinning of the cervix
S/S of Labor and Delivery: -WORLD
-W: wgt loss
-O: observe change in sensations
-R: rupture of membranes (baby should be delivered in 24 hours to prevent infection)
-L: lightening: baby droppin
-D: dilation & effacement
-S: show bloody (mucous plug)
Stage 1: -Latent phase:
*mild and frequent contractions
*every 5min lasting 30-40"
-Active phase:
*increase in FID (freq. inten. dura.)
*2-5min frequency
*lasting 40-60"
-Transition phase:
*very strong contractions
*1.5-2min frequency
*lasting 60"
Hypertonic Contractions: -Contractions that
*have 1-2min frequency
*last 90sec
-No time for the uterus to relax and allow blood to flow back to the placenta and fetas
Lacerations: -1st degree: vaginal mucousa, skin of perineum
-2nd degree: vagina, perineum, fascia muscle
-3rd degree: all perineum, external anal sphincter
-4th degree: all perineum, rectal sphincter, some rectal mucus membrane
Morphine: -Can be reversed by 0.4mg narcan via IVP
Epidural: -Can only be give during 2nd phase of labor
-Local: for perineum repair and pudendal block for vaginal/forceps delivery
-Regional:
*Epidural: outside the dura mater
*Intrathecal: into the subarachnoid space
*Spinal: subarchnoid space with loss of motor and sensory function
-General: usually used for life threatening emergencies
Anesthesia: -REGION
-R: respiratory paralysis
-E: elimination
-G: gastrointestinal
-I: inform of procedure
-O: observe for hypotension
-N: no trauma (prevent trauma to extremeties
Mechanics of Labor: -4Ps
-Power of uterine contraction
-Passenger: size, lie, presentation, attitude, postion, station
-Passage: pelvic inlet, midcavity and outlet
-Pstchy of mother
Active Phase: -4-7cm dilated
-Contractions every 3-5min
-Lasting 30-60"
-MAD
-M: medication (can only be given in this phase
-A: assess and anticipate needs
-D: dry lips (ointment) and dry linens
Transition Phase: -8-10cm dilated
-Contractions every 2-3min
-Lasting 45-90"
-TIRED
-T: Tires (needs support)
-I: Inform of progress
-R: Restless
-E: Encourage and praise
-D: Discomfort (no pain meds)
Dysfunctional Labor: -Problems with: power, passage, passenger, psyche
-Problems of: presentation, position, effacement, dilatoin, and descent
PROM: -Prolonged premature rupture of membranes
-Hypovolemic shock???
-Nitrazine or fern test on fluid (will be blue if amniotic fluid is present)
Prolapse Cord: Compression of cord can happen after water breaks
Uterine Rupture: Hypertonic dysfunction
Amniotic fluid embolism: -in baby's circulatory system
Early Decelerations: -Fetal head compression
-Intracranial pressure
-Cause vagus nerve to slow HR
-HR > 100 BPM
-Return to baseline at end of contraction
-Mirror images of contractions
-Are not associated with fetal compromise and require no added interventions
Late Decelerations: -Decrease in oxygen
-Less water exchange
-Indicates danger d/t uterus/placenta insufficiency
-Variable HR due to stimuli are ok
-Late decelerations are not good
-Begin well after the contraction begins (right shift)
-Return to baseline after contraction ends
-Reflect impaired placenta exchange
-Placenta blood flow and fetal oxygen supply needs to be addressed
Variable Decelerations: -Shape like a v or flat u
-can occur at any time and may be non-repetitive
-Cause: cord compression
-Nursing care: change position of the mother
-Mother may need oxygen to help the fetus
Nursing Intervention for Late Deceleration: -COIL
-C: change position (left lateral position)
-O: oxygen (admin oxygen to morther to correct fetal insufficiency, if oxytocin is infusin stop infusion)
-I: IV fluids (will increase the maternal blood pressure and the uteroplacenta circulation)
-L: lower head of bed (to encrease perfusion to uterus)
Side Effects of Pitocin: -PITOCIN
-P: pressure elevated
-I: intake and output (watch)
-T: Tetanic contractions
-O: Oxygen decrease in fetus
-C: Cardiac arrhythmia
-I: Irregular fetal HR
-N: N&V
-Stop the pitocin drip
H&H: -RBC mass and Plasma volume increases during pregnancy
-The resulting dilution of RBCs (d/t greater and earlier increase in plasma volume) causes a decline in maternal hematocrit
-Hmg: >10.5
-Hct: >33%
Nausea and Vomiting Causes: -Generally beginning about 6wks after last period
-Believed to be caused by the increased levels of hormones hCG, estrogen..., decreased gastric motility and relative hypoglycemia
Rhogam: -Admin to women who are Rh- at 28 wks gestation and 72 hours after delivery
Chorionic Villus Sampling: -Removal of a small sample of chorionic tissue
-Dx for genetic disorders
-9-ll wks optimal time
-Indications:
*family history of genetic abnormalities
*Advanced maternal age
*mother is carrier for x-linked disease
*parents known carriers of autosomal recessive disorders
*History >3 successive SAB
Precipitate Labor: Labor that lasts <24 hours???
Macrosomia: Unusually large fetal size, infant birth > 4000g
Shoulder Dystocia: -Delayed or difficult birth of the fetal shoulders after the head is born
Ritodrine: -Beta-adrenergic drug
-Yutopar
-S/S: tachycardia (M and F), decreased BP
-May be given: IV, SC, oral
Nitrazine Paper: -Paper to determine pH
-Helps to determine whether the amniotic sac has ruptured
Fern Test: -Microscopic appearance of amniotic fluid that resembles fern leaves when the fluid is allowed to dry on slide
Fetal Heart Rate: 110-160 BPM
Fetal head engagement: -Descent of the widest diameter of the fetal presenting part to at least zero station
Fundal Height: -22wks roughly when fundus reaches the umbilicus

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