Summary NSG 307 Exam 2 Study Guide Marian University - NSG 307 | RATED A

Ch 13 NSG 307 Care of the Childbearing Client Exam 2 Study Guide • Stages and phases of labor o 1st stage: onset of contractions – full cervical dilation ▪ Latent phase: labor onset to active phase (longest phase of 1st stage) ▪ Active phase: 6-10 cm (rotate from resting  upright) o 2nd stage: full cervical dilation (10 cm) until birth of baby o 3rd stage: birth of baby until placenta delivery o 4th stage: delivery of placenta until about 2 hours of recovery • 5 P’s of labor o Passenger: fetus – Fetal head: sutures & fontanels fetal presentation & position – Preferred attitude is “flexed” where the head is flexed into the chest w/ fetal back rounded with the arms and legs flexed in front of the fetus o Passageway: birth canal – relaxin: hormone to relax muscles of bony pelvis, preparing pelvis to receive & pass the baby through birth canal o Powers: Primary (frequency, duration, intensity, effacement (thinning of cervix – 0-100%), dilation (opening of cervix 1 cm-10cm), Ferguson reflex (urge to bear down)—Secondary (bearing down efforts  delayed pushing o Position of laboring woman: upright, “all fours”, lithotomy, semirecumbent, lateral o Psychologic response “psyche” • Fetal Presentations: cephalic (LOA or LOT or ROA or ROT or LOA or LOP), breech (butt 1st), shoulder o Station: Ischial spines 0 station (above – number, below + number) o Engagement: largest diameter of fetal head in inlet – usually 0 station  presenting part that no longer ballots out of the pelvis & has entered maternal pelvic brim & into the true pelvis & corresponds to “zero” station • Signs Preceding Labor o Lightening (1st time mothers: few weeks before)—bloody show/mucus plug—Stronger Braxton-Hicks – Surge of energy “nesting”—Cervical ripening (cervix positioned anterior & easier to reach  soft, begins to dilate & efface) • Physiologic adaptations to Labor o Onset of labor= inc. uterine distention, aging of placenta, inc. estrogen & prostaglandins, dec. progesterone o Fetal adaptation: FHR= 110-160 (responds to how well oxygenated fetus is) ▪ Fetal circulation: affected by maternal position, contractions, BP, umbilical cord BF ▪ Preparation for fetal respirations: lung fluid clears through labor & vaginal birth  dec. PO2, inc. PCO, dec. pH, dec. HCO3 ▪ PREVENT NEURO ISSUES DUE TO INADEQUATE FETAL OXYGENATION o Maternal adaptation: ▪ Cardiovascular: during contractions (blood shunting)  peripheral resistance & BP inc. (check BP between contractions)– possible supine hypotension (remain off back & more side lying) – WBC inc. ▪ Respiratory: inc. O2 consumption with inc. activity & anxiety – Hyperventilation  respiratory alkalosis, hypoxia, & dec. CO2 ▪ Renal: drink & urinate q1h to keep lower abdominal area more comfortable – Voiding difficulties & proteinuria ▪ Integumentary: perineal stretching ▪ Musculoskeletal: inc. muscle activity (leg cramps  do NOT point toes) ▪ Neurologic: euphoria, serious, amnesia, elation/fatigue, endogenous endorphins ▪ GI: dec. GI motility, stomach-emptying time dec. & N/V Ch 14 ▪ Endocrine: dec. progesterone, inc. estrogen & metabolic rate, dec. glucose • Gate-control theory: pain sensations travel along the sensory nerve pathways up the spinal cord & to the brain, but only a limited # of sensations can travel these pathways at a time. By stimulating the nerves to transmit message, pressure, heat & cold, water therapy, positioning, helps to close the hypoethical gate of pain transmission along those same fibers. • Nonpharmacologic methods of pain management: knowledge & information— Lamaze/Psychoprophylactic method—Bradley: Husband-Coach Childbirth o Relaxation & breathing techniques: Focusing & relaxation (Imagery) o Effleurage & counterpressure—Touch & massage/therapeutic touch—Heat & cold— Acupressure & acupuncture—TENS unit—water therapy (hydrotherapy)—Intradermal water block • Systemic analgesia: IV/PCA/IM dose: provide sedation, euphoria, & rest—cross placenta (smallest dose is GOAL) & newborn effects (FHR, fetal sleep pattern, respiratory depression use more during early labor and not as labor is advancing) • Opioid agonists: No amnesic effect but create feeling of well-being or euphoria to enhance woman’s ability to rest between contractions—should be administered until labor is well established o Meperidine (Demerol): crosses placenta & cause prolonged neonatal sedation & neurobehavioral changes CANNOT BE REVERSED BY NALOXONE, Fentanyl (Sublimaze): rapidly crosses placenta so is present in fetal blood w/in 1 min., Remifentanil (Ultiva): OA is 1 min. & crosses placenta but metabolized quickly by fetus so no neonatal depression (PCA pump only)—RESPIRATORY MONITORING: hypoventilation & oxygen desaturations • Opioid agonist-antagonist: Nalbuphine (Nubain)—abstinence syndrome if opioid dependent & NO respiratory depression in newborn • Opioid antagonists: Naloxone (Narcan)—antidote for narcotic OD—CONTRA: opioid-dependent women—can cause excessive CNS depression in mother & newborn • Epidurals and spinals including nursing care o Local infiltration: given into perineal area (given just before birth for episiotomy & repair of laceration & Lidocaine) o Pudendal block: transvaginal injection to pudendal nerve – use end of 2nd & 3rd stages—provides broader area of pain relief  can provide relief for a forceps delivery or vacuum assisted delivery o Spinal anesthesia: Bupivacaine, lidocaine – c/s births  requires 500-1000 pre-hydration bolus w/o dextrose ▪ Advantages: no catheter placed for future dosing ▪ Disadvantages: hypotension (place on side wedge & IV bolus fluids), total spinal block, postdural puncture headache • Loss of sensations of contractions or urge to bear down during vaginal birth, use of vacuum extraction or episiotomy, full bladder = bladder distention, CSF may leak from puncture causing shift in brain & intense HA  Epidural blood patch ▪ Nursing implications: sterile technique on insertion  monitor for hypotension & has BP checked frequently o Epidural anesthesia: Used for vaginal birth or unplanned c/s: Bupivacaine, ropivacaine, or opioids (fentanyl) or both  L4 or L5 ▪ Advantages: pain relief at all stages ▪ Disadvantages: hypotension, Dural puncture w/ resulting HA, bladder distention, prolonged 2nd stage ▪ Pre-hydration bolus, ephedrine ▪ CONTRAS: maternal hypotension, coagulopathy, infection at needle site, inc. ICP, allergies, maternal refusal, maternal cardiac conditions o General anesthesia: emergency situations or contraindications to nerve block anesthesia  agents: Propofol, succinylcholine, isoflurane ▪ Nursing implications: NPO, sodium citrate (dec. acid out of stomach), uterine displacement, cricoid pressure ▪ AEs: maternal aspiration, maternal or neonatal respiratory depression, & uterine relaxation: pp hemorrhage • Effects of medications on mom and baby o Neonatal Crisis: CNS depression caused by narcotics or anesthetic agents  respiratory depression, hypotonia or dec. muscle tone, unstable thermoregulating mechanism dec. alertness & responsiveness to stimuli, hard to console = may continue regardless of Narcan & may last 2-4 days Ch 15 • Factors affecting fetal oxygenation (decrease in oxygen supply) o Dec. BF through maternal vessels (hypotension or hypertension) o Dec. oxygen content in maternal blood (mom bleeding heavily or having asthmatic event) o Alteration in fetal circulation (impeded by pressure on umbilical cord or placenta separating from the uterine wall (abruption) o Dec. BF to intervillous space in placenta (tachysystole, HTN, diabetes) • What determines a normal fetal heart rate pattern: Normal FHR = 110-120 up to 160 bpm o Variability: tells us how well oxygenated out fetus is @ that time. This is the up & down or peak to trough movement of the FHR o Absent: No undulations. Sign that fetus is lacking oxygen. INTRAUTERINE RESUSCITATION o Minimal: 5 bpm amplitude range; can be normal variation if fetus is taking a nap if for longer period of time = dec. oxygenation o Moderate: 6-25 bpm amplitude range—adequately oxygenated fetus  Normoxic o Marked: 25 bpm amplitude range—unspecified significance  continue to monitor fetus for any signs of change in oxygenation o Tachycardia: 160  maternal infection, drugs, fetal anemia ▪ Check maternal temperature & ensure proper oxygenation  minimal to absent variability  re-position mom & place oxygen on a tight non-rebreather mask o Bradycardia: 110 for 10 min.  fetal cardiac anomaly, viral infections ▪ Needs to differentiate from prolonged decelerations  initiate intrauterine resuscitation • Fetal heart rate pattern interpretation: Early, late, variable decelerations o Early decelerations: transient fetal head compression o Late decelerations: Placental insufficiency: ▪ Turn Pitocin drip off—turn pt. on side—admin. oxygen via non-rebreather—inc. IVF to inc. maternal BP o Variable decelerations: umbilical cord compression = CHANGE MATERNAL POSITION o Prolonged decelerations: 2 mins 10 min o Accelerations: (15 by 15)  peak 15 beats above baseline & Duration 15 seconds = OK • Factors affecting baseline, variability, accelerations, decelerations • Nursing interventions for abnormal fetal heart rate (FHR) patterns o Oxygen (non-rebreather face mask), lateral position, IV fluids o Interventions for specific problems: Hypotension & Tachysystole (can cause dec. fetal oxygenation because during a contraction BF to the uterus dec. or has a stais) by dec. amount of contractions, it will naturally allow for more O2 to be diffused through placenta (5 contractions w/in 10 min.) • Reassuring vs non-reassuring FHR o Normal= reassuring patterns Abnormal = non-reassuring patterns Ch 16 • Assessment of laboring woman o Prenatal data: age, height, weight, OB history such as gravida/parity/bleeding/gestational HTN/DM/anemia/infections/EDD/fundal height/FHR/lab tests/previous deliveries o Interview: chief complaint: rupture of membranes (ROM) or bag of waters (BOW), onset of labor presence of bloody show, illness, allergies, last oral intake  birth plan, infant feeding method, type of pain management, childbirth education, drug use o Lab workL urine, CBC (Hgb, Hct, platelets, blood type & Rh) o Assess amniotic membrane rupture  Nitrazine (pH) test & Fern test (clear or meconium- stained) o s/s of potential problems: FHR, contractions, meconium-stained fluid, lack of progress, materbal fever, vaginal bleeding