The ____ begins with regular uterine contractions and ends with full cervical effacement and dilation.
first stage of labor
effacement: refers to a thinning of the cervix
The ____ begins with full cervical dilation and complete effacement. This stage ends with the baby’s birth.
second stage of labor
The three phasesof the first stageof labor are defined by the degree of cervical dilation: A, B, and C.
A) latent phase (up to 3 centimeters)
B) active phase (4 to 7 centimeters)
C) transition phase (8 to 10 centimeters).
During the ___, the ideal place for the woman is often the familiar environment of her home.
Latent phase
When the woman arrives at the perinatal unit, the nurse performs a ____.
screening assessment
Women in labor usually have concerns that they will express A___. B____ increase a woman’s stress and can inhibit the process of labor.
A) only if asked
B) Unresolved fears
During labor, the nurse should monitor the intake and output of a woman receiving IV fluids because of the risk of ____.
hypervolemia
The nurse should encourage the woman to void every ____ because a distended bladder may impede descent of the presenting part and slow or stop uterine contractions.
2 hours
____ during the first stage of labor enhances the progress of labor.
Frequently changing positions
A woman who receives support throughout labor is A____, B____, and C____.
A) less likely to use pain medication or epidurals
B) more likely to have a spontaneous vaginal birth
C) less likely to report dissatisfaction with the birth experience
The only objective indication that the second stage has begun is ____.
an inability to feel the cervix during vaginal examination
During the second stage of labor, women usually begin to push naturally, as the intensity of contractions increases and the ____ strengthens.
Ferguson reflex (or urge to push)
The third stage of labor starts at A____ and ends with the B____.
A) birth
B) expulsion of the placenta
During the fourth stage of labor, ____, both mother and newborn begin recovering from the physical process of birth.
the first 1 to 2 hours after birth
Maternal assessment during the fourth stage of labor includes checking A____, B____, and C____.
A) fundal tone
B) lochial flow
C) vital signs
True labor contractions are A____; false labor contractions are B____.
A) painful
B) typically not.
Although false labor contractions A____ with activity, true labor contractions are B____ with activity such as ambulation.
A) decrease
B) enhanced or stimulated
A regular pattern of frequency is a sign of ____ labor.
true
The major risk for women during the third stage of labor is ____.
postpartum hemorrhage
Which characteristic is associated with false labor contractions?
C. Decrease in intensity with ambulation
A pregnant couple has formulated a birth plan and is reviewing it with the nurse at an expectant parent’s class. Which aspect of their birth plan would be considered unrealistic and require further discussion with the nurse?
A. “We do not want the fetal monitor used during labor since it will interfere with movement and doing effleurage.”
Because monitoring is essential to assess fetal well-being, whether to use monitoring is not a factor that can be determined by the couple. The nurse should fully explain its importance. But ____.
The option for intermittent electronic monitoring could be explored if this is a low risk pregnancy and labor is progressing normally.
When performing vaginal examinations on laboring women, the nurse should be guided by what principle?
D. Cleanse the vulva and perineum before and after the examination as needed.
Cleansing will reduce the possibility of secretions and microorganisms ascending into the vagina to the cervix. Maternal comfort will also be enhanced.
Baby to breast ASAP: this release natural oxytocin which prevents mom from hemorrhaging
Placenta Previa
It is: Low-lying or overlaying the os
May cause: Painless bleeding
Of the 4-6% of previas Dx in 2nd trimester, 90% will have resolved by term
If Pt had a full meal and shows up with late deccelerations what is the likely outcome?
Cesarean
"Bicitra" will
decrease the chances of vomiting during delivery
Enemas
Small benefits do not outweigh the disadvantages
If stool is expelled, clean it up and assure the woman that this is normal
Screaming or closed-glottis (Valsalva) pushing are...
Not good because they reduce oxygen being made available to fetus
T/F: When performing vaginal examinations on laboring women, wear a clean glove lubricated with tap water to reduce discomfort.
F: Sterile gloves and sterile gell lubricant must be used to prevent infection.
T/F: When performing vaginal examinations on laboring women, perform the examination every hour during the active phase of the first stage of labor.
F: Vaginal examinations should only be performed as indicated to limit maternal discomfort and reduce the risk for transmission of infection, especially when rupture of membranes occurs.
T/F: Examinations are never done by the nurse if vaginal bleeding is present.
T: Because the bleeding could be a sign of placenta previa and a vaginal examination could result in further separation of the low-lying placenta.
Following rupture of membranes, a prolapse of the cord was noted on vaginal examination. A recommended action to alleviate cord compression would be to:
B. Keep the protruding cord moist with warm sterile normal saline compresses.
The hips should be elevated using a ____ when cord prolapse is detected.
Sims or knee-chest position
T/F: Following rupture of membranes, a prolapse of the cord was noted on vaginal examination. A recommended action to alleviate cord compression would be to insert a Foley catheter to keep the bladder empty.
F: A distended bladder has a beneficial effect; it elevates the presenting part and inhibits uterine contractions, so a catheter insertion is not recommended.
T/F: Following rupture of membranes, a prolapse of the cord was noted on vaginal examination. A recommended action to alleviate cord compression would not be to attempt to reinsert the cord.
T: Never attempt to reinsert the cord because it may be injured in the process.
The nurse recognizes that a woman is in true labor when she states:
B. “The contractions in my uterus are getting stronger and closer together.”
Loss of the mucous plug (operculum) often occurs during the ____, but it is not the indicator of true labor.
first stage of labor or before the onset of labor
Spontaneous rupture of membranes often occurs during the ____, but it is not the indicator of true labor.
first stage of labor
The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor. It A) IS, or B) IS NOT a indicator of true labor.
IS NOT
What is an expected characteristic of amniotic fluid?
D. Pale, straw color with small white particles
Yellow-stained fluid up to 36 hours before rupture of membranes may indicate A, B or C.
A) fetal hypoxia
B) fetal hemolytic disease
C) intrauterine infection.
Amniotic fluid produces an A____ result on a Nitrazine test. The results would be in this color range B____ and indicate this pH: C____.
A) alkaline
B) blue-green to blue-gray to deep blue
C) 6.5 to 7.0 to 7.5
Possible false negative Nitrazine test results may occur with: A, B, and C.
A) bloody show
B) insufficient amniotic fluid
C) semen
Negative Nitrazine test results "color range" and "pH range"?
Yellow - Olive-yellow - Olive-green
5.0 - 5.5 - 6.0
The absense of ferning in an amniotic fluid test counld result from....
inadequate specimen
specimen that is: urine, vaginal discharge or blood
Which action would be correct when palpation is being used to assess the characteristics and pattern of uterine contractions?
B. Evaluate the intensity of the contraction by pressing the fingertips into the uterine fundus,
T/F: To assess the characteristics and pattern of uterine contractions, place the hand on the abdomen below the umbilicus and palpate uterine tone with the fingertips.
F: Many women may experience labor pain in the lower segment of the uterus (i.e. below the umbilicus) which may be unrelated to the firmness of the contraction detectable in the uterine fundus.
T/F: Assess uterine contractions every 30 minutes throughout the first stage of labor.
F: Assessment of uterine activity is performed in intervals based on the stage of labor. As labor progresses, this assessment is performed more frequently.
The nurse knows that the second stage of labor, the descent phase, has begun when the:
A. Woman experiences a strong urge to bear down.
During the descent phaseof the second stage of labor, the woman may experience an increase in the urge to bear down.
T/F: Rupture of membranes has no significance in determining the stage of labor.
True
T/F: The second stage of labor begins with full cervical dilation and 100% effacement.
True
T/F: Woman may experience a strong urge to bear down in the first stage of labor.
True: Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5-cm dilation.
Nurses can help their patients by keeping them informed about the distinctive stages of labor. Which description of the phases of the first stage of labor is accurate?
D. Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours
T/F: Latent phase of first stage: Mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours
F: The latent phase is characterized by mild-to-moderate, irregular contractions; dilation up to 3 cm; brownish-to–pale pink mucus, and a duration of 6 to 8 hours.
T/F: Transition phase of first stage: Very strong but irregular contractions; 8- to 10-cm dilation; duration of 1 to 2 hours
F: The transition phase is characterized by strong- to–very strong, regular contractions; 8- to 10-cm dilation; and a duration of 20 to 40 minutes.
In documenting labor experiences, nurses should know that a uterine contraction is described according to all of these characteristics except:
A. Appearance (shape and height).
T/F: Uterine contractions are described in terms of frequency, intensity, duration, and resting tone.
True
Concerning the third stage of labor, nurses should be aware that:
B. An expectant or active approach to managing this stage of labor reduces the risk of complications.
T/F: The placenta eventually detaches itself from a flaccid uterus.
F: The placenta cannot detach itself from a flaccid (relaxed) uterus. It must be firm and contracting to the villi to break away.
Active management facilitates placental separation and expulsion, reducing the risk of complications. This must occur within ___ time-frame and if not complete with ___, the placenta is considered to be rtetained and interventions to hasten delivery instituted.
A) 10-15 minutes
B) 30 minutes
Chapter 9, p278, says that this may be as short as 3-5 minutes but that up to 30 minutes is considered within normal limits.
T/F: It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface.
F: Which surface of the placenta comes out first is not clinically important.
The major risk for women during the third stage is ___
Hemorrhage
Perineal lacerations occur as the fetal head is being born. The extent of the laceration is defined in terms of its depth. A first-degree laceration extends through ___.
the skin and superficial structures
Perineal lacerations occur as the fetal head is being born. The extent of the laceration is defined in terms of its depth. A second-degree laceration extends through ___.
the muscles of the perineal body
Perineal lacerations occur as the fetal head is being born. The extent of the laceration is defined in terms of its depth. A third-degree laceration extends through the ___.
anal sphincter muscle.
Perineal lacerations occur as the fetal head is being born. The extent of the laceration is defined in terms of its depth. A fourth-degree laceration extends through the ___.
anterior rectal wall
Labor that is stimulated and increased during ambulation
True
True labor is often felt in the A___, while false labor can be felt in the B___
A) lower back radiating to the lower portion of the abdomen
B) back or abdomen abovethe navel.
The cervix in true labor A___, while in false labor it is B___.
A) moves to an increasingly anterior position
B) often is in a posterior position
T/F: The cervix may be soft in both true and false labor
True, but in false labor, there will be no significant change in effacement, dialation or bloody show
In true labor the presenting part A___, while in false labor it B___.
A) usually becomes engages in the pelvis which eases breathing, but presses down and forward on the bladder resulting in urinary frequency
B) is usuallyNOT.
EMTALA is a A___ and in essense it requires emergency medical treatment or active labor care whenever such treatment is sought. This includes ROM, which is not a sign of true labor. This seems at odds with "a pregnant woman presenting in an obstetric triage is considered to be in "true" labor until a qualified health care provider certifies that she is not."
A) federal regulation
A bloody show is distinguished from bleeding by the fact that
it feels thiock and sticky because of its mucoid nature
Because vomiting and subsequent aspiration can complicate an otherwise normal labor, the nurse will record...
the time and type of the woman's most recent fluid and solid intake.
Fathers in Japan
may be present
Assessment of contraction strength:
Nose: Mild
Chin: Medium
Forehead: Strong
Fathers in China
not usually present
Fathers in India
not usually present
Fathes in Iran
not present
Fathers in Mexico
may be present along with female relatives
Fathers in Laos
May or may not be present
Somali women...
extremely stoic (no shows of weakness)
Japanese women...
natural childbirth practised
may labor silently, but also may request meds when pain becomes severe
may eat during labor
Chinese women...
Stoic
side-lying delivery thought to reduce infant trauma
taking first offer of pain meds impolite, so ....
Indian women...
Natural childbirth
female relatives usually present
Iranian women
Female support and caregivers preferred
may be voacl in response to pain
may prefer meds to relieve pain
Mexican women
May be stoic until second stage and then request pain meds
Laosian women...
May use squatting position
Female attendants preferred
Native American women...
East
Wall rug
"Cord" from ceiling
Leopold maneuvers used to determine...
Number of fetuses
Presenting part and fetal lie and attitude
Degreee of descent into pelvis by presenting part
Location of PMI (point of maximal inyensity) of FHR (fetal heart rate)
Leopold maneuvers Prep steps
Woman to empty bladder
Supine with one pillow under head and knees slightly flexed
Small rolled pillow under left or right hip to prevent supine hypotension
FHT
Fetal Heart Tones
Objectives for latent phase of first stage of labor...
No pain meds
Woman should be walking, drinking & eating
Risks of a Ventouse or vacuum-assited vaginal delivery
The baby will be left with a temporary lump on its head, known as a chignon.
There is a possibility of cephalohematoma formation, or subgaleal hemorrhage.
Handle baby with ___ until its first bath
gloves
PMI of FHT found above umbilicus indicates a
breech presentation
Duration of contractions in this range: ___, but should not exceed them
45-90 seconds
Amniotomy can be performed by...
Physician
Nurse-midwife
PA
Labor is initiated at term by SROM in approximately ___ percent of pregnant women.
25
After SROM, a lag period rarely exceeeding ___ hours may preceed the onset of true labor.
24
The BOW (Bag of waters) can rupture spontaneously at any time during labor, but most commonly___.
in the transition phase of the first stage of labor
Times to perform a vaginal exam:
On admission
Significant change in uterine activity
Maternal perceptionof perineal pressure or the urge to bear down
ROM
Variable decelerations of FHR
Following ROM, the ___. To ensure fetal well-being ___.
the umbilical cord may prolapse
monitor the FHR and pattern closely for several minutes immediately after ROM.
Following ROM, ___. To ensure maternal as well as fetal well-being assess maternal temperature and vaginal discharge at least every ___.
microorganisms may ascend into the amniotic sac causing chorioamnionitis and placentitis to develop
T/F: Sign of potential labor complcation: more than 10 contractions in a 20 minute period
F: 5 and 10
T/F: Sign of potential labor complcation: relaxation between contractions last less than 30 seconds
True
T/F: Sign of potential labor complcation: absent or minimal FHR variability during fetal sleep cycle
F: when notassociated with a fetal sleep cycle
T/F: Sign of potential labor complcation: Maternbal temp >= 37
F: 38
T/F: Ice chips and sipsof fluid are the only oral intake recommended during labor in the U.S. by the American Society of Anesthesiologists Task Force on Obsettric Anesthesia.
F: sips of clear fluid
Why is the ice chips and sips of clear fluids practise beign challenged?
Because regional anesthesia is used more often than general anesthesia, even for emergent cesarean births, and so women are awake and able to protect their airways.
Women in labor will usually change their position spontaneously. If they do not do so every ___, assist her to so so. The ___ position is preferred because it ___.
30 to 60 minutes
side-lying (lateral)
promotes optmal uteroplacental and renal blood flow.
A women with ___ may not be able to squat, but may assume the ___ position.
epidural anesthesia
hands and knees
Some maternal positions during labor and birth
Sedmirecumbent
Lateral
Upright
Hands and Knees
Advantages of Semirecumbent
At least 30 degrees and pillow under one hip to prevent supine hypotension
The greater the angle, the more gravity will promote fetal descent andf progress of contractions
Position is convenient for rendering cxare measures and external fetal monitoring
Advantages of Lateral
Left or right side-lying.
Removes pressure from vena cava (enhances uteroplacental profusion) and back (relieves backache).
Associated with less frequent, but more intense contractions.
Good fetal monitor tracings possible, but more difficult.
May be used as birthing position.
Takes pressure off of perineum allowing it to stretch gradually and in so doing reduce the risk of trauma to it.
Advantages of upright
Downward pressures cause impulses from cervix to pituitary to increase, resulting in more oxytocin increasing the intensity of contractions, but with less pain
Fetus is aligned with pelvis and pelvic diameters are widened slightly
Adbvantages of Hands and Knees
Ideal position for posterior positions of the presentign part.
Gravity cause the fetal back to rotate with the head.
Median duration for second stage of labor
50 minutes for nulliparous
20 for multi's
Second stage of labor considered "prolonged" if...
> 2 hours for nulli's with no anesthesia
> 3 hours with regional anesthesia
> 1 hour for multi's with no anesthesia
> 2 with regional anesthesia
episiotomy, when
If used it is at the end of the second stage of labor
Nuchal chord
encircling of the fetal neck one or more tims by the umbilical cord
Uterine contractions
Primary powers of labor that act involuntarily for birth and expulsion of placenta, but also to prevent hemorrhage
Pre-eclampsia is a medical condition in which hypertension arises in pregnancy (gestational hypertension) in association with significant amounts of protein in the urine.
Pre-eclampsia is a set of symptoms rather than any causative factor, and there are many different causes for the condition.
It appears likely that there are substances from the placenta that can cause endothelial dysfunction in the maternal blood vessels of susceptible women.
While blood pressure elevation is the most visible sign of the disease, it involves generalized damage to the maternal endothelium, kidneys, and liver, with the release of vasoconstrictive factors being secondary to the original damage.
Pre-eclampsia may develop from 20 weeks' gestation (it is considered early onset before 32 weeks, which is associated with an increased morbidity).
Its progress differs among patients; most cases are diagnosed before labor typically would begin.
Pre-eclampsia may also occur up to six weeks after delivery. Apart from Caesarean section and induction of labor (and therefore delivery of the placenta), there is no known cure.
It is the most common of the dangerous pregnancy complications; it may affect both the mother and fetus.
Steps for all non-reassuring FHR...
POISON
Position change
Oxygen @ 8-10 L/min by non-rebreather
Increase or start IV
Stop
Oxytocin (Pitocin)
Notify PCP
Check maternal Temp
Assist with amniofusion if ordered
Prolapse of cord...
POISON +
With gloved hand push up against presenting part.
Extreme Trendelenburg, Sims or knee-chest
Rolled towel under one hip.
If cord ouside vagina, wrap it loosly in warm NS saturated sterile towel.
DO NOT LEAVE WOMAN ALONE.
This will probably result in an emergent Cesarean
Average duration of phases of second stage of labor
Latent: 10-30 minutes
Descent: varies
Transition: 5-15 minutes
Frequency of contractions duration of phases of second stage of labor
Latent: none
Descent: 2-2.5 minutes
Transition: 1-2 minutes
Station of presenting part in phases of second stage of labor
Latent: 0 - 2+
Descent: 2+ - 4+
Transition: 4+ - birth
The umbillical cord ___ encircles the neck (nuchal cord), but ___ so tightly as to cause hypoxia.
often
rarely
Tissue of ___ women, especially those with ___ hair is less distensible compare to women of ___, and healing may be less efficient.
light-skinned
red
darker-skin
___ and ___ positions allow the perineum to stretch more slowly with fewer indications for episiotomies.
Side-lying
squatting
Fourth Stage Labor Care
Pulse: q15 minutes for first hour
Temperature: Beginning of recovery and at 1 hour after
Fundus: firm & midline, +fb or cm if above umbillicus, - for below; If not firm, massage to expell clots, but only until firm
Lochia: Look under buttocks!
Perineum: On side, lift upper buttock and inspect perineum and assess for hemorrhoids
Dirty Duncan & Shiney Shultz
"Dirty Duncan" and "Shiny Schultz" are ways to remember the presentation of the placenta. Duncans are called "dirty" because they come out messily, with trailing membranes, and a good amount of blood. Shultz are shiny because the fetal side comes out first, with the maternal side, blood and any clots wrapped up neatly in the membranes. Duncan placentas are usually because the placenta was low-lying. Low-lying placentas tend to be followed with a good amount of bleeding after, and because it was low-lying, the usual massage etc., may not work.IME, those dirty Duncans often need a shot of pit to control bleeding, more so than the Shultz, but not enough for me to routinely administer pit (pitocin), but enough for me to make sure I know where it is right away.So, maybe your midwife eyeballed the amount of blood coming after the placenta and just wasn't comfortable with it.
Ice for edema
20 minutes on, 20 minutes off
Uterus will or will notreturn to nulli size.
will not
T/F: Increased number of babies leads to stronger afterbirth pains
True
Hemorrhage is defined as exceediung ___ amount for ___ type of delivery.
500ml for vaginal
1000ml for Cesarean
Straight catheterization is a common or uncommonpractice after a vaginal birth.
