Exam review 2 Update version Nclex RN. Review Notes review and exam PDF

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Exam 2 Review

OB Exam #2 (Intrapartum) Labor and Childbirth: Intrapartum: occurs from the onset of true labor until the birth of the baby. Signs of Approaching Labor:  Lightening (when the baby drops; in the last trimester the head goes back down and its engaged)  Braxton-Hicks contractions (start to get a little stronger)  Backache  Bloody show  During pregnancy, there is a mucus plug in the cervix called operculum, which seals the cervix to prevent ascending infections. When the woman is going into labor this mucus plug comes down with a little blood on it and that is called a bloody show.  Spontaneous rupture of membranes (tested with nitride or fern test)  Spurt of energy (all of a sudden they can do everything that they couldn’t do before)  Weight loss True vs. “False” Labor  False labor does not have any effect on the cervix! If a woman is having pain, but the cervix is not opening, SEND HER HOME!  True labor causes dilation & effacement of the cervix Cervical Dilatations and Effacement:  Dilatation – the opening of the cervix  Effacement – the thinning out of the cervix  1 finger = 2 cm … 2 fingers = 4 cm Theories of Onset of Labor  Oxytocin production (as the body gets closer to labor, it produces excess amount of oxytocin; this triggers uterine muscles to contract)  Prostaglandin (helps soften the cervix)  Estrogen stimulation  Fetal influence o Once the uterus has stretched to capacity it is going to empty, which is why someone with twins goes into labor earlier cause they take up more capacity.  Others o Sperm produces hormones that stimulate the cervix to get ripe and start contractions. “P’s” of Labor  For us to have good labor the “P’s” must be right  Passageway  the vaginal area, pelvic bone, and the soft tissue that the baby has to pass through  Passenger  the baby  Powers  maternal strength of the mother pushing and the contractions  Position  how the baby is positioned in the uterus; if abnormal the baby won’t be able to be delivered normally  Psychologic changes  if a woman is not mentally prepared to push, the baby will never come out. PUSH LIKE YOU ARE CONSTIPATED  Passageway  The Pelvis o Implications of Pelvic Type for Labor & Birth

Exam 2 Review

 A woman must have the right pelvic structure to give birth. The Passenger  The Head o Anterior & Posterior Fontanelles o Sutures  the sutures in between the fontanelles are flexible and they cause the skull bones to overlap so that the head can come out, this is called molding. o Molding  The Fetus o Fetal Lie  the relationship of the baby’s spine to the mother’s spine.  Longitudinal lie = the long axis of the fetus is longitudinal and roughly parallel to the long axis of the mom; the presenting part may be either the head or breech.  Transverse lie = perpendicular  Oblique lie = diagonal o Fetal Presentation (cephalic, breech, shoulder presentation) o Fetal Attitude o Fetal Position o Presenting Part Delivery presentations 

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Normal Delivery:

Abnormal Deliveries:

When you insert your fingers, feel for the fontanel. This helps to determine whether the back of the head is to the front or if the back of the head is to the back.  Shoulder presentation will definitely be a C-section or the doctor may try external version.  External version = turning the baby to cephalic presentation Relationship Between Fetus and Passage  Engagement o When the baby’s head gets to the ischial spine the head is engaged. o If it is above it is “floating”.  Station o The head is either engaged or at station 0.  Fetal Position Powers: The Forces of Labor  Primary force – Uterine contractions o Frequency o Duration o Intensity  Secondary force o Abdominal muscles  It’s easier to give birth if you have abs o Perineal muscles o Pelvic floor muscles  If a woman is having irregular contractions, this won’t bring delivery of the baby. The doctor will give her Oxytocin/Pitocin.  If a lady comes in at 40 weeks and she ruptured her membranes but has no pain at all  the doctor might induce labor = (INDUCTION)

Exam 2 Review

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When labor does not naturally start on its own and vaginal delivery needs to happen soon, labor may be started artificially (induced).  If a lady is having contractions that are not strong enough and the baby is not coming out and she is in PAIN = (AUGMENTATION)  If active labor has started on its own but contractions have slowed down or completely stopped, steps need to be taken to help labor progress (augmentation). (4) Stages of Labor  First Stage - from onset of true labor to complete dilation of the cervix of 10 cm. o First stage has (3) phases:  Latent / Early phase (0-3 cm)  During this phase the mother is usually happy, talking, and eating pastelis.  Active Phase (4-7 cm)  Pain gets stronger in this phase and irritability begins.  Transition (8-10 cm)  At this point, the woman is screaming at everyone. o Complete dilation is 10 cm  Second stage o Crowning  the appearance of the fetal scalp at the vaginal orifice in childbirth. o Positional changes of the fetus o Second stage is the delivery of the baby  Third stage o Placenta separation  How do you know that the placenta is ready to come out? 2 signs of placenta separation:  There will be a gush of blood  The umbilical cord lengthens  because the placenta has now separated from the wall of the uterus o Delivery of placenta  When the placenta comes out we have to check it because we do not want any area of the placenta to be left inside. We have to check the fetal side, the chorion and the amnion. The amniotic membrane is what formed the amniotic sac that enclosed the baby. We are checking the amnion to make sure there are no raggedy ends because that can indicate that something was left behind. We also check the maternal side. Check to make sure that all the lobes are intact and nothing is missing and the membranes are not rugged.  2 mechanisms of placenta expulsion:  Mathieu Duncan or “Dirty Duncan”  If the placenta comes out of the mother maternal-side first.  Shiny Schulz  By far the most common mechanism of placental expulsion. Delivery of the placenta with the fetal-side presenting.  Fourth stage o Recovery 1-4 hours o 1-4 hours after the delivery of the placenta o Within these hours we need to monitor mom and baby carefully o (2) Things that we do to prevent mom from bleeding:  If the abdomen is soft … massage the uterus until it is nice & firm.  If the uterus is to the left or to the right, it could mean a full bladder so empty the bladder; the displacement of the uterus can be causing the bleeding. Cardinal Fetal Movements: 1. Engagement 2. Decent

Exam 2 Review

3. 4. 5. 6. 7. 8.

Flexion Internal Rotation Extension Restitution External Rotation Birth of the shoulder o The doctor will deliver the anterior shoulder and then deliver the posterior shoulder because the shoulders should be lined up nicely under the pelvic bone. 9. Expulsion  https://www.youtube.com/watch?v=PUQobQVOCuQ  Intraportal Nursing Assessment:  Data collection  Physical assessment  Evaluation of progress of labor o Leopold’s maneuvers (feeling the baby to see His/her position; you feel for the head and the back which helps to determine the HR because you listen to baby’s heart on the back.) o This maneuver helps to determine:  The # of fetuses  Fetal Presentation  how the baby is presenting (transverse, cephalic, breeched)  Fetal Lie  Fetal Attitude  whether the head is flexed or extended  Degree of fetal descent  FHR pattern o Leopold’s maneuver steps: o First thing you do is palpate the fundus, the sides, and feel the head 1. You feel the fundus to check for what is there. Palpate for the fetal part that occupies the fundus to help identify fetal lie and presentation. Feel for shape, consistency, and mobility. The fetal head will feel firm and round. The breech, that is, the buttocks and legs, will feel softer and less defined. 2. Feel the sides of the patient’s abdomen. Use the palmar surface of one hand to locate the fetal back and the various irregularities to identify hands, feet, and elbows. The fetal back will feel smooth and hard. The smaller fetal parts, such as the hands, feet, and elbows, will feel like irregular nodules when you palpate them. This also helps you identify the fetal presentation. 3. Feel what is in the pelvis. Use your right hand to grasp the lower section of the patient’s abdomen between your index finger and thumb and press inward over the inlet to the true pelvis. Note any movement and determine whether the presenting part is soft or firm. If there is movement, the presenting part is not engaged. If the head is the presenting part, determine fetal attitude, that is, whether the head is flexed or extended. 4. Check FHR pattern, to determine how the baby is dealing with the contractions. If the HR is dropping every time there is a contraction this baby will not be able to manage labor.

Exam 2 Review

For Exam 2. VEAL CHOP FETAL MONITORING

STRIPS V: variable- Cord compression (low fluid, cord around neck) i. ii. iii. iv.

L-lay on side prefer left side I- increase IV fluid O-oxygen via face mask (nonrebreather) N- notify physicians

E: early deceleration (normal) -Head compression i. ii. iii. iv.

Active labor-check for dilation Or no interventions due to baby head compression Bottom part of strip is maternal contraction top part is babies heart rate Deceleration will occur at same time as contraction HR goes does while contraction temporary loss of oxygen for baby

v.

L: acceleration (just ok) – Ok reassuring i. ii.

Document findings—continue to monitor Up by 15—over by 15

L: late (bad indication)- Placenta insufficiency ****Heart drops after and continue after—will always be to the right of the contraction—possible C-section i. S- stop Pitocin ii. L- lay on side iii. I- increase IV fluid (NS_LR)

Exam 2 Review

iv. v.

O- oxygen via nonrebreather N-notify MD

vi.

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Fetal monitoring o Baseline o Tachycardia > 160 bpm o Bradycardia < 110 bpm Accelerations – 15 bpm x 15 seconds   Decelerations: o Early = head compression o Late = placental insufficiency o Variables = cord compression  Turn the lady on her side if the baby is lying on the cord or try to get the baby off the cord  Mnemonic “Veal Chop”: o V–C o E–H o A – O (Accelerations = Ok) o L –P  Contractions are measured by: o Frequency – beginning of one contraction to the beginning of the next contraction o Intensity o Duration – beginning to end of one contraction; how long it is lasting  Vaginal exam  FHR monitoring  Evaluation of FHR Tracing Maternal Responses to Labor Cardiovascular 

Exam 2 Review

o Mothers HR is going to increase. Respiratory Gastrointestinal o She is going to start vomiting if she is eating which is why we keep her NPO because her body is relaxing (cervix, pelvis, stomach) or in case she is an emergency C-section. Genitourinary and Renal  Immune and other blood values   Pain Psychosocial  Fetal Responses to Labor  Auscultation of FHR  Electric Fetal Monitoring o External Fetal monitoring o Internal Fetal Monitoring o Fetal scalp electrode monitor is put on the head of the baby in order to monitor the fetal heart. o In order to put the a monitor on the babies head:  The cervix has to be open!  The membranes have to be ruptured! Fetal Heart Rate Patterns  Baseline fetal heart rate Baseline bradycardia   Baseline tachycardia Baseline variability   Periodic and episodic changes  Acceleration  Deceleration  Early deceleration Late deceleration   Variable deceleration Managing Decelerations  Early decelerations: o No intervention necessary; however, the nurse may choose to reposition the patient.  Late and variable decelerations: o Reposition to left lateral (she could be compressing the cord) o Administer oxygen via face mask o Give IV fluids (bolus) o Turn of Pitocin, if applicable… o Notify physician as needed! The Family in Childbirth: Needs and Care Nursing responsibilities:  o First stage (Admission): Family expectations  Cultural beliefs  Pain, modesty  o Second stage:  Promoting comfort  Assisting during birth  Birthing positions  Women should choose the position they want to deliver in.  Labor support  Doula’s help with breathing techniques.  

Exam 2 Review

o

o

Third stage (initial care of the newborn):  Apgar (Appearance, Pulse, Grimace, Activity, Respirations)  each is out of 2 the higher the better.  Umbilical cord (cut the cord after it stops pulsating)  Warmth (make sure that the baby is warm because they can go hypothermic and become ill; dry the baby, wrap the baby, put the baby skin to skin, which is when bonding begins)  Newborn identification (Before the baby leaves the room the ID has to be on the baby and has to match the significant other!)  Collection of cord blood  Newborn assessment  DNA sample Fourth stage: Bonding   Safety  We do not want the baby or the mother to bleed and we want them both to stay alive.

Types of Vertex Presentation:

Exam 2 Review

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We have positions that we prefer in the vertex The occiput-anterior position is ideal for birth Look at the ears, the pointy part of the ears will tell you where the baby is pointing to (Right, Left, Straight, Transverse) Occiput = back of the head When the head is coming down and you put your finger inside you should feel for the anterior fontanel. That usually tells you which direction the head is turned in. We use whatever is presenting to describe the presentation o Occiput o Sacrum o Mentum If the baby is coming face down, feel for the chin If the baby is coming butt first, try to figure out where the sacrum is pointing If the baby is coming down head first, try to find out where the occiput or the back of the head is

Pharmacologic Management: During Labor: Cultural Influences and Pain  Can a woman cultural background influence her response to pain? o Yes; some people are louder or quieter than others Discomfort During Labor and Birth • Factors influencing pain response o Physiologic factors • Someone that exercises, is young, and has firm abs will push the baby out easier. o Culture o Anxiety o Previous experience

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o Childbirth preparation o Comfort and support o Environment Discomfort during Labor 1. Distribution of labor pain during first stage  Pain starts at the back and radiates to the front 2. Distribution of labor pain during later phase of first stage and early phase of second stage  Pain is on the lower back and perineal area 3. Distribution of labor pain during later phase of second stage and during birth  Towards the end the pain is concentrated in the perineal area and less in the back Non-pharmacologic Management of Discomfort • Non-pharmacologic measures often simple, safe, and inexpensive • Provide sense of control over childbirth and measures best for woman • Methods require practice for best results • Try variety of methods and seek alternatives, including pharmacologic methods, if measure used is not effective • Relaxing and breathing techniques: o Relaxation o Imagery and visualization o Music o Touch and massage o Breathing techniques o Movement and positioning o Water therapy (hydrotherapy) o Continuous labor support Types of Pharmacologic Pain Management  Opioid analgesics o Morphine sulfate o Demerol o Reversal agent (Narcan/Naloxone) -- given to the baby if the mother gets any of these narcotic analgesics late in pregnancy because the baby will come out with respiratory distress  Narcotic agonist-antagonist compound o Stadol o Nubain  Anesthesia o Local anesthesia o Pudenda anesthesia o Epidural anesthesia block o Combined spinal-epidural anesthesia o Spinal anesthesia o General anesthesia  Epidural Anesthesia Block o Most common method currently used in the United States o Controversial  Not mandatory to get epidural  The excessive fluid that is in the baby’s lungs get’s squeezed out when the baby is born vaginally; which is why these babies have less chances for respiratory illnesses than babies who are born by c-section. o Most effective and flexible method of pain management for vaginal births o Administration:

Exam 2 Review

 Given in the active phase of the first stage of labor; cervical dilation 4-5 cm  Fetal head engaged at zero station  Reassuring FHR pattern; you don’t want to give it if you’re decelerations o Advantages:  Fully awake during labor and birth  Promotes good relaxation  Airway reflexes remain intact  Gastric emptying not delayed  Minimal blood loss o Disadvantages:  Some people take a longer time to regain sensation in their legs  Can stay paralyzed if not administered correctly o Technique for Epidural Block: Threading the Catheter  The epidural space is entered with a needle below where the spinal cord ends. A fine catheter is threaded through the needle.  Pudendal Anesthesia o Administered during the second stage of labor o Provides pain relief in the perineal area within 2-10 minutes and last for approx. one hour o They block the pudendal nerve to stop the pain o Provides anesthesia for vaginal births, forceps or vacuum extraction, perineal repair o Monitoring o Assess maternal FHR and maternal BP  Combined Spinal-Epidural Anesthesia o Administered in the subarachnoid space o Has a faster onset of pain relief than epidural anesthesia o Use in the second stage of labor o Usually used for cesarean births o Helps to get rid of sensation in more areas o Duramorph protocol  Spinal Anesthesia o Advantages:  Immediate onset  Ease of administration  Smaller dose  Excellent muscle relaxant  Does not pass through placenta o Disadvantages:  Cannot sense urge to push which results in an episiotomy, forceps or vacuum extraction  Bladder and uterine atony (loses the ability to contract)  Spinal headaches  Demerol passes through the placenta and can cause respiratory distress  General Anesthesia o General anesthesia rarely used for vaginal birth o May be used for cesarean birth or when needed in emergency childbirth situation o Used in emergency situations o Patient totally unconscious o Tubed and trached Before Receiving Medications….

Exam 2 Review

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The woman should understand: o Type of medication o Route o Expected effects o Potential adverse effects o Implications for fetus or newborn o Safety measures Nursing Care Management • Assessment of mother o Willingness to receive medication (Must get informed consent!) o VSS o Contraindications • Assessment of fetus o Baseline FHR  Make sure that the fetal HR is okay o Any abnormality must be reported o Short and long term variability present o Exhibits normal movements/accelerations present o Term pregnancy (Baby should be at least 38 weeks) • Assessment of labor o Contraction pattern established o Dilating cervix  Make sure that the cervix is dilating; is she is at 2cm for week you are not going to give her epidural; make sure she is at 4-5cm and is having regular contractions o Progressive decent of fetal presenting part • Epidural anesthesia o Monitoring maternal and FHR o IV access established o Loading dose (500ml-1000ml) of LR or NS over 15-30 minutes o Monitor VS according to agency policy o Monitor O2 sats o Positioning o Insertion of Foley catheter o NPO o Adverse reactions and complications • Spinal anesthesia o Positioning  Make sure that she is kept in the right position because if you mess up she can stay paralyzed. o Adverse reactions and complications o Postural spinal headache o Epidural blood patch • General Anesthesia o Adverse reactions and complications o Controlling malignant hyperthermia o Discontinuation  Patients take a longer time to wake up, so you have to monitor them for a longer time after the c-section.

Exam 2 Review

Labor and Childbirth: At Risk Classification ...